Interview Chapters

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  Chapter 21: A View of Women’s Careers at MD Anderson

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting offers observations and personal experiences to illustrate changes in the climate for women at MD Anderson.

  She talks about challenges when she was not accorded respect or opportunities. She notes that she was the fortieth woman at MD Anderson to be promoted to full-professor.

  Dr. Elting observes that the executive leadership at MD Anderson expresses concern about women’s representation, but this was not repeated at the mid-level of management until Dr. Elizabeth Travis [Oral History Interview] began working on advancement for women. Dr. Elting explains why she was reluctant to align herself with the Women Faculty Organization and Women Faculty Programs. She observes that women have an equal chance at becoming a department chair, but not at rising any higher. She explains why this is the case.

  Dr. Elting points out some differences in the ways that men and women look at their subject matter, particularly the way men are quicker think in entrepreneurial ways about their work. She explains how she developed this perspective.

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  Chapter 22: Cultivating Talented People Willing to Dedicate Themselves to a Research Life

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting talks about her mentoring strategy of identifying talented people who can dedicate themselves to the demanding life of a researcher and principle investigator. She talks about the role of senior faculty in weeding out junior faculty who will not be worth a department’s investment.

  
  
  Next, she explains that leadership involves a wide range of skills, including presentation and fund-raising skills and the ability to sell their ideas to for-profit companies.

  Dr. Elting observes that too many women accept roles that involve a lot of work, but that do not showcase their skills. She talks about her style of mentoring women for leadership.

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  Chapter 23: Projects Remaining Before Retirement

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting first talks about the writing and research she will focus on in her remaining time at MD Anderson. She notes that she is very proud of her work on the Institutional Review Boards (she was the first woman chair of an IRB) and her early work on treatment outcomes. (Health Issue raised, no HIPPA authorization needed.) She says she never realized how much her work on controlling infection effectiveness mattered until her mother was treated for cancer.

  Dr. Elting recalls that when she came to MD Anderson nearly everyone died from infection. She notes that it could be a depressing place, but the researchers and support people who stayed helped each other through that time and achieved great things.

  Dr. Elting also observes that she was one of the first people at MD Anderson to look at health issues from a population perspective. She is pleased at how far the institution has come in supporting that research.

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  Chapter 24 : Overview of MD Anderson Presidents and the Effects of Rapid Growth

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting begins this chapter by sketching the approaches of MD Anderson’s presidents. (She worked under all of them.) She observes that R. Lee Clark was primarily focused on patient care. Dr. LeMaistre [Oral History Interview] was an “ambassador president” who worked well with the University of Texas System. Dr. Mendelsohn [Oral History Interview], she says, brought a research perspective and now Dr. Ronald DePinho [Oral History Interview] is moving MD Anderson into new areas of science.

  Dr. Elting states that MD Anderson’s next challenge is to determine how to function as a research institution and deliver care at the same time. She explains how MD Anderson has “seesawed” between these two poles over time. She observes that the negative press the institution is receiving is a function of the institution growing big very rapidly in an environment of financial complexity. She asks, How big is big enough? She observes that the institution has lost its cohesive feel. She compares MD Anderson with the Dana Farber Institute, which has remained small and focused.

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  Chapter 01: A Sketch of a Family

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Escalante names her family members and sketches their ethnic and economic background (Mexican/Cajun).

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  Chapter 02: Encouraged to Get an Education and Leave a Small Town

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  p>Dr. Escalante talks the value of education in her family and the encouragement she received from her parents to a good education. She tells a story about her mother opening savings accounts for her children, to be used specifically for a college education.

  Dr. Escalante next talks about two woman who mentored her in high school, confirming that she had the ability to excel and encouraging her to become a doctor. She explains what she found exciting about a medical career. She finishes this segment with memories of her two mentors and their responses when she sent them each a copy of Legends and Legacies: Personal journeys of women physicians and scientists at MD Anderson Cancer Center, a collection of essays by women physicians and scientists at MD Anderson.

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  Chapter 03: Deciding to Practice General Internal Medicine

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante explains how she chose to attend Nicholls State University in Thibodaux, Louisiana (BS, Chemistry 1981). She notes the lack of direction she had in making choices because of her own inexperience and the lack of informed support in her family and the small town where she was raised and educated. She also talks about the concern with money at the time. She worked throughout college and asked her family physician about jobs. She eventually worked as a ward clerk in a local hospital and Dr. Escalante explains how this experience added to her understanding of what medical practice involved. She also explains that she majored in chemistry, as opposed to biology, because she was attracted to the “rigor and challenge” of chemistry. She notes that she always had to work hard to excel, but wanted to distinguish herself.

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  Chapter 04: Selecting a Medical School

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Escalante explains why she chose to go to Louisiana State University for medical school (MD 1985) and how she was suddenly competing with other top students and had to adjust to not always being the best in the class. Next she describes how her rotations at Charity Hospital led her to focus on Internal Medicine. She speaks at length about the negative impression she had of surgery because of her rotation. She found Internal Medicine the most stimulating because it was intellectually challenging and involved looking at the whole patient.

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  Chapter 05: Uncertain about a Career at MD Anderson

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante explains her career moves as she was nearing the end of her residency and describes the process that brought her to MD Anderson in 1988, to be part of the new Section of General Internal Medicine headed by Edward Rubenstein. She recalls that she had done a rotation at MD Anderson when she was an intern and found it very difficult to adjust to a context in which patients were doing poorly. When a position opening in 1988, she wasn’t certain it would be a good fit, but decided to take the job for a year to think things out.

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  Chapter 06: The New Section of General Internal Medicine in the Late Eighties

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante talks about MD Anderson’s section of General Internal Medicine (GIM), the first to open in the country. She explains the roles that GIM physicians serve in treating oncology patients and the supporters of GIM at MD Anderson, though it was novel for internists to be on staff at a cancer center. Dr. Escalante explains her daily routine and notes the increasing for services. She talks about the role of GIM in Station 19 (the Emergency Service). She traces changes in how internists’ services were tracked and charged for.

  She notes that her appointment at that time was 100% clinical, with no protected time and no discussion with her superiors of how to move to promotion. (She notes that GIM faculty were considered “help.”)

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  Chapter 07: Choosing to Stay at MD Anderson

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante describes why she decided to stay at MD Anderson despite her original misgivings. A primary consideration: she like the people and the patients. Dr. Escalante explains how oncology patients have taught her a lot and helped her “reset her life priorities.” She also explains that she would never have predicted a career for herself that included academic medicine. She also notes that it was of benefit that she didn’t fully visualize her future, as this kept her open to opportunities.

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  Chapter 08: Learning to Build a Research Career

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante next describes how she expanded her career vision to include a research program, noting a few mentors, but the general lack of attention to career development within her department. She explains that Dr. Robert Bast [Oral History Interview] came in as Head of the Division of Medicine and changed the requirements for promotion, raising the standards for publications. She describes the process she went through to learn how to write reviews and research papers without formal mentoring.

  Dr. Escalante then explains that Dr. Andrew von Eschenbach helped further her career by arranging for her first administrative appointment on the Disaster Committee (which she eventually chaired). She observes that committee work provides valuable opportunities to network and learn about the institution.

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  Chapter 09: Research into Dyspnea

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante explains that her first research focused on symptoms that patients presented in the emergency service, Station 19. She first looked at dyspnea, combing through records to discover what kinds of patients presented symptoms of shortness of breath, eventually developing a derivation model that predicted who would die from dyspnea, a signal that “the end is coming.” She explains the significance that this information could have for physicians, patients, and families making end of life treatment decisions. Dr. Escalante explains that she conducted this research with very little money (none at the beginning) and learned research methods from the bottom up. She describes the impact her findings might have had, but observes that in practice this information is not used enough to have long term impact.

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  Chapter 10: Research into Cancer-Fatigue

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante describes cancer-fatigue then tells how MD Anderson established the first cancer-related fatigue clinic in 1998. She describes services that patients received and notes that the MD Anderson clinic served as a model for others all over the world. She explains what was offered for patients: treatment for depression, anxiety, sleep deprivation, “cheerleading”, and advice about exercise. She notes that she enjoyed the level of interaction with patients and the confirmation that “we can make a clinical difference”. Dr. Escalante explains that, at first, she served as medical director and both managed and staffed it on her own. She and others are now working on national guidelines for treating cancer fatigue and she has given lots of interviews and lectures for other providers and patients. She describes how the clinic really functioned as a “virtual multi-disciplinary clinic” with connections in services all over MD Anderson.

