Chapter 02: Attracted to the Division of Surgery at MD Anderson

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Chapter 02: Attracted to the Division of Surgery at MD Anderson

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Dr. Roth begins this chapter by noting that Dr. Balch called him in 1985 about a position as founding Chair of the Department of Thoracic and Cardiovascular Surgery. He explains why the job attracted him from the perspective of both research and administration. Dr. Balch comments on Dr. Charles LeMaistre’s [oral history interview] financial investment in the Division of Surgery’s recruitments. Next, Dr. Roth sketches his first impressions of the Division of Surgery and criticisms of the divisional model from long-term surgical faculty. He sketches his attraction to administrative work and explains that many of them believed that a surgeon could not be a great clinician and devote time to research.

Identifier

RothJ_01_20190314_C02

Publication Date

3-14-2019

City

Houston, Texas

Topics Covered

Overview: Joining MD Anderson/Coming to Texas; The Researcher; Multi-disciplinary Approaches; Portraits; Leadership; On Leadership; Controversy; Growth and/or Change; Understanding the Institution

Transcript

Jack Roth, MD:

+ But then Charles called me up. Let’s see, it had to be 1985.

Charles Balch, MD:

It was ’85, yes.

Jack Roth, MD:

Nineteen eighty five, right.

Charles Balch, MD:

I was recruited here in March of 1985 and officially started on July 1, 1985. And just for the record, Jack Roth and his wife, Elizabeth Grimm, were my first outside recruits.

Tacey A. Rosolowski, PhD:

That’s exciting.

Jack Roth, MD:

You remember that tennis game [ ].

Charles Balch, MD:

I do.

Tacey A. Rosolowski, PhD:

And so how did the opportunity, how was the opportunity presented. What made you perk up your ears and say oh yeah, this is the exit strategy?

Jack Roth, MD:

Well, it was presented as a really very interesting and outstanding opportunity. The offer was to be a chair of the Department of Thoracic Surgery here, and as Charles mentioned—

Charles Balch, MD:

The founding chair.

Jack Roth, MD:

Well I guess so, they really—Cliff [Mountain; oral history interview] was not a board-certified thoracic surgeon.

Charles Balch, MD:

He was in the Department of General Surgery.

Jack Roth, MD:

You know, I never knew that. Well, he didn’t have boards obviously, in thoracic, no one did at that time. Marion McMurtrey was the other faculty member and they had a fellow named Louis DeCaro, I don’t know if you remember Louis.

Charles Balch, MD:

Yeah, I remember him.

Jack Roth, MD:

He did a fellowship with John Benfield but again, he was a general surgery person and also came here as a fellow and then sort of stayed on as staff. So they has those three individuals who were doing the thoracic surgery.

Charles Balch, MD:

The context here is they were really good clinical surgeons doing standard operations as referred to them, but there was no research activities, either clinical or laboratory, and there was no training program, and all three of those were charges from Mickey LeMaistre to me, to recruit people like Jack Roth. I wanted to make the statement at the beginning, that there was going to be a fundamental change in surgery and that we were going to do bona fide, peer review funded, productive laboratory research. Recruiting both Jack and his wife, Elizabeth Grimm, made a huge statement to the institution that going forward, that translational research and clinical trials and training surgical specialties was going to be our mission in the Division of Surgery.

Tacey A. Rosolowski, PhD:

So what were the primary themes that were important to you as you made that decision?

Jack Roth, MD:

Well the primary themes were number one, the ability to carry on translational research and have adequate resources to be able to do that. The importance of translational research is you can move it into the clinic, so you must have the clinical resources to be able to do clinical trials. And these are just not small clinical studies. These would be randomized clinical trials that would be looking at specific endpoints or with very high impact, and early stage trials such as the gene therapy trials we did. We can get into that later. Trials that would have a major impact, and in order to do that, you not only need the patients but you need an infrastructure that’s supportive of research nurses, data management, computers, IT, biostatisticians. I don’t think any of the places I interviewed really had this infrastructure, but Charles was here and I knew that MD Anderson was acquiring this. The other thing was, I knew about MD Anderson. I mean this was an institution, when you read the literature on lung cancer, you see papers from Cliff Mountain all the time. He actually established the first staging system for lung cancer, which was very important because before that, you really didn’t know the outcome and you really didn’t know which patients were at higher risk, which patients might benefit from surgery, which patients might not. Staging is really, really important. He did this with David Carr, who is a medical oncologist who was at the Mayo Clinic at the time, although David, as you might remember, was recruited down here to head thoracic medical oncology.

