Chapter 04: The New Division of System (mid-Eighties) and the Symbiosis of Departments within the Division of Surgery

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Chapter 04: The New Division of System (mid-Eighties) and the Symbiosis of Departments within the Division of Surgery

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In this chapter, Dr. Sawaya and Dr. Balch begin by talking about the rationale for the new division system and how the strategy worked to create a different culture among surgical departments. They compare the Division of Surgery’s decentralized operation with the more centralized Division of Medicine. Dr. Balch shares his philosophy of administration, and they discuss the impact that the Division of Surgery and the strategic plan had in facilitating planning, creating transparency in budget discussions. They discuss the role of Donna Sollenberger (Division of Surgery interview; oral history interview) in implementing the division system. Dr. Balch comments on the challenge all faculty face working in silos and how this has an impact on delivering multi-disciplinary care. They discuss the Breast Center as an early example of how the institution reorganized on this model. Dr. Balch then explains the foundation for multi-disciplinary care that R. Lee Clark, MD laid with the practice plan and discusses a landmark paper he published based on collaborative work. Drs. Sawaya and Balch next discuss Dr. Balch’s role in directing research resources to the departments.

Identifier

SawayaR_01_20190312_C04

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; Overview; MD Anderson Culture; Leadership; On Leadership; Institutional Politics; Controversy; Understanding the Institution; Growth and/or Change; The Researcher; Research; Discovery and Success

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

Charles Balch, MD

Ray, could you talk a little bit about how the division --how that fit organizationally into facilitating what you did. I think conversely, I tried to have all of the department chairs collectively have a role in the strategies, in the budgets, in the core facilities, for all of the departments that were common to them.

Raymond Sawaya, MD

I think it’s fair to say, and how diplomatically you would put it I leave it up to you and Charles, but it was and is still obvious to this day that the culture in Surgical Oncology as a division was, I will use the term healthier, than in Medical Oncology. Let me explain what I mean by this. Through and thanks to Charles’s vision --Charles used to tell me, who better knows neurosurgery than you do. The delegation of authority to run the department was very obvious in Surgery. In Medical Oncology, unfortunately, they have had the culture of wanting to control, and why do I say that, why I know that? Because when I needed to hire a faculty, whether it’s a research faculty or a surgeon clinical faculty, I would come to the division; you have to go through the division to get to the VPs obviously, and I would get support because they said, well you know your needs and so on. My counterpart in Neuro-oncology, in this case Al Yung [oral history interview], would have similar needs and he would be blocked up there, and numerous times. This didn’t happen once or twice or three, numerous times. There is something about Medical Oncology that has kept things under severe control up at the division level, while the Division of Surgery had the concept of helping to facilitate. I think this is a very wise approach because if a department in the Surgical Oncology Division, Surgical Oncology, succeeds, well guess what, the whole division succeeds. I saw that and it continued with Raph [Raphael] Pollock [oral history interview]and of course now with Steve Swisher. Charles was the first division head, Raph was the second, I think Goepfert [oral history interview] did it for a year as an interim but that didn’t stick. So really, Raph was the second and now Swisher, and so we only had three division heads in 25, in 30.

Tacey A. Rosolowski, PhD

That’s important continuity too.

Charles Balch, MD

But historically, can you describe how the division, as an organizational entity, helped you as a department chair, but vice-versa, how you felt, as an ownership of the division, as part of the executive council, because there were common elements of what we did that crossed specialty lines.

Raymond Sawaya, MD

No, absolutely, and I think I was alluding to what you’re asking, but let me be more specific. MD Anderson had gotten so big that divisions were created to really facilitate the work of the administration in terms of planning, in terms of budgeting and so on. So now imagine the VPs have to work with five, six division heads. Or maybe nine now because Pharmacy and Imaging and Pathology, whatever. It doesn’t mean we didn’t have access to the top layer of the institution, we of course had access. But when it comes to budgetary planning, we have to work with a division, and that’s what I was alluding to: is that the Division of Surgery had not only forward thinking, it was very encouraging, it was facilitating, what each department needed to grow and develop and so on. Charles alluded to the council. We did have regular meetings, I don’t remember now if it was a monthly or biweekly or what, but we certainly had very regular meetings.