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  Chapter 11: Research into Venous Thrombosis

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante explains that she is the Site Principle Investigator for a national study investigating how to treat blood clots in cancer patients. She explains why cancer patients develop clots and describes the results: the superiority of low molecular weight Heparin over Coumarin (Warfarin). Heparin is now standard of care and covered by insurance.

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  Chapter 12: Research on Hypertension, A Side Effect of Inhibitors

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante describes her studies of hypertension control, work begun when inhibitors were prescribed to cancer patients. She talks about the severity of the hypertension and the research questions that she posed. Dr. Escalante explains that her team began to do data-mining to design prospective studies and also collaborated with clinical trials to study side effects. She describes the process of acquiring data from data pools and patient charts. She also compares the electronic medical records systems, EPIC and ClinicStation. Dr. Escalante notes that she will be presenting this work at a conference this June. She also explains that this information will help community physicians treating patients and survivors as well as providing opportunities to inform the public and health professionals about drug toxicities.

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  Chapter 13: General Internal Medicine: From a Section to A Division and Department

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante notes evidence that it has taken a relatively long time for internists to be accepted as part of oncology teams. She lists the individuals she recruited to the Department of General Internal Medicine once funding began. She says she is pleased with the progress this young Department has made in the past nine years.

  Dr. Escalante sketches the history of the Division and the Department of General Internal Medicine, noting increasing acceptance of generalists. She explains that “we need a team approach to take care of these patients.” She discusses ways in which MD Anderson is far ahead of other institutions in allotting resources to General Internal Medicine and notes the creations of support care teams that provide patients with services not available at other cancer centers.

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  Chapter 14: Section Chief and Department Head: Learning to Lead

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante begins this segment with a description of how she replaced section chief Ed Rubenstein in 1997 because of complaints about his leadership. She explains that morale was very low in the section during this difficult time for her and for the section. A central problem: when she replaced Dr. Rubenstein, she was also promoted above him. Dr. Escalante next talks about the challenges she faced during this period when she had to cope with a great deal of conflict within the section. After a year, she explains, she went to her supervisor, and Dr. Rubenstein was moved to another section. Dr. Escalante talks about her leadership style: she stresses consensus, but she is also a decision-maker. She has learned a great deal about organizing administrative structure effectively and also cultivates leadership talent within the department.

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  Chapter 15: A New Department is Created: Growing the Department

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante explains how she came to be Department Chair once the Section of General Internal Medicine was reorganized as a Department within the Division of Internal Medicine. She applied internally during the search process, which lasted until 2005, a difficult period in which she was a leader, but without any resources to build the Department. In 2005 she received a package and was able to develop both research and clinical activities. She gives an overview of what has been accomplished in the last nine years. Next she notes that Dr. Robert Gagel instructed her to build a research program. She reports that he also told her that he never thought she would be able to do it and speculates that this was a gender-motivated comment and might also have been influenced by the fact that she does not have an Ivy League degree.

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  Chapter 16: The Hospitalist Program

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante talks about the Hospitalist Program, beginning with the need that this program addresses. She talks about controversy over integrating hospitalist support to care teams. She lists supporters of the Hospitalist Program and those who are interested in establishing a connection with the service. She talks about the three existing service teams and explains the difficulties that an internist can face working as part of an oncology team. She explains how a focus on general internal medical conditions has resulted in a different process for admitting patients. She notes that the Hospitalist Program is one of the most important in the Division and how its services will be important to bundled care structures as it decreases the number of consults.

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  Chapter 17: Developing Educational Initiatives in the Department of Internal Medicine

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante explains her educational mission as Department head. She talks about programs to develop educational initiatives to the same level as research and clinical programs. She notes that, in collaboration with Sai-Ching [Jim] Yeung and Robert F. Gagel she wrote the textbook, Medical Care for the Cancer Patient. She actively attends conferences on cancer patients and survivors. She notes that Dr. Jeong Oh received an Educator of the Year award. She explains that everyone in the Department has exceeded her expectations and her success is due to her good faculty.

  Next, Dr. Escalante explains what remains to be done to develop the Department: build up the Hospitalist Program, invest in research, and develop the Suspicion of Cancer Program, which enables patients to obtain a diagnosis and get care at MD Anderson.

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  Chapter 18: Developing Station 19 and the Emergency Medical Center

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  She explains the administrative re-structuring of Station 19 as well as changes in physical location. She explains the staffing of the Emergency Center and the challenges of hiring faculty for these positions. She recalls Station 19 when she first worked there and notes the growth and improvement in treatment of patients since that time. She explains that, in 2010, Dr. Robert F. Gagel decided that the Division of General Internal Medicine was too big and split Emergency Medicine into a separate department, with positive results. She notes that Chairman Dr. Todd is developing a research program and filling clinical positions. She also notes that the economic crisis has created a lot of stress in the emergency service.

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  Chapter 19: A Chemotherapy Clinic to Serve the World’s Largest Ambulatory Clinic Center

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Escalante explains her role as Medical Director of the Chemotherapy Clinic. She notes that services have grown immensely and that the Clinic serves the largest ambulatory clinic in the world.

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  Chapter 20: Work on Significant Committees: Disaster Committee; Transfusion Committee; Medical Practice Committee

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Escalante explains that the committees she worked on helped her grow as a leader, with each being a step up in importance. She mentions the Disaster Committee and Transfusion, then goes into detail about some of the issues examined when she served on the Medical Practice Committee. She also explains how this committee worked with the JCHO in the credentialing process and notes her role on the Credentialing Committee, indicating the types of issues addressed. Dr. Escalante explains the lessons she learned from this process and explains that this kind of close review of processes have led to evaluation of quality of care, formalized with hiring of Quality Officers. Dr. Escalante then sketches the leadership skills she acquired through her committee work.

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  Chapter 21: Changes for Women at MD Anderson

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante provides an overview of the status of women at MD Anderson.

  She begins by talking about what Margaret Kripke, Ph.D. (Oral History Interview) contributed to the institution after her arrival in 1984. She also points out what needs to be done, particularly in seeing women represented in executive leadership, and notes the contributions of Elizabeth Travis, Ph.D. who administers the Office of Women Faculty Programs designed to promote women. Dr. Escalante explains what she believes women bring to leadership.

  Next Dr. Escalante notes generational differences in attitudes about family and work/life balance. She talks about her own difficulties in arranging time to address family issues in a Department that was inflexible about scheduling meetings. She cites changes to tenure clock policies as an indication of positive progress and notes that younger women have started a faculty moms’ group.

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  Chapter 22: Changes at MD Anderson Under a New President: for the Institution and General Internal Medicine

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante offers observations about changes that Dr. Ronald DePinho has brought to the institution after assuming the role of president in 2011.

  She first discusses Dr. John Mendelsohn’s contributions to the institution, recalling times of uncertainty. Today, she explains, there are shifts in leadership at the senior level and a lack of information from senior administration about budgets and institutional directions has made it difficult for her, as a Division Head, to communicate effectively with her faculty and staff.

  Next, Dr. Escalante talks about the uncertain future of the Division and Department of General Internal Medicine, given that “we’re not the group that’s going to cure cancer.” She also notes that the balance between clinical and basic research is shifting, with clinical functions pressured to become much more efficient and funds for research shrinking. She explains that these shifts raise questions about faculty responsibilities, requirements for promotion.

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  Chapter 23: Refining Policies While Serving on Executive Committee of the Medical Staff

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  Dr. Escalante reviews her decade of service on the Executive Committee of the Medical Staff and notes the networking opportunities it offered. She explains how the Committee works and lists some of the issues addressed.

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  Chapter 24: A Girl Scout Leader Pursues Her Passion for Women’s Advancement

  Carmen Escalante MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Escalante explains that she is a very private person, then notes that she is very passionate about women’s rights and providing opportunities for women even in her life outside work. Because of this, she took became a leader of her daughter’s Girl Scout troop. She describes some of the activities organized for the girls and expresses how much enjoyment she derives from this role and from “teaching them to be leaders.”

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  Chapter 01: Education with a Strong Humanities Thread

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  Dr. Ewer begins this chapter by sketching his family background: German parents who met in England, a father who was a lawyer and a communist agitator in Nazi German, and a physician uncle who had a great influence on him.

  Next, Dr. Ewer begins to recount his educational path, noting that he originally intended to be a violinist and attended the High School of Music and Art in New York. He explains his continued participation in music despite his decision not to continue with training in this area once he went to Hunter College [Bronx, New York; BA, 1964]. There he majored in chemistry and credits his father with solidifying his decision to go to medical school at the University of Basel in Basel, Switzerland [MD, 1969]. Dr. Ewer explains his choice to minor in theology to take a philosophical approach to human nature. He talks about features of Swiss medical education, which stressed the clinician’s ability to take care of people. He comments on living overseas.

  Next, Dr. Ewer explains the evolution of his interest in anatomy and the opportunity he had to work with the famous surgeon, Rudolph Nissen, then at the University

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  Chapter 02 : Residency Training and Trials

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ewer covers his post medical school experiences, beginning with his Rotating Clinical Internship at Norwalk Hospital in Norwalk, Connecticut (1970-1971). He talks about his work in internal medicine and pediatrics and tells anecdotes about medical education at that time.

  Next, he notes that he undertook his Junior Residency at Norfolk General Hospital in Norfolk, Virginia (1972-1973). He then explains how he came to be fired from that position.

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  Chapter 03: Two Years on the “Love Boat” and Reflections on a Dissertation

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  Dr. Ewer begins this chapter by noting that he needed a job in a hurry after being let go and found a position as a staff physician (1972 – 1974) on a Princess Cruises ship (which served as a model for the ship in the television series, the Love Boat).

  He tells several stories from his work on the ship and also comments on how this position expanded his medical practice: he set up a water potability testing lab and an ICU on board the ship. He talks about the success of these ventures and notes that the water potability studies were his first bona fide academic pursuit. He explains that he technically received both and MD and a PhD in medical school, he does not count his brief dissertation as true research, even though he made a discovery considered significant.

  He also notes that the ICU was established primarily to treat older patients and explains that he had worked in a nursing home earlier in his career to pay for flying lessons.

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  Chapter 04: A New Residency Program and Thoughts on Challenging the Status Quo

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ewer explains why he left his job with Princess Cruises returning to his medical education with a Senior Residency at Pawtucket Memorial Hospital at Pawtucket, Rhode Island, where he also served as chief resident (1974-1975). To demonstrate his belief in questioning the status quo and conventional ways of operating, he tells an anecdote about a choosing a controversial and unorthodox stress test he applied to assess cyanosis in his own son. He goes on to talk about the importance of assessing how much of medical treatment actually benefits the patient.

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  Chapter 05: A Fellowship in Cardiology at Baylor University Medical Center, Dallas

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ewer discusses his fellowship in Cardiology at the Baylor University Medical Center (Dallas, Texas, 1975-1977).

  He notes that he was very intrigued by the new cardiac ultrasound capabilities being developed (and set up the first echocardiogram progam? At MD Anderson). He explains that during his fellowship period, he was very focused on assessing the value of cardiac interventions, given that there was no data about how various interventions effected outcomes.

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  Chapter 06 : Building Intensive Care at MD Anderson

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  Dr. Ewer begins this chapter by explaining how he found out about an opening at MD Anderson and the interview and selection process. He joined the institution in 1978 and notes that he only expected to be at MD Anderson for six months to work on the cardiotoxicity of chemotherapeutic agents.

  He then talks about how he assumed the de facto leadership of the intensive care unit, a role he served until the early 1990s. He talks about a prevailing attitude that had an impact on the perceived value of intensive care: that cancer is more interesting in the early stages, when medicine could have more impact than at the end of life. He talks about the growing acceptance of critical care at the institution and also recounts advice he received from Robert Benjamin, MD [oral history interview], who told him never to get tunnel vision about medicine. He talks about working with Dr. Benjamin on a heart biopsy program and conducting two thousand procedures with no deaths.

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  Chapter 07: A Shift in Philosophy and the Growth of Medical Ethics at MD Anderson

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  Dr. Ewer begins this chapter by explaining that in the early eighties, as a result of his work in intensive and critical care, he began to develop the philosophy that clinicians shouldn’t assume that anyone wants to be in intensive care on a ventilator to die. He speculates that intensive care at MD Anderson may have been the first setting to develop a process of “terminal weaning.” He notes how controversial the practice was, but that his group prevailed in gaining acceptance for it. He next talks about two important figures in ethical care at the institution: the head of the chaplaincy program, Sister Alice Potts, and Jan Van Eys, MD, a former head of the Ethics Committee.

  Next he talks about his own role on the Ethics Committee (formed in the early 80s prior to the national mandate for academic institutions to have such a body). CLIPS He gives examples to demonstrate the conventional approach to ethical issues at the time and his new approach that considered ethical cases as an appeals court. One of these cases highlights MD Anderson’s relationship with drug companies and how these contextual factors can influence ethical decisions.

  Next, Dr. Ewer explains his view of why the Ethics Committee was disbanded and how this indicates the relationship between the practice of ethics and the administration of healthcare in the institution.

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  Chapter 08: The Ethics Committee at MD Anderson, Part I: an overview

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  Dr. Ewer begins this chapter by stressing that MD Anderson has always been interested in ‘doing the right thing for patients.’ He goes on to sketch how that desire was first formalized when the Ethics Committee was formed under President Charles. A. LeMaistre [oral history interview]. Dr. Ewer sketches the membership of the committee. He then talks about the main types of policy issues the Committee worked on during the period when he was a member and chair (1985-1993; 1988-1993). First he discusses the committee’s development of a “decision triangle” to determine the weight that patient/family input should have in medical decision making. Next he talks about how MD Anderson stopped the current (in the 80s) “go slow” code in use at many institutions. Next he explains why the Ethics Committee decided not to become involved in the IRBs and examine issues in research protocols, but focused on clinical situations.

  Dr. Ewer notes that the Committee made many controversial decisions, which eventually led to its disbanding (as sketched in the last session). He discusses two cases of controversy.

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  Chapter 09: The Ethics Committee at MD Anderson, Part II: Practicing Ethics in a Context of Innovation

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  Dr. Ewer begins this chapter by discussing some political infighting in the Ethics Committee. He then goes on to describe how much of the committee’s work was conflict resolution. He gives an example to demonstrate.

  Next, Dr. Ewer explains how pushback against Ethics Committee recommendations was often philosophical and rooted in the prevailing mindset that “a patient who doesn’t survive is a failure.” He explains that that mindset cannot serve the institution as cancer care and healthcare environment has evolved over the last 40 years. CLIP He also talks about the challenges of balancing ethical concerns with the creative impulse to push the research envelop that is also so important to the institution.

  At the end of this chapter, he expresses concerns for the institution, its financial health, and how MD Anderson might be positioned for a takeover, which would destroy its research identity.

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  Chapter 10: Ethics after the Ethics Committee

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ewer sketches how ethics evolved at the institution after the Ethics Committee was disbanded in 1993. He explains that Rebecca Pentz, PhD, was appointed head of ethics (though was uncertain if it had been formalized as a department at that time) and recounts a story to demonstrate how her perspective on handling ethical situations differed from his own. He notes that some of the original members of the disbanded ethics committee joined Dr. Pentz’s group.

  Next he talks about Colleen Gallagher, PhD, who came to MD Anderson in XXX to head the Department of Integrated Ethics. He describes the leadership she has built and notes similarities in their perspectives. He talks about their collaboration on a book.

  Next, Dr. Ewer explains his terms, “macro ethics and micro ethics.”

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  Chapter 11: Bringing a Legal Perspective into Ethics Work

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ewer explains why he earned a legal degree (JD 2001, Advanced degree in Health Law) and the impact it has had on his thinking about ethics. He begins by how he first thought of law school when he worked for Princess Cruises because of a chance encounter with Earl Warren, former Chief Justice of the Supreme Court. He sketches the process of getting into law school at the University of Houston then gives examples to demonstrate how this perspective has shaped his thought.

  Next, Dr. Ewer talks about his roles as Special Assistant to the David Callendar (1994-1997), the VP of Patient Care.

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  Chapter 12: Views on Changes at MD Anderson

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ewer offers his perspective on how the institution has changed since 2011. He offers his view of Dr. Ronald DePinho’s vision for developing MD Anderson’s research capacity and the struggles the institution had implementing this during a period of financial change in healthcare. He then talks about offering his services to Dr. Peter Pisters, the new president of MD Anderson.

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  Chapter 13: Research on Cardiology

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ewer sketches his research on the cardio-toxic effects of chemotherapy. He tells the story of one set of trials focused on Herceptin. He talks about formulating a controversial theory of Type 1 and Type 2 cardiotoxicity. At the end of the chapter, he sketches his formal retirement in 2013 and changes to his partial appointment thereafter.

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  Chapter 14: Final Comments

  Michael S. Ewer MD and Tacey A. Rosolowski PhD

  Dr. Ewer begins this chapter by looking back at the impact he feels he has had on the institution. He notes that he wishes he could have had more of an impact on young faculty in cardiology, helping them to think outside of the box in the ways that are essential to address cardiac issues in cancer patients. He notes that he is currently working on a case study of basal cell carcinoma. At the end of the session, he comments on the profession of oncology.

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  Chapter 01: From Veterinary Medicine to Cancer Research

  Isaiah J. Fidler DVM, PhD and Tacey A. Rosolowski PhD

  In this Segment, Dr. Fidler talks about his youth in Israel, the decision to study veterinary medicine that brought him to the United States in 1958, and the later events that inspired his shift from veterinary medicine to the study of cancer in humans. In 1961 he received his B.S. in Veterinary Medicine at Oklahoma State University, Stillwater, Oklahoma. Dr. Fidler was awarded his Doctorate in Veterinary Medicine from the same institution in ’63. He describes the difficulties of setting up a veterinary practice upon returning to Israel, where pet owners chose to terminate the lives of even beloved pets much more quickly than they do today. “I didn’t work so hard to become an executioner,” he recalls, explaining decisions that took him from private practice, to pharmaceutical research, and eventually back to the U.S. for a fellowship at the University of Pennsylvania Veterinary School, where his work on animals with cancer sparked his passion for problems of metastasis. After receiving a fellowship that enabled him to conduct basic research at the U. Penn. Medical School, he was advised to apply to the Department of Pathology, where many scientists were conducting research on metastasis. He received his Ph.D. in (human) Pathology from the University of Pennsylvania Medical School (Philadelphia) in ’70. There he framed the basic question that would govern his career: how cancer moves from the primary tumor via the circulatory system to create secondary tumors and ultimately the metastases that are still the primary killers of cancer patients. After receiving his Ph.D., he went to work in the Department of Pathology in the U. Pennsylvania Dental School with a Luther Terry Fellowship(late ’70).

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  Chapter 02: A New World of Research at University of Pennsylvania: Focusing a Research Career

  Isaiah J. Fidler DVM, PhD and Tacey A. Rosolowski PhD

  Dr. Fidler details how he began to look more deeply into the question of cancer cell differentiation, a groundbreaking discovery that was ultimately published in Nature. (Dr. Fidler shows the interviewer a Plexiglas containing a unit he invented to facilitate injection of cells into the tail veins of up to 100 mice per hour, underscoring the resourcefulness that a researcher had to have to move ahead quickly with a study.) Through this success, he was recruited to join the National Cancer Institute at Frederick, Maryland. His wife-to-be, Margaret Kripke, known for her pioneering work in photoimmunology, was also hired in a concurrent recruitment, and he describes how Dr. Kripke challenged him with the question that inspired a new line of research: “How do you know whether the cells you are culturing from a line are a selection or an adaptation?” His discovery that the differentiation of metastasis cells is a priori “revolutionized the world,” he states, noting that “you cannot treat a heterogeneous disease with homogeneous therapy” –the origin of individualized therapy. Dr. Fidler then explains connections between Paget’s “seed and soil” theory and his next experiments with transplanting metastatic cells between the organs of mice.

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  Chapter 03: Metastasis: A Regulated Process

  Isaiah J. Fidler DVM, PhD and Tacey A. Rosolowski PhD

  Dr. Fidler begins this segment by explaining that, in contrast with the prevailing belief (in the 70s) that cancer is the “ultimate expression of cellular anarchy” and that metastasis is random, his work has shown that cancer is a regulated process along every step of the way; similarly, metastasis is predictable. In response to a question about why scientists held (and still hold to) these conventional assumptions about cancer, Dr. Fidler notes how difficult it can be for a scientific community to accept innovative ideas. He then talks about significance of training clinicians in research and the basic sciences.

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  Chapter 04: Reflections on Research; Becoming a Citizen; Influences: Words of Wisdom

  Isaiah J. Fidler DVM, PhD and Tacey A. Rosolowski PhD

  In this character-revealing segment, Dr. Fidler talks about his ability to think outside the box. He recalls becoming a citizen and some of the cross-cultural challenges he faced. He recalls family members who influenced his independent thinking. He reflects on the contributions he has made to his field and the influence of Dr. Judah Folkmann on his thinking.

  He ends this session by talking about the implications of his discoveries for research, its links to the current push for individualized care. He also questions how quickly they have been translated into therapies that will benefit patients.

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  Chapter 05: Recent Research: A Focus on Brain Metastasis

  Isaiah J. Fidler DVM, PhD and Tacey A. Rosolowski PhD

  Dr. Fidler discusses his research focus for the last four years: brain metastasis. He emphasizes that very few researchers focus on brain metastasis, largely due to the complexities presented by the blood-brain barrier. Dr. Fidler explains that the blood-brain barrier is already compromised in metastasis, a fact that has implications for treating as well as studying the condition. He discusses his work on astrocytes, which protect tumor cells from chemotherapy, until he and his group discovered a drug (now patented) that interrupts the astrocyte’s protective activity.

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  Chapter 06: Brain Metastasis: Activating the Body’s Capacity to Heal Itself

  Isaiah J. Fidler DVM, PhD and Tacey A. Rosolowski PhD

  Dr. Fidler begins this segment by noting his roles as the president of the International Differentiation Society and as the youngest president of the American Association for Cancer Research. He talks about how leadership of professional societies. He then returns to a discussion of the mechanisms of brain metastasis. He notes that the death of his friend, Judah Folkman, led him to re-evaluate his life and step down from his administrative responsibilities, a move that left him with more time to think about his research and investigate the role of astrocytes. He believes that intervening in the role of astrocytes in interacting with the genetics of metastatic cells has implications for treatment of many different diseases as well as other forms of cancer. He then turns back to a discussion of his work on activating macrophages to attack metastasis, quoting from “The Doctor’s Dilemma,” a play by George Bernard Shaw (1911), to dramatize that the body has all it needs to cure itself: “Nature has provided in the white corpuscle… a natural means of devouring and destroying all disease and germs…. Drugs are a delusion.”

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  Chapter 07: Translational Research at MD Anderson

  Isaiah J. Fidler DVM, PhD and Tacey A. Rosolowski PhD

  Dr. Fidler explains that changes at NCI had threatened to limit his research freedom and motivated his move in 1983 to MD Anderson, where collaboration with clinicians was fostered: his main goal at that time was to understand metastasis at a clinical level. He speaks about his work training clinicians, many of whom now work at MD Anderson. In the final fifteen minutes of the session, Dr. Fidler tells an amusing anecdote about how he came to occupy the R.E. “Bob” Smith Distinguished Chair in Cell Biology (as his wife, Margaret Kripke was simultaneously offered the Vivian Smith Distinguished Chair in Cell Biology). He describes his relationships training Japanese and Korean clinicians, and notes that the work at MD Anderson he is most proud of is training the next generation. He closes with an anecdote about his most significant award, though he also quotes words attributed to King Solomon: “Don’t do things for the sake of an award.”

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  Chapter 01: An Interest in Sports Shapes a Fascination with the Body

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch begins the interview by sketching his family background and then talking in detail about his lifelong interest in sports. He explains that he “understands the world through sports and sports metaphors.” He explains the process of visualizing how to execute a series of plays and links this to mindfulness skills he would become interested in as a medical professional. He cites his mentor, Dr. Waun Ki Hong [Oral History Interview] who told him (ironically) that his job is “easy,” since meeting healthy goals is a step-by-step process. He observes that his interest in sports probably led to his fascination with the physical body.

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  Chapter 02: An Early Desire to Become a Doctor and a Range of Interests and Gifts

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch recalls that he decided to become a physician at the age of eleven, inspired by physicians on TV shows. He notes that his grandmother took his interest very seriously and bought him Gray’s Anatomy. He also observes that he was “drawn to complexity” very early and that this interest became a theme in his career.

  Dr. Fisch talks about his high school experience, recalling that he was a motivated, hard worker with many extracurricular activities. He also explains why he considers himself a creative person, noting that his style creativity lends itself to working in groups, a characteristic important for conducting team science. Dr. Fisch explains that he loves team science for the way it brings together people from different disciplines. He makes observations about his inspirational style of leadership, noting that his love of leadership roles began in high school. He also notes that he is at his best when he is in the state referred to as “flow.”

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  Chapter 03: Challenges in College and Medical School; Seeking a Specialty

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this chapter, Dr. Fisch talks about selecting his college (University of Virginia at Charlottesville, BA conferred 1986) for financial reasons and explains the value of a state education. He notes that he was not a top student and had to work very hard as an undergraduate. He notes that he discovered his lack of visual/spatial ability, which made certain courses very difficult and caused him to consider a career in nursing.

  Next, Dr. Fisch talks about his medical education at the University of Virginia Medical School (MD conferred in 1990), noting how he loved surgery, but his lack of visual/spatial ability made this specialty impossible for him. By working with surgeons, however, he learned to love clinical medicine and post-operative patients in particular because they were “endlessly complicated.”

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  Chapter 04: Early Research Experiences Leads from Infectious Diseases to Hematology/Oncology

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch describes the evolution of his interests leading to his focus on oncology.

  He discusses a college research projects and tells an anecdote about an ethical mistake he made while interacting with participants.

  Next, Dr. Fisch explains that he discovered hematology/oncology during his rotations and he was attracted to the field because it afforded the opportunity to build long-term relationships with patients and their families. He also notes that he was inspired by experiences of an uncle and his grandfather with cancer.

  Dr. Fisch explains why he tracked into hematology/oncology and was always focused on academic medicine and a career in research. He describes his studies in medical school reflects on his residency (Internal Medicine, University of Virginia, 1990-1993).

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  Chapter 05: Bringing Focus to Patients’ Emotions

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this chapter, Dr. Fisch describes the process of entering a fellowship program in Hematology/Oncology and General Internal Medicine at Indiana University at Bloomington. He then explains that it was during this time that he became interested in “things that were happening to cancer patients that we weren’t talking about.” He gives examples, first discussing the problem of depression in cancer patients. He then explains that on the transplant service, patients were uniformed about treatments and he did a project on the effect of informed consent on emotions.

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  Chapter 06: Entering the New Field of Symptom Experience

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this chapter, Dr. Fisch explains how his career path evolved once he decided, during the second year of his fellowship, to focus on symptom experience. He was involved in a research project on cisplatin adducts when he decided to focus on quality of life research and realized he needed additional training to work in this new field. He took another fellowship in general internal medicine and worked with Dr. Robert Diddis, who advised him to do a Masters in Public Health (Indiana University, Bloomington, Indiana; MPH conferred in 1997). He explains how this training benefited his approach to quality of life problems.

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  Chapter 07: Coming to MD Anderson to Learn Palliative Care on the Job

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this chapter, Dr. Fisch explains how he moved to MD Anderson from a position as Assistant Professor at the University of Virginia Health Science Center in Charlottesville. He recalls management issues in Charlottesville that helped convince him to take another position. He talks about presenting a paper on cancer and depression at a conference held by the American Society of Clinical Oncology. There he met Dr. Eduardo Bruera, who had been recruited to set up a palliative care program at MD Anderson. Dr. Fisch describes the advantages of the offer he was made to join MD Anderson to help establish that program, working from the Department of Critical Care and Anesthesiology.

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  Chapter 08: Building a Palliative Care Program at MD Anderson

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this chapter, Dr. Fisch talks about the challenges faced as he and others set up palliative care program at MD Anderson from scratch. He defines palliative care, which he stresses is much broader than pain management. He also explains how the culture of MD Anderson worked against acceptance of palliative care. Dr. Fisch notes that the palliative care program stressed quality of life and that a decision was made to change the name to the Supportive Care Center to help overcome resistance . He gives examples of how he and other palliative care providers would figure out how to “create an interface” with treating oncologists, so they would integrate a palliative care provider into the team.

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  Chapter 09: A Precarious Time for the Palliative Care Program

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this chapter, Dr. Fisch talks about a period when the Palliative Care Program seemed less valued than anesthesiology and the administration was splitting off groups from the department of Anesthesiology and Critical Care. He recalls that Dr. Bruera interviewed for a new job and he himself began calling about positions in Virginia. He tells an anecdote about where he was on 11 September 2001. He explains why he remained at MD Anderson and how, after a meeting with leaders, the situation for the department and program seemed to improve.

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  Chapter 10: Building the Reputation of Palliative Care

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this chapter, Dr. Fisch sketches how the talented team in palliative care was successful in securing regular referrals from a few oncologists, building the program’s reputation. He tells anecdotes about the surprising and positive results they would get from integrating palliative approaches into treatment protocols.

  At the end of this chapter, Dr. Fisch shares lessons he learned about how to interact successfully with oncologists to ensure they would call on him as a palliative care providers.

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  Chapter 11: Defining the Scope of General Medical Oncology

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch begins with an explanation of why he felt like a disciplinary “refugee” when he arrived at MD Anderson and joined the Department of Critical Care and Anesthesiology.

  He then defines the purpose and scope of General Medical Oncology as a practice: the long-term care of patients with cancer when overall care is the focus, including delivery of pharmaceuticals and injections and after care following surgery, radiation or chemotherapy. The GMO clinician work with a patient over a lifetime. He notes some controversy in the field over when the GMO clinician “lets go” of a patient who is transitioning to survivorship.

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  Chapter 12: Reimbursement for General Medical Oncology; the Value of Generalists in a Field of Subspecialties

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch begins this segment by explaining the challenges of arranging insurance reimbursement for services and value that general medical oncologists deliver. He also notes that losing connection with the GMO clinician can be very setting for a patient, and he gives examples of problems that can arise.

  Dr. Fisch also explains that “people’s health stories are not completely oncology.” They often have co-morbidities and challenges can arise in bringing together specialists to fully treat a patient. In a fragmented system organized by subspecializations, often the patient must serve as “project manager” of his or her own care.

  Next Dr. Fisch talks about the value of having a generalist perspective in this situation. He then talks about LBJ Hospital. He comments that eventually generalists will define the pathways into a patients care and then specialists will take over.

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  Chapter 13: The Community Clinical Oncology Program (CCOP)

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this segment, Dr. Fisch talks about the history of the Community Clinical Oncology Program (CCOP). (He has served as Medical Director since 2004.) He notes NCI involvement providing funds for community based initiatives and explains the purpose: to develop clinical trials linked to the community contexts where eighty percent of patients are treated. He characterizes MD Anderson’s reputation as a “solution shop” driving treatment, with the CCOP’s different approach to treatment and research, including that community practice has something to teach about treatment.

  He then notes that, as Medical Director, he served as a facilitator and broker for trials. He talks about how CCOP trials and research worked at MD Anderson, including how biases against randomized trials worked into the planning process, with efficacy trials conducted with MD Anderson patients and Phase 3 trials conducted in the community. He gives an example.

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  Chapter 14: The Community Clinical Oncology Program (CCOP); Transitioning to Research in Cancer Control and Prevention

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this segment, Dr. Fisch explains how research conducted via the CCOP transitioned from a focus on treatments to a focus on prevention, cancer control, and symptom management.

  He first talks about his role as a facilitator setting structures for research collaborations. He notes that community settings offered a comprehensive view of patients, driving his own interest in symptom management. He talks about the overlap of different specialties whose borders are all debated. He illustrates with the example of pain management.

  Next he sketches the factors that led to his decision to “sunset” the treatment focused trials. He was partnering with Dr. Blyer, who shared his vision. The NCI was also requiring that more research focus in these areas. Many regional research groups were putting together trials focused on prevention and control.

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  Chapter 15: The Community Clinical Oncology Program (CCOP); Finances, Organization of Research, Some Examples

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch begins this segment by noting that he began looking for experts to begin developing the new focus of the CCOP. He explains why MD Anderson physicians need community based patients.

  He explains finances: the program pays for the infrastructure, not the drugs and other related costs. He discusses strategies researchers use to address this challenge. He gives an example of a trial run by Dr. Lorenzo Cohen comparing the impact of meditation versus relaxing music on patients’ inflammation cascade. He discusses how to convince community physicians of the value of such studies.

  Dr. Fisch notes his role as facilitator and stresses the importance of being respectful of the research issues that behavioral scientists confront. He gives some examples.

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  Chapter 16: A New Department of General Medical Oncology

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  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.

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  Chapter 17: Concern about the MD Anderson Brand as the Satellite System Grows

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch responds to a question about the growing acceptance of General Medical Oncology at the institution.

  He first explains the concerns about brand and quality of care that faculty have had as the satellite system grows. Dr. Fisch explains decisions that had to be made about protocols offered in satellite centers. He talks about his own view of the controversy and notes that it takes skill to work with community people and subspecialists alike.

  He notes that “the MD Anderson story has been about subspecialization” and “becoming like our competitors is difficult.” He explains that MD Anderson’s general medical oncologists have raised the bar of care in the community and at the satellite centers. He also stresses the importance of building shared research programs and harmonizing budgets to stress that satellite centers create a shared win for MD Anderson rather than competition.

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  Chapter 18: Accomplishments at MD Anderson and a New Career Opportunity

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch then talks about his plans to leave MD Anderson for a position as Medical Director of Medical Oncology Solutions at Ames Specialty Health in Chicago, Illinois. He notes that, with changes at the institution, general oncology and cancer control are not top priorities, and he wanted a new opportunity to rise to the next level.

  Dr. Fisch talks about the skill set he will bring to Ames, where he will be assessing value-driven quality care. It is also an opportunity for him to learn a great deal, saying “It will be like doing a fellowship in managed care” and give him an opportunity to have an impact on care.

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  Chapter 19: International Travel and Providing Team Care to VIP Patients

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch notes that global oncology has become an increasingly important dimension of MD Anderson’s business. He explains that, as MD Anderson set up links with international partners, he helped them set up team-based treatment plans, multi-disciplinary care, and research. He gives examples of the types of research projects that might be set up.

  Dr. Fisch talks in depth about his participation in international clinical care teams making “global house calls.” He explains that his role was to offer palliative care, manage anxiety, sleeplessness, and rehabilitation, sometimes spending weeks abroad. He notes that these special trips helped clarify the services he could offer as a general medical oncologist and demonstrate their value to the patients and the institution. He also describes how people would receive MD Anderson faculty overseas, which helped increase his own feeling for the institution.

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  Chapter 20: The PREDICT Trial: A Unique Study of Biomarkers for Cardiotoxicity

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this segment, Dr. Fisch talks about the PREDICT trial, a landmark study he conducted in the late 2000s on predictors for cardiotoxicity in patients treated with anthracyclines. He explains the effects that anthracyclines can have on the heart and notes that this is a survivorship treatment issue. The study asked Can you use point-of-care biomarker testing to assess cardiac toxicity of chemo regimens. Dr. Fisch notes that when this project began around 2007, cardiac studies were very new. He describes some challenges enrolling patients (eventually enrolling over five hundred) and reports the outcomes. He says that it was a good descriptive study, unique in the realm of oncology. His role, he explains, was facilitating set up and implementation of the project and executing the trial as part of a team effort.

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  Chapter 21: A Landmark Study on Chemotherapy and Depression

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch begins this chapter by explaining that as Chair of the Eastern Cooperative Oncology Group’s Symptom Management Committee, he wanted to study how to manage patient symptoms, but there was a lack of basic data about symptom experience. This led to a landmark study of more than three thousand patients that surveyed a broad range of symptoms and practice patterns for lung, breast, colorectal and prostate cancers. (He observes that such long-term studies sometimes fail, discouraging some researchers in the process.)

  Dr. Fisch notes that the SOAPP study continues to make a unique contribution. An unusual feature is that the study has a website (http://www.ecogsoapp.com/) to facilitate dissemination of information. Data also is available through twelve published papers, with more coming. Dr. Fisch talks about the difficulties of maintaining the website when money runs out.

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  Chapter 22: An Emerging Field of Cardio-Oncology

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  In this chapter, Dr. Fisch notes that field of cardio-oncology emerged over the last seven or eight years, concurrent with the PREDICT trial. He observes that the field is becoming important because new classes of drugs are cardio-toxic and many of the molecular and genetic pathways involved in cancer are also important to cardiologists. He notes that his own contributions to this field have become increasingly important.

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  Chapter 23: Compassionate Care

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch begins this chapter by defining compassionate care along with the division of labor required between symptom management, communication and inter-disciplinary team work. He stresses that “words matter, how you talk about things matters,” and notes the importance of learning how to ask patients questions to encourage them to tell their story, though current time pressures make this challenging. He stresses, however, that there are skills a physician can learn to make patients feel they are receiving compassionate care.

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  Chapter 24: The Schwarz Rounds at MD Anderson and Mindful Medical Practice

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch talks about the Schwarz Rounds implemented at MD Anderson in 2007. He describes the focus on the experiences of the care providers and the emotions that come up for them while offering care to patients. He explains that the need for the Schwarz Rounds arose because the Medical Oncology fellows were experiencing fatigue and burnout. Dr. Fisch explains why the program stopped.

  Next, Dr. Fisch talks about mindful medical practice, which helps reduce burnout and fatigue among. He gives examples of the stresses of an oncologist’s job. He notes that the value of awareness is increasingly recognized in medicine. He has worked to bring visibility to the issue at MD Anderson by drawing attention to research that shows how mindfulness can ensure delivery of high-quality care.

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  Chapter 25: Exploring Uses of Social Media

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch talks about his fascination with social media and his attempts to introduce its creative use at MD Anderson to communicate more effectively with patients and the public.

  Dr. Fisch talks about his introduction to Twitter and his efforts to use it in healthcare, beginning with the Community Clinical Oncology Program. He explains why ASCO now has a Social Media Working Group. (Dr. Fisch serves on that committee.) Dr. Fisch explains the impact that social media can have on individuals and institutions and stresses the importance of making education about social media part of medical curricula. He states that MD Anderson has made some headway in this area, and he lists the consequences of not keeping up.

  Dr. Fisch next talks about his involvement in a clinical trial that proposed to use social media to increase patient enrollment. He contributed to the grant, which the South Western Oncology Group has funded.

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  Chapter 26: MD Anderson’s Focus on Patient Experience

  Michael J. Fisch MD, MPH and Tacey A. Rosolowski PhD

  Dr. Fisch talks about two initiatives to involve patients as partners in planning processes: the Patient Experience Steering Committee and the Patient and Family Advisory Council. Dr. Fisch notes that though he received invitations to serve on both committees, he was given no charge or mission and there is no natural momentum on patient experience at the institution. He talks about the advantages to the institution of addressing patient experience and notes that MD Anderson’s attention to this matter is a response to an Institute of Medicine report that other institutions are moving ahead.

  Dr. Fisch then observes that if an institution is not patient-centered, shifting focus is difficult. He suggests ways in which MD Anderson communicates that it is not patient centered. He then talks about Leadership Rounds, which help leaders see the institution from a patient’s perspective. He acknowledges that the institution is listening to patients more and coming up with creative ways of reorganizing care.

  At the end of the session, he makes some final comments about working at MD Anderson.

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  Chapter 01: Growing Up in a Small Town; Medical Education

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Dr. Foxhall gives a brief overview of his family life then notes his first interests in science. He touches on his experiences at the Baylor College of Medicine and explains that his interest in primary clinical care and in health populations began at this time, particularly when he spent time in his home town working with family physicians and saw a wide range of health problems. He also cites the influence of school integration –the seventies were a time when the nation was changing and there were opportunities to learn and grow.

  Dr. Foxhall notes that his interest in cancer and cancer prevention grew during his residency and the first years of his private practice at Houston Northwest Medical Center where he was able to follow patients over many years and recognized the missed opportunities to intervene with patient and avert cancer risk.

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  Chapter 02: A Growing Interest in Cancer, Cancer Prevention, and First Connections with MD Anderson

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Dr. Foxhall notes that his interest in cancer (and tobacco) began during his private practice; he mentions other professionals in Houston who were also focusing on tobacco. He lists the projects he implemented during this time and notes his involvement in the Texas Academy of Family Physicians and its subgroups focused on prevention.

  Dr. Foxhall then explains that he met and worked with Dr. Joseph Painter of MD Anderson was also interested in community outreach at the time. He describes the projects the worked on to educate physicians (part of a national movement). Dr. Foxhall also explains that it was key to demonstrate to physicians the value of collaborating with a large cancer center. He explains the previous mindset physicians held about their relationship to cancer centers.

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  Chapter 03: An Opportunity to Leave Private Practice for MD Anderson

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Dr. Foxhall first describes the ways in which he and Dr. Joseph Painter worked together in the late 80s. He then explains why he decided to leave private practice at that time: Dr. Foxhall first took a faculty position with UT Health Science in Family Medicine in 1991. In 1993 Dr. Foxhall was hired to help Dr. Painter with outreach and educating primary care physicians.

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  Chapter 04: MD Anderson’s Outreach Programs—the Physician Relations Programs

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Here, Dr. Foxhall describes what was involved in the Outreach Programs, which resulted in the Physicians Relations Programs. He notes the ill will created immediately after the Texas Legislature’s 1995 decision to allow patients to self-refer. He talks about the scope of the programs set up to preserve patients’ connection to the primary care physician during and after cancer treatment; he also outlines the significance of the primary care physician’s role in this process.

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  Chapter 05: The Charity Care Program

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Dr. Foxhall describes MD Anderson’s work with indigent patients and the Charity Care Program.

  He notes that MD Anderson was founded as a charity care institution and sketches the later history of this obligation. He explains the financial stresses this caused the institution. He explains that he worked with the Charity Care Program to reduce costs while paying for care, helping to stablilize the financial situation. He notes the partnership with the Lyndon Baines Johnson Community Hospital to serve charity cases.

  Dr. Foxhall observes that patients at MD Anderson in general represent the cancer levels in the general population, though MD Anderson sees insured patients and the rates of the uninsured in Houston are very high (1/3 of population). He explains why the level of uninsured is so high.

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  Chapter 06: The Office of Health Policy: Focusing on Outreach

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Dr. Foxhall lays out the history of the Office of Health Policy. He explains that it originated in the need to reach out to community physicians and develop their relationships with MD Anderson. He explains how a team was created to conduct surveys and also to work with programs internal to MD Anderson. Dr. Foxhall explains the issues that community physicians had in sending their patients to MD Anderson, largely in the area of need for more communication with the institution after their patients went into treatment at the institution.

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  Chapter 07: The Office of Health Policy: Focusing on Survivorship

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Dr. Foxhall goes into detail about the Office’s focus on survivorship, including connections with community physicians and mechanisms for survivorship information to community physicians so they can partner in a cancer patient’s after care.

  He explains the origins of the Survivorship Initiative and discusses his role on the Survivorship Committee and other programs designed to create an integrated approach to care.

  He lists health policy challenges that have an impact on survivors. He describes results of studies that have confirmed the benefits of survivorship programs for patients.

  Dr. Foxhall sketches the history of thinking about survivorship. He lists key people at MD Anderson involved in the survivorship program. He also lists some of the places he has been globally (through the GAP program--Global Academic Programs—MD Anderson’s network of sister institutions) to speak about survivorship, stressing that the focus on survivorship is a world issue.

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  Chapter 08: Work that Takes Eternal Optimism

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Dr. Foxhall responds to a question about those particular gifts that suit him and others to policy work. He explains that a focus on outreach beyond the institution is key, as well as a comfort with collaboration. He also talks about the commitment to the institution and to its mission to cure cancer and a commitment to a sense of equity in reaching out to all patients. It’s a challenge financially to do that in an environment of limited funding and requires a high level of patience, persistence, and optimism to move issues forward.

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  Chapter 09: Associate Vice President of the Office of Health Policy

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Dr. Foxhall talks about his role as Associate VP for Health Policy.

  He defines the scope of “health policy” and gives examples of policy issues addressed in collaboration with other health organizations. He stresses MD Anderson’s role as a resource and support for public officials who lobby for health policy in the legislature.

  Dr. Foxhall next explains the relationship between the Office of Referral Relations the Office of Health Policy.

  Dr. Foxhall next talks about the big projects he undertook as Associate Vice President: creating the network of physician referrals; a program to educate physicians about cancer screening; creating an internet based educational outreach program.

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  Chapter 10: The Texas Cancer Data Center

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  He explains the funding and mission to collect information from the state cancer registry and convert it to a searchable system that includes statistics on patients and other information. He explains how the system evolved, shifts in its management, and the programs it includes. He notes that a related education program has reached about 500 nurses and 1000 social workers with information about programs for patients. He notes that this was one of the first data centers of this type in the country.

  Dr. Foxhall notes partnerships with the American Cancer Society and with other public health agencies to educate patients about cancer risk. He also notes the work with the Harris County Healthcare Alliance to support prevention programs in community clinics and improve access to healthcare for low income patients. (Additional information on the Texas Cancer Data Center is presented in Segment 09.)

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  Chapter 11: Grant-Funded Projects in the Office of Health Policy: The Texas Cancer Data Center

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Here Dr. Foxhall talks about a number of key projects run by the Office of Health Policy. He first follows up on a discussion of the Texas Cancer Data Center (discussed in Segment 10), explaining difficulties in collecting information in the early days of the project and then sketching how services have evolved an been updated since the late eighties. He lists the kinds of information that the Center provides, its heavy use (around one million hits per year) and its impact. Dr. Foxhall notes that it is used as a platform for educational programs supported via CPRIT money. He also describes how the Center provides information for individuals with no insurance and education for nurses and social worker to help people get access to care. This need has been intensified since Texas made the decision not to participate in the Medicaid portion of the Affordable Care Act.

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  Chapter 12: Grant-Funded Projects in the Office of Health Policy: Services for the Uninsured

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Here, Dr. Foxhall describes initiatives supported by the institution and by federal money that are designed to reduce cancer risk among low-income individuals. He first talks about the tobacco program, mentioning the ASPIRE program designed to reach maximize tobacco avoidance/cessation in adolescents. Dr. Foxhall explained how the Office of Health Policy helped support this project. Next he talks about the project, Ask, Advise, Connect, a quit line service that services HIV patients. Dr. Foxhall notes that this is a good example of how the Office of Health Policy identifies a government program that can provide funding for initiatives relevant to the needs of at-risk individuals. He describes the individuals involved in organizing the funding mechanisms and notes where difficulties arise in the process. Dr. Foxhall explains that this is a slow and often frustrating process, but the benefits come when “you see that you help someone” and can track progress with use rates.

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  Chapter 13: Grant-Funded Projects in the Office of Health Policy: Screening for Colorectal Cancer and Breast Cancer

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Foxhall talks about projects that support screening for colorectal cancer and for breast cancer (via a mobile unit). The Office of Health Policy “provides the infrastructure,” identifying an opportunity and partners who can help accomplish goals that fit with MD Anderson’s mission. He provides additional information about both of these screening programs.

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  Chapter 14: Grant-Funded Projects in the Office of Health Policy: Cancer Survivor Management

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Foxhall talks about a grant that the Office is now preparing for Cancer Survivor Management –a training program that will be instituted in clinical around the state. Dr. Foxhall explains that his “love in life is education,” and that such projects are very significant for him. He explains the elements of the training program: identify survivors; create care plans to maximize the effectiveness of aftercare following MD Anderson guidelines; follow up with providers to help them adhere to best practices; monitor patients receiving services. He discusses a tele-mentoring system that will be used to provide support for health care personnel. He talks about collaborating on the Cancer Survivorship Manual that will be published this summer.

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  Chapter 15: Educational Projects with Physicians and Medical Students

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Dr. Foxhall talks about the importance of educational outreach to the mission of the institution.

  He lists the impact that educational initiatives have in the community.