Charles Balch, MD:

Let me interject based upon what I just said. Cliff Mountain was very visible and really traveled all over the world to talk about the lung cancer staging program that he really had organized through the HACC. He was a very patrician person, he was an excellent speaker.

Jack Roth, MD:

If I could interject, his nickname was the Silver Eagle.

Tacey A. Rosolowski, PhD:

Oh really?

Jack Roth, MD:

Because he had this mane of white hair and [ ] he traveled a lot.

Charles Balch, MD:

I think in fairness, at the time, when I met Cliff in 1985, by that time he spent most of his time traveling and speaking. He, besides doing bronchoscopies and things like that, he did very little surgery.

Tacey A. Rosolowski, PhD:

Let me ask you, were there aspects of the administrative role of being a department chair in this environment that attracted you? Was there something you felt you could achieve in terms of organizing a thoracic department that was intriguing to you?

Jack Roth, MD:

Well yes, I think here we had a department with lots of potential, in a cancer center, so everybody is focused on the disease type that you’re interested in. You have the support of medical oncology, you have the support of radiation oncology. The key thing here is the organization of a multidisciplinary program for the treatment of cancer. We were realizing at the time --and this was work through Mack Holmes in the Lung Cancer Study Group. It was clear that surgery alone, radiation therapy alone, is not going to be adequate for treating lung cancer, that we need to bring in multimodality therapy. Here was the opportunity to work with all these different groups, and this requires an administrative construct that will bring people together. I mean that’s the key thing: so many academic institutions, you have problems with turf. I’m sure you’ve probably not heard of this ever, right, political problems or anything.

Tacey A. Rosolowski, PhD:

It’s life in an institutional environment.

Jack Roth, MD:

Yeah, but people kind of like to guard their own bailiwick, you know?

Tacey A. Rosolowski, PhD:

Of course, of course.

Jack Roth, MD:

A patient comes to a surgeon, they get surgery, a radiation oncologist, they get radiation, so forth. We had to break down those walls, but do it in a way that people would see that it’s going to be beneficial for the patient and it’s going to help their career and their research as well, it’s going to be better for everybody. So breaking down those barriers, organizing multidisciplinary therapy and also building a thoracic surgery practice that would be the top thoracic surgery practice in the world. That was enticing and attractive and challenging to me.

Tacey A. Rosolowski, PhD:

What did you discover when you arrived and you’re getting the read on the institution and what the existing culture is like? What were your impressions of kind of the state, if you will, and I don’t mean to use that in a negative way, but what was the petri dish of MD Anderson surgery at that moment that was going to be changed?

Jack Roth, MD:

Well you know, Charles, you remember this, I didn’t take your first offer to come down here.

Tacey A. Rosolowski, PhD:

Oh, is that true?

Jack Roth, MD:

Or maybe it wasn’t you, maybe it was Mickey [LeMaistre; oral history interview] and Bob Hickey who tried to get me the first time I think.

Charles Balch, MD:

Yes, that’s true, that there was an attempt beforehand.

Jack Roth, MD:

There was an attempt.

Tacey A. Rosolowski, PhD:

Why did you say no?

Jack Roth, MD:

Well, for the reasons you outlined. I wasn’t sure that the culture here was going to be conducive to what I wanted to do. The surgeons here were very practice driven, not research driven, there was very little going on in the way of translational clinical research. Very few of the clinical departments had [ ] research laboratories. There was a Tumor Institute that had some basic science going on, but it wasn’t clear to me that was in any way working together with the physicians to do translational research, so I turned that offer down. It really was when Charles arrived and we could talk about building up this type of infrastructure and research program that it became attractive.

Charles Balch, MD:

So, Mickey LeMaistre gave me a very generous resource package. Half of that package went to Jack Roth and Elizabeth Grimm, as the investment to make a bold statement of recruiting them. I think in fairness, Jack and I were very copasetic in terms of our philosophy professionally. We were very much the triple threat; people who were operating, who had laboratory research, that was R01 funded, NIH supported, immunology research. Maybe part of the attraction was that his wife, Elizabeth Grimm, and I, were working in exactly the same area at the time, on natural killer cells and cellular immunology. So there were a lot of reasons that we were very likeminded in our approach in what we wanted to accomplish. When we came back to Jack and Elizabeth the second time, there were a lot more resources, and I think what they both saw was that philosophically and in terms of research, that the institution through me was going to be very supportive of having them develop a program and have that program grow.