Charles Balch, MD

You saw all the data for the whole division.

Raymond Sawaya, MD

We saw the data, exactly, and we would discuss and we would prioritize because you know, the institution is not going to give us 50 surgeon positions; they may say we have five positions for Surgery. So with the help of Charles and his administrator, Donna Sollenberger [oral history interview], who is another person that should appear in this review, this history, a phenomenal lady, she just, just retired. I saw her at UTMB three months ago and I think it was November. She told me February was the date she definitely was retiring.

Tacey A. Rosolowski, PhD

I heard her on the radio not too long ago.

Raymond Sawaya, MD

You did?

Tacey A. Rosolowski, PhD

Yeah. She was doing an ad for UTMB. I interviewed her for the oral history project.

Raymond Sawaya, MD

You did?

Charles Balch, MD

We’ll have Donna come up here again. She actually lives in Sugarland now.

Raymond Sawaya, MD

Yeah, yeah, she lives in the Houston area.

Charles Balch, MD

So, let me interject historically here as a division head, because I was chair of a department but I was also the division head, and part of the philosophy was one of delegating authority for the operations of each of the departments. But I also wanted to make sure as we grew, that people like Ray Sawaya, would help me as a division head. Also, by everybody being at the table and seeing what they were doing, their publications, their clinical programs and so forth, Ray’s success helped set a standard for other departments who may not have had that philosophy. But in the competitive world we live in, when they’re seeing neurosurgery, thoracic surgery, plastic surgery, surgical oncology thrive, and how we did it, and help defining the core resources and the philosophy, I think it helped raise the bar for everyone, including those that didn’t quite come with that culture. I think adopted it, because we were in a universe where you were seeing successes. The other thing I believed philosophically was a collective wisdom. I really do believe that no matter how good your idea is, you can always make it better by listening and getting input from everyone else and having what we call the divisional strategic plan, and trying to define here at the things that need to occur at the department level. Then I really tried, as people would take the initiative, to take their leadership and their perspective and bring it to the division in terms of developing the strategic plan, the core resources that are necessary, but also as a role model, because everybody at the division head saw all of the data for all the departments. They saw their academic productivity, their clinical productivity, their ability to get grants. We talked about training programs, and I think one of the reasons that it became more uniform over time was remember there were some who got the idea early on, leadership in academic surgical oncology, those four things. Some people brought that because it was inherent to them and some people had to adopt that as we went along. But I think the reason the division is still there and succeeded is because we really worked proactively in defining here’s your role as a department chair, but you have an additional role as a member of the division collectively, for looking after those things that are common to us as surgeons.

Raymond Sawaya, MD

And if you put it in the context of the time, we’re talking now late-Eighties, early Nineties—

Charles Balch, MD

We take that for granted now. This was a culture change.

Raymond Sawaya, MD

Sharing data can be tricky, can be very controversial. You know a lot of this stuff was kept hush-hush, including people’s salaries and so on and so forth, so it really was a trailblazer.

Charles Balch, MD

I have to put in here: I remember very well, one of the department chairs of another department, who came in and complained to me that the neurosurgeon salary was higher than theirs and they thought it should be the same. So I pulled the AAMC book and said this is the standard that we set from the AAMC tables: the mixed private/public tables that said we want people to start out at the 50th percentile, we want them to get up to the 80th percentile, but then move on to the next level. And I said if your faculty want that salary, they should have been a neurosurgeon. I remember that specifically because part of the difficult job I had was everybody, when they saw somebody else succeeded, they wanted that but they didn’t necessarily want to do the same effort to get there and to develop it on their own.

Tacey A. Rosolowski, PhD

Doctors, would you like a glass of water? I neglected to bring any.

Raymond Sawaya, MD

I am perfectly fine, thank you.

Tacey A. Rosolowski, PhD

I didn’t want you to be jealous with a water here.

Charles Balch, MD

So, Ray, one thing that also didn’t exist, we worked in silos, and I wondered if during that time when you came until I left, we really moved forward in terms of the concept of multidisciplinary care. The disease-site specialty centers, we eliminated the surgery departments. There was a place called Station 80, where at least in general surgery and the surgical oncology, the patients went for their surgical evaluation and their follow-up. During this time, we eliminated that. We started out with the Breast Center, but the reason that also happened, because the culture of the entire institution, it was a horizontal relationship between medicine, surgery and radiation therapy—

Raymond Sawaya, MD

I agree.

Charles Balch, MD

—that didn’t exist in many other places. One of those goes back to a brilliant strategy of Lee Clark, of having one practice plan. So you don’t have the financial silos of people worrying about, well, if we all get together and make a decision collectively, who gets the revenue from that? Because it goes into one practice plan. I think this was also something that was very forward thinking at an institutional level that we were leading in. Of course, I went on to be the vice president of the Hospital and Clinics, so I had keys to the kingdom, the authority to do that, that might not otherwise have happened.

Raymond Sawaya, MD

I completely agree that the concept of multidisciplinary care was and is essential, and that now we are equal partners, the radiation docs, the medical oncology docs and the surgeons, and so it wasn’t an issue of ego. We were all together, working for what’s best for the patients. Having said that, it’s obvious and clear to me, throughout my 28-plus years at MD Anderson, from day one, that surgeons at MD Anderson are highly respected within that team, that the other specialists have recognized the critical role that a surgeon can and should play in helping manage patients. I’ll share with you one example that turned out another landmark paper, early on, early on. I came here—just to put it in context, we talked about brain metastases, right? This is cancer, lung, breast, melanoma, goes to the brain. The standard of care in 1990, the year I came here, was single brain metastasis, you remove it and treat with radiation. If a patient had more than one brain metastasis, that’s called multiple brain metastasis, is a contraindication to surgery. Now why am I telling you this story? Because our medical oncologists, they knew that their lung cancer patients, who may have two or three brain metastases, nothing is going to help them if we don’t—aren’t more aggressive.

Charles Balch, MD

Especially if they’re in different parts of the brain.

Raymond Sawaya, MD

Exactly. And so they would push us, help us with our patients. So I had a series of patients with multiple brain metastasis that I’ve operated on, and published that paper in 1993, barely two, three years into my tenure here at MD Anderson. And this is also, one of the most quoted and referenced and cited papers in the neurosurgical world. You see the role of the medical oncologist here, saying, Help us. They help us break barriers, they help us create new approaches, and so I do believe to this day, that at MD Anderson, if you talk to medical oncologists and radiation oncologists, they have a high respect for the role of surgeons in this multidisciplinary care.

Charles Balch, MD

So let me actually amplify on that, because Ray is exemplifying that and it was one of the reasons we wanted to recruit him. When I came here --because of my training as an associate director of a cancer center and my influence from John Durant, who is a medical oncologis-- and because the medical oncologists weren’t taking care of melanoma stage four, so I had to do that. When I came, part of that was the philosophy of the surgeon as an oncologist. Now typically, including here when I came, the surgeons did the operation, they focused on the perioperative period, right before, right afterwards, but not disease management. Oncology as a way of thinking, is about the disease, not just the episode of care. It’s the horizontal platform of the disease in the long-term follow and the integration of surgery with medical and radiation oncology, which here to fore, somebody else made that decision and if we have a need for an operation we’ll call the surgeon. Now the surgeon comes as an oncologist and is a full partner in the decisions on what operation: when do they get it, do they get medical care and what kind of medical care, before and after surgery. So the philosophy, the cultural change here, was the surgeon as an oncologist, which is something that I think now people take for granted. But I can tell you when I came, there were very few surgeons who thought about disease management, about being an oncologist to be a partner in the decision making of the long-term oncologic needs of the patient. Ray brought that and embraced that with Al Yung as a partner. But wasn’t --as you said earlier-- you didn’t react when somebody else said oh, we have a brain metastasis, please do this operation. You’re there at the beginning, in the treatment planning of all of these patients.

Raymond Sawaya, MD

To exemplify or amplify on this, all what you need to do now is go around the whole institution when each program --there are multidisciplinary programs-- hold their tumor boards. We have our tumor board on each Wednesday afternoon. You walk in the room, you will see five of six neurosurgeons, you will see five or six neuro-oncologists, you will see three or four radiation oncologists, you see a neuro-pathologist, you see a neuro-radiologist, you see all our trainees --back to training. And we are showing case after case, and each of us brings our expertise and specialty, lean-in on how should we, should we not, should we operate again, this patient had two surgeries before. Where is the tumor? The radiologists shows us a scan. The pathologist says, yeah, this is a bad tumor, it has molecular mutation. Do you see that I mean? You bring all that, and then the fellows and the residents are sitting there soaking in all of this and learning from all of this. But surgeons are there. It’s a given, you know? We don’t even think about it.

Charles Balch, MD

This goes back to collective wisdom. We talked about collective wisdom organizationally, administratively. But also this is the collective wisdom of bringing the surgical perspective to the decisions on the multidisciplinary care of the cancer patient, and that collective wisdom, bringing that perspective, it’s the proactive as opposed to the reactive.

Tacey A. Rosolowski, PhD

I’m also thinking too, how all of this approach has been very open to absorb everything outside of surgery that’s new. You have immunology, you have new types of chemotherapeutic interventions, radiology has evolved so much, imaging has evolved so much, and so the collectivity expands, as these new fields develop and have more to offer.

Charles Balch, MD

Exactly. Ray, in our final minutes, there’s one other aspect of this. When I came, there was virtually no laboratory research and the people who had that precious space were neither funded nor publishing. It was a real political fight to take that away, and to reorganize it, and to say, “If you have lab space, you have to have independent peer review funding and you have to publish, and you need to include the trainees as part of the training, and you have to be linked with the basic sciences, like the Josh Fidlers and so forth.” You also, as part of this, brought a laboratory research program, and I wonder if you could briefly describe that and how that came about.

Raymond Sawaya, MD

Absolutely.

Charles Balch, MD

This did not exist before.

Raymond Sawaya, MD

No it did not exist and it has been a critical component of our credibility in building the department. If we did not have laboratory research, I don’t think we would be viewed on the international scene as a credible player, so essential was to bring PhDs in the department. Now, there’s a lot of collaboration, to this day, across the institution, and so that’s not an issue.. But you still have to have your own nucleus. You have to have your own basic infrastructure built in laboratory research. So yes, we asked for lab space, and it was very tough to get because they were giving preference to basic scientists, basic research departments. The clinical departments were not prioritized to get that. I’m sure Charles played a major role in the creation of the Tan Zone. This is a building we call the Tan Zone, because each building has a color associated with it. The Tan Zone is a precursor to the Mitchell Building, the basic science research.

Charles Balch, MD

We call it the Clinical Science Building, that’s next to the new hospital.

Raymond Sawaya, MD

So … And it was intentionally created and built for clinical departments and surgical departments in particular,. So surgical oncology, although they were based on the South Campus, in part because of Fidler [oral history interview], whom you mentioned, and because they had some space there, they created laboratories in that building for surgical departments. So my department benefited from this. Thoracic benefited from this, Surgical Oncology and so on. And so yes. We were not being given a priority at the beginning, and I know the struggle I had. So as I grew my department, I had one lab in the Blue Zone, I had one lab in the Yellow Zone, eventually I had two labs in the Tan Zone, so that’s not healthy, right, if you want to build a program, cohesion, mass and so and so. So eventually we were fortunate to get all our brain tumor laboratories, all neurosurgery research, on one floor of the Mitchell Building, but how many years did it take for that?

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Chapter 04: The New Division of System (mid-Eighties) and the Symbiosis of Departments within the Division of Surgery

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