  Next he describes the Preceptorship Program initiated in the eighties at the UT Medical School in Houston. The challenge, he explains, was (and is) that “we need more primary care physicians” and medical students need to know that family medicine can be a viable career path. Dr. Foxhall explains that the Preceptorship enables medical students to spend a month with a family physician. He talks about the importance of targeting students early. He notes that in a national ranking of states and the availability of primary care physicians, Texas ranks #42. The grant supporting the Preceptorship was renewed several times and the program has been successful at convincing medical students to enter family medicine. Recently funding was cut and then transferred to the Texas Council of Family Physicians.

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  Chapter 16: Projects in Cancer Prevention; the Lung Cancer Moonshot; CYCORE

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Foxhall talks a cancer prevention programs and the place of the lung cancer screening trial in the Lung Cancer Moon Shot. He then talks about CYCORE, a program that uses electronic devices to address patient needs and treatments. This project was funded by stimulus money and uses a tele-monitoring device created by Time Warner. He describes some of the benefits and also mentions the video conferencing systems that can support patients. Dr. Foxhall notes that the Office tries to keep up with the latest electronic advances that can help patients.

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  Chapter 17: A Major Challenge: Serving the Uninsured as Health Care Changes

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Foxhall talks about the challenge of expanding access to care, his role as a governor-appointed member of the Texas State Health Services Advisory Council (2009 – present), and the challenge of transitioning from a fee for service system to a value-based care system.

  He notes that Texas ranks number one in numbers of uninsured individuals, but there are early signals that the Affordable Care Act is reducing those numbers, though the issue is complicated by the decision Texas made not to participate in the Act.

  Dr. Foxhall describes services provided by the Texas State Health Services Advisory Council and gives examples.

  He defines value-based care, founded on careful documentation of care provided and outcomes. He explains the related concept of “the triple aim”: to improve quality of care, to reduce cost, to increase levels of patient satisfaction, noting that some policy makers include a fourth aim, insuring equal access to care. He explains why the status quo cannot continue.

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  Chapter 18: Impact of Institutional Growth on the Office of Health Policy

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Foxhall comments on how the MD Anderson’s growth since the nineties has had an impact on the activities of the Office of Health Policy.

  He notes the huge expansion of external connections with network affiliates and also with international connections, with MD Anderson adopting the CDC’s Comprehensive Cancer Control Program to organize information provided to the external connections. He sketches the history of that program. He notes that the Lung Cancer Moon Shot is part of the Prevention and Control Platform.

  Next, Dr. Foxhall talks about how the institution’s financial structure has changed: healthcare delivery has changed and it is increasingly difficult to secure funding for research and also raise income from patient care. He notes that the institution’s ability to provide personalized and compassionate care for patients has not changed, because it is imbedded in the culture and tradition of MD Anderson.

  He ends this segment with comments on how MD Anderson is seen by the community.

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  Chapter 19: The MD Anderson Presidents; No Plans for Retirement

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  Dr. Foxhall begins this segment with comments on MD Anderson presidents, Dr. Charles LeMaistre, Dr. John Mendelsohn, and Dr. Ronald DePinho. He then notes that he has no immediate plans for retirement (he is “having too much fun”), and explains that intends to further the tobacco agenda and to develop survivorship management, positioning the institution to work within more effective shared care models for survivorship.

  Dr. Foxhall comments on the legacy he will leave: a network of collaborative connections designed for cancer control and management. He comments briefly on his love of travel, the enjoyable time he spends with his children, and his hobby, landscape photography.

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  Chapter 20: Texas and the Affordable Care Act

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Foxhall discusses the Affordable Care Act (ACA) passed on 23 March 2010 and its impact on Texas Health and the activities of MD Anderson. He begins by noting that Texas has the highest rate of uninsured individuals in the nation and that only a limited number of categories of individuals are eligible for Medicaid, with the result that a percentage of individuals who are diagnosed with cancer are uninsured. He explains the hopes that the ACA would provide coverage to the uninsured, to cancer survivors unable to get affordable insurance, and to low income individuals in need of cancer prevention services. He then goes into more detail about the Texas limitations on Medicaid as well as some alternatives under discussion in the Texas Legislature to provide coverage to ineligible individuals.

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  Chapter 21: MD Anderson’s Response to the Affordable Care Act; ACA Requirements; Value-Based Purchasing

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Foxhall continues discussion of the Affordable Care Act.

  He sketches MD Anderson’s programs to help with financial assistance.

  He then talks about the requirement that institutions report on the quality of care. He gives examples to explain what is involved in this process, noting that historically, medical practices have not had enough transparency in care and outcomes. Reporting enables consumers to have a better idea of how well providers are doing. In addition, this information will be used as a basis for determining payment. Next Dr. Foxhall explains that the ACA requires that institutions participate in an Accountable Care Organization. He explains the reasoning for this, and notes that it is not clear how a specialized hospital will engage with them.

  Next Dr. Foxhall talks about the ACA’s requirement for Value-Based Purchasing, giving examples of how examining processes has revealed unnecessary costs in deliver of care.

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  Chapter 22: The Future Under the Affordable Care Act: the Value of Prevention Services

  Lewis E. Foxhall MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Foxhall sketches what the future looks like under the Affordable Care Act, noting that a change in leadership in Texas might change any predictive scenario and the state will continue to have poor and undocumented individuals to cover.

  Dr. Foxhall explains that the focus on preventive services is a very positive feature of the ACA. He explains the requirements and notes the benefits that can come from screening services and tobacco cessation programs. He cites statistics for the increase cancer risk that comes with smoking and obesity. He explains why institutions tend not to invest in prevention, noting that the ACA is unusual in adding this to its requirements.

  In conclusion, Dr. Foxhall notes that the ACA is “still a political football” and that politics has an impact on each decision connected with it.

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  Chapter 01: An Early Desire to Enter Medicine and a Growing Interest in Oncology

  Ralph Freedman MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Freedman talks about his family life and education in South Africa, noting that his family physician inspired him to enter medicine. He explains the differences of the South-African, British-based educational system and then, during the next twenty-five minutes he turns to his growing interest in endocrinology (Ph.D. on breast feeding habits on maternal disease of the endometrium) and cancer. He explains that he applied for an Eli Lily fellowship (instead of going to England, as was more usual for South African residents and post-doctoral fellows) because “the future was more in the States than in Britain.” Dr. Freedman explains that he came to the U.S. to work with Dr. Joseph Sinkovics in 1976. He talks about how South Africa’s apartheid system affected his medical training: his exposure to the variety of uterine diseases among Black South African women led him to do a Ph.D. and to collaborate with virologists on a variety of studies of uterine cancer. Immunology, virology, endocrinology, and his interest in cancer coalesced at exactly the right time to create a new research path leading to MD Anderson, working with on cervical cancer cell lines, a precursor to his work on vaccines and cytokines and immunotherapy.

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  Chapter 02: Discovering and Rich and International Community at MD Anderson in the Seventies

  Ralph Freedman MD and Tacey A. Rosolowski PhD

  Dr. Freedman begins this chapter with a fuller discussion of how he came to MD Anderson. He also comments on his family’s adjustment to life in the United States and the social life of MD Anderson in the mid-Seventies, with its international faculty.

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  Chapter 03: Research into Treatment for Gynecologic Cancers

  Ralph Freedman MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Freedman discusses his “travels in the lab,” first explaining how his Fellowship work on cell lines transitioned to the development of vaccines for gynecologic cancers. He talks about the prevalence of these cancers, explaining the special challenge of ovarian cancer. He explains the logic behind the vaccine strategies tested (e.g. intra-peritoneal injection) and the immune mechanisms stimulated, and also notes the clinical challenges faced, which led to work on an approach using T-cells. He then details his work with T-cells, describing some of the equipment used, the procedures attempted, and his evaluation of those procedures, concluding that his work added “building blocks” to the understanding of the immune system, as well as the creation of a mono-clonal human antibody. Dr. Freedman then goes on to talk about the relationship between the immune system and the inflammatory system and his work with ecosinoids and inflammatory responses to tumors. It may be possible, he explains, that if the inflammatory response can be stopped, a tumor will stop growing. He notes that his research has given him new respect for how difficult it is to treat cancer, pointing out that mortality rates for cancer has not changed substantially over the past years. He discusses the difference between private practice and academic medicine then describes what it was like to establish his own laboratory after working collaboratively in others’ labs. He offers his views on translational research. Dr. Freedman then talks about how he dismantled his lab and projects when he decided to retire.