Tacey A. Rosolowski, PhD:

Was that your perception, was that the dinner table conversation?

Jack Roth, MD:

Well, full disclosure here. My wife was not really excited about coming down to Houston, Elizabeth had some real reservations about this.

Tacey A. Rosolowski, PhD:

What were here reservations? I mean certainly we’ll ask her, but what was your recollection of this?

Jack Roth, MD:

Well, first of all quite honestly it’s Texas and she was [not excited about the cultural change]. And we were living in Bethesda, Maryland, which is a beautiful area, very close to her family, and she had a tenured position at the National Cancer Institute, which is very difficult to get. For a basic scientist that’s a real plum. [As long as she was there, she did not] have to write grants, [and she had multiple] resources available that she would have to give that up coming here.

Charles Balch, MD:

And come into a Division of Surgery.

Jack Roth, MD:

Right.

Tacey A. Rosolowski, PhD:

So how did the conversation evolve so that you guys said yes?

Jack Roth, MD:

Well, obviously we both have to compromise to some degree.

Tacey A. Rosolowski, PhD:

Ah, marriage.

Jack Roth, MD:

Yes, but you know, she’s wonderful in that respect and I believe that she was able to see the opportunity. I saw the opportunity here and I said Liz, this is a place that is not going to stay stagnant. It’s going to grow, it’s going to expand, and it’s going to grow in the way that we want it, that we would like to see it grow in terms of science and in terms of clinical resources and patient clinical trials. This place has real potential for growth and that was very attractive to us, the idea that we could be part of something that’s going to be expanding in this way, that’s going to be making a huge impact potentially, in cancer. I think that was the major attraction. Now the fact that Charles brought together this resource package and that Liz would actually have an appointment also, in a basic science department, a really good Basic Science Department here. Fred Becker [oral history interview] just recruited Josh [Fidler; oral history interview] a few years a before, and some other very good recruitments. Reuben Lotan was here and others, that she saw that yes, there is a real potential for basic science here as well. That all attracted her and you know, we felt that of the places we’d seen and the opportunities we had, this would be the best opportunity. Now, we weren’t looking forward over 30 years, to being here. We thought maybe this would be a way station to another place, but as it turned out, it’s been such a fantastic opportunity for both of us that we saw this as the best career opportunity and it’s continued to be our best career choice throughout.

Charles Balch, MD:

Let me interject here because one of the characteristics of all the people we’ve recruited, they were risk takers, they had vision. They had to see the potential for an organization that Jack Roth just articulated. That wasn’t there at the time, but that there were the resources and the environment and the expectations to create something that made it a little bit more favorable. But each of these people, whether it’s Jack Roth or Ray Sawaya [oral history interview; Division of Surgery interview] or others, started programs from scratch that did not exist. The credit I give to them is they had the vision to see where it could be and they were willing to take the risk that the institution would come through with the resources to not only recruit them but to build entire programs and recruit other people along with them. I think part of the other attraction that I saw and was willing to make the commitments for both Jack and Liz is when I came I was a professor of immunology in the Department of Immunology, with Margaret Kripke [oral history interview], working alongside with Josh Fidler, and brought my whole immunology team from Alabama, including Kyoko Ito, which came on to the faculty. Our work was exactly what Steve Rosenberg was doing at the time on TIL cells in tumors and so forth, and NK cells, so I was willing to make a big commitment to both Jack and Roth because they were so likeminded in their research productivity and even down to the exact type of research that they were doing, was something that I thought would be very compatible for continued collaborations. I hope what they saw also, is between the Kripke/Fidler departments in the Smith Building, the recruitments of Fred Becker, and the things that I was doing personally, coming just a few months before them, was something that we could work together and build a really productive program that was funded.

Jack Roth, MD:

Yes, it was clearly an institution that was on the upslope. The administration had the right ideas, the right concepts, they were bringing in good people. Now, all that being said, all the scientists you talk about, and you and I and so forth, we’re a relatively small group in this very large institution.

Tacey A. Rosolowski, PhD:

Right.

Jack Roth, MD:

Where not everybody is buying into this cultural shift.

Tacey A. Rosolowski, PