Chapter 03: Shifting Surgical Culture and Research; Building Subspecialization and Training

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Chapter 03: Shifting Surgical Culture and Research; Building Subspecialization and Training

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Dr. Sawaya begins this chapter by observing that his vision for developing the Department of Neurosurgery was controversial when he came to the institution. He explains that the culture viewed surgery in the mid- and late 80s viewed surgery as a “reactive practice.” A surgical oncology perspective did not exist widely at that time, though other researchers at the institution used a medical oncology particularly in treatments involving chemotherapy. Dr. Sawaya notes that Dr. Balch brought the vision that surgeons could establish their own lines of research and Dr. Sawaya explains that he implemented this perspective by establishing training programs in the Department of Neurosurgery. Dr. Balch adds that the training programs were designed to produce strong researchers and leaders as well as excellent clinicians. The discussion stresses that training was designed to produce surgical oncologists who could participate in multidisciplinary research and treatment teams. Dr. Sawaya next discusses recruitments that built the subspecialities in the Department of Neurosurgery.

Identifier

SawayaR_01_20190312_C03

Publication Date

3-12-2019

Publisher

The Historical Resources Center, The Research Medical Library, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

Building the Institution; Leadership; On Leadership; Mentoring; On Mentoring; MD Anderson Culture; Education; On Education; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Portraits; Controversy

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History | Surgery

Transcript

Tacey A. Rosolowski, PhD

I actually wanted to ask a very quick question and I don’t know if we need to spend a long time on it. But obviously, both of you brought a very different kind of vision and energy to the institution, given the traditional culture of surgery in place at the time. I didn’t want to move into the growth spurt and the future, until we kind of looked at what was your impression when you arrived. You were very excited about taking this job, being a founding chair, promise of resources, but we’ve got an environment, a culture on the ground. Tell me a little bit about what the was like. Were you guys controversial, you know what was that existent culture like?

Raymond Sawaya, MD

It’s interesting, what you just said, because there was—I was told that there was opposition to creating a department of neurosurgery, certainly not by Charles. Charles had the vision, the foresight and made it happen, but there was opposition.

Tacey A. Rosolowski, PhD

Did you get a sense of why?

Raymond Sawaya, MD

No, but one surgical chair, after I arrived here, he said—he was being kind. He said, “Ray, you may hear—” Because he doesn’t want me to hear that there was opposition to this. His point was, it has nothing to do with you. We’re not opposed to you, we were just opposed to the idea.

Tacey A. Rosolowski, PhD

Well people hate change.

Raymond Sawaya, MD

Well, yeah, yeah, and I don’t know if you know who I’m talking about.

Charles Balch, MD

Yes I do.

Raymond Sawaya, MD

It shows you that when a vision is based on something real, something valuable, something that is ahead of its time, then it turns out to be a hit. The rest of the story that we are discussing about today originated, was Charles’s idea, was a hit, and all what you need to do is look at today, who we are and what we have accomplished. Yes there was, it was controversial.

Charles Balch, MD

And part of that is the risk we take. Not just me but you, Jack Roth and others, who are bringing in this idea which did not exist in the culture of the institution. So this is counter to the culture, at least in surgery, but it was more friendly in the Division of Medicine, because they had started doing this a little bit earlier.

Raymond Sawaya, MD

One aspect that I think must be recognized and recorded, that Charles alluded to a few minutes ago, is in the context of the mid-Eighties let’s say. I came in the 1990s, so late-Eighties, cancer oncology, the focus was in terms of research, was on the medical side, on the drugs, on the chemo, on the combination of chemo. MD Anderson was very much part of that, right? When you look at J Freireich [oral history interview] and what he did. Even though MD Anderson was established by a surgical oncologist, R. Lee Clark, and he brought obviously fantastic technical abilities to do surgery, the research side was more on the medical side. I think Charles already said a couple times earlier today, that in working with Mickey LeMaistre [oral history interview], they wanted to make sure that surgeons and surgical oncology was going to establish its own line of research. Of course that applies to how we do surgery, to outcomes research, to the use of technology, education, that we will come to at any moment here. So I came at a time when it was a goal. It wasn’t like we’re going to break walls to make it happen. It was a goal because Charles had already been here.

Charles Balch, MD

Eighty-five I came, 1985.

Raymond Sawaya, MD

Eighty-five, so five years before he was working on that, and I do believe, as I said earlier, creating departments would allow the growth of these areas within those departments and will benefit the entire institution. Neurosurgery --we talked about Milam being here, all that they were doing, you know-- eventually they became two neurosurgeons: Rick Moser and Milam Leavens, they were doing about 300 tumor operations a year. When I got here it was 300 and it was mostly reactive. It was this service had this patient with a brain tumor, who had a seizure, and then they do a scan, they find a tumor, and so they would take care of the patient. So we had people to just take care, but we didn’t have people to build, and so it goes back to the original point that we were making here: to really truly grow, you had to establish the entity and so forth.

Now, you were very interested in education, and it is an essential part of what we do. Having established a department with super experts within the field, I created a fellowship early on, in 1991. My first fellow was a neurosurgeon from the Cleveland Clinic, who was from Singapore and went back to Singapore. We went on a trip, Charles and I, and Krakoff, to Singapore in 1992. I served as a consultant to the Minister of Health, because they have a main hospital there and they needed to have a chief of neurosurgery, a chair for neurosurgery, and I was able to convince them to put that fellow of mine, Prem Pillay, to be the chair of neurosurgery there. He was my first fellow at MD Anderson in Neurosurgical Oncology. Fast-forward, we train four a year now in neurosurgery. Four in a year. And the reason we can train this many, there is no other place in the country, anywhere, that trains essentially more than one neurosurgical oncologist, not even Sloan Kettering Memorial. They take one. Cleveland Clinic takes one, Mayo Clinic takes one, UCSF takes one. We take four, and why do we take four, why can we take four, is for multiple reasons. Number one is the super sub-specialization that we talked about. Number two is the volume, the number of patients that we operate on, so that there’s enough material for this fellow to learn from. Number three is the technology or the use of technology, and we started that 25 years ago, doing awake craniotomy, meaning a patient is awake during the critical moment when we are cutting through the brain and removing the tumor, so that we don’t hurt speech or motor. To this day we have fellows coming to start working with us from very good institutions in this country. They say well, we lack experience in awake craniotomy, we haven’t seen enough, we’re not comfortable enough. Well, this is something that we do almost daily, daily, for the whole year. So these fellows come here, they could be extremely well trained in some of the top institutions in this country but somehow, the level of the kind of things we do here, they just don’t have it.

Charles Balch, MD

Let me interject here, because when I came, the primary outcome of the training programs in all of the surgical specialties was training good surgeons who would go into the community, whereas we stated early on, we wanted to train leaders in academic surgical oncology. We wanted them to be all four things; leaders, academic, good clinicians, but also oncologists in multidisciplinary care. You might mention, not only had you attracted really good people, but where did they go? And were they equipped to rise to leadership positions once they went to other places?

Raymond Sawaya, MD

Exactly. So, let me interject that it’s not always possible to find an academic position for a trainee, because there are a limited number of them in the country. So, when I started here and we were one fellow, and then two, and then three and now four, so we have trained almost 150 fellows over the past 25 years. Two-thirds of them in my earlier years at MD Anderson, went into private practice. Two-thirds, just because they—now, two-thirds and more, over 80 percent, go into academic practice, in part because our reputation rose, in part because we have really established very high standards and universities know, if they really want a top notch person in neurosurgical oncology, the first place they look at is here.

Charles Balch, MD

And the fundamental part of that exposure is not just being an excellent technical surgeon, but the broader issue of being a clinical investigator and also being an oncologist. This is something that I think also, that we brought: is the surgeon as oncologist, in feeling like they’re a partner, not a passive one but an active partner, in multidisciplinary care and the treatment planning around these patients.

Raymond Sawaya, MD

And I think the ultimate proof of what Charles just said is the SPORE grants. You are familiar with what the SPORE grants are. What’s impressive are the number of SPORE leaders at MD Anderson who are surgeons, whether it’s in thoracic—

Charles Balch, MD

Which didn’t exist before.

Raymond Sawaya, MD

—in neurosurgery in gynecology, in breast, melanoma, with Gershenwald. You have so many surgeons who are in leadership roles leading the SPORE. The SPORE is the ultimate in NIH funded research for oncology. I mean these are $14-$15 million grants, and MD Anderson --I don’t know what the number is now-- but has had between nine and eleven SPORES. No other institution has had this number of SPORES in oncology. No other institution. And at least half of these, their PI is a surgeon. In my department, Fred Lang is the PI of our brain tumor SPORE. I mean it’s really truly impressive. So it speaks to not only that vision that started by saying we want to promote physician scientists, surgeon physician scientists. That’s true. Charles pushed that, and the outcome of this 20 years later, 25 years later, is half of the leaders at MD Anderson are surgeons in research.

Charles Balch, MD

So maybe just briefly, one of the things I remember is the super-specialization and developing spine surgery, which did not exist here. Base of skull surgery, which did not exist here at all. Dr. Moser and Dr. Leavens did the classic brain surgery, as you say, reactive to a patient who had symptomatic metastatic disease in the brain.

Raymond Sawaya, MD

Exactly.

Charles Balch, MD

But we didn’t go into those other areas, one because we didn’t have the technology --and we got that. But you also have to have the people that will spend the time and develop the expertise, because this is very complex surgery.

Raymond Sawaya, MD

Yes. So that goes back to the tree. You know, if you look at that neurosurgical oncology tree, you would see of course, a big part of it are brain tumors, gliomas. A big part are the brain metastases. A very, very common problem, and we do hundreds of these operations a year. But then you look at the other branches. You see all the spine tumors, primary bone spine, metastatic bone spine, and they’re a serious problem because the spinal cord gets compressed. The patient cannot walk, the patient is in severe pain, they lose bladder, bowel and sexual function because the spinal cord is compressed. So having the expert to help the oncologist. Now these are not neurosurgical patients. These are lung cancer patients, these are colon patients, these are prostate patients. They’re not directly neurosurgical patients, but now they get a neurosurgical problem that the other specialists cannot handle, it’s totally out of their field. So having the top notch expert to provide top notch care, whether it’s clinical or surgical, was absolutely essential. To expand on that and show you how, with the help of Charles, the Division of Surgery and MD Anderson --I come in 1990. In ’91 I hire McCutcheon to help me with mapping, brain mapping, something we didn’t do here, and he trained at Montreal Neurological Institute, where mapping was created, was invented by Penfield, in ’91. In ’92, I bring Franco DeMonte to build the Skull Base Program. He trained with Ossama Al-Mefty, the top leader in the country in skull base. In ’93, and I think we must emphasize the need for a neurosurgeon to handle pain, cancer pain. Sam Hassenbusch was a Johns Hopkins trained, phenomenal guy, a PhD, Sam passed away from a malignant brain tumor, glioblastoma, sadly, in 2008. But I hired him in ’93 to help us build the stereotactic and the pain side, and he did a phenomenal job, eventually became the medical director of our practice plan at MD Anderson, a very smart guy. So ’93. Ninety-four, Zia Gokaslan to do the spine, build the spine program. In ’95, we went through a tough time at the institution, we laid off a lot of workers because managed care...

Charles Balch, MD

This is in preparation for managed care.

Raymond Sawaya, MD

Managed care was coming and so they wouldn’t allow me to hire anybody. But in ’96, I hired Fred Lang to lead our clinical research program. I now had all the subspecialists in place, now I needed to focus on the things that we had to develop, and that’s clinical research. Fred Lang was the clinical research director, he did viral therapy, injected viruses in brain tumors and all kind of stuff, and now he’s the chairman of the department.

Charles Balch, MD

Let me interject here, Zia Gokaslan, who trained here, went to Johns Hopkins and Zia was my wife’s spine surgeon, doing things that nobody else could do. He was my spine surgeon when I needed it and now is the Chair of Neurosurgery at Brown University. It exemplifies the fact that people could come here as a young person, get super specialized, do things nobody else in the country was doing.

Raymond Sawaya, MD

Exactly.

Charles Balch, MD

But I think more than just having people come to MD Anderson, they went out into other reputable places, developed their own program, and expanded the field of neurosurgery because they had those early exposures to not only how to do the operation but how to do the clinical research, the prospective databases. That philosophy went out throughout the nation and around the world, to not only do good clinical surgery but to be a clinical investigator.

Raymond Sawaya, MD

Yes. You would hate to lose somebody like this. Zia was such a dynamite force here and such an incredible surgical innovator, but you know, when he was offered the vice chairman position at Johns Hopkins --I mean it’s incredibly prestigious and it allowed him to build his own program there and we’re very proud of him, as Charles just alluded to. But at the same time, we are lucky to have retained many top talents. Ian McCutcheon is still with me, Franco is still with me. Fred of course now is the chair, and then after him, had several successful recruitments who are still here. So you know, you win some, lose some, but you’re right. When they leave here we’re proud of them.

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Chapter 03: Shifting Surgical Culture and Research; Building Subspecialization and Training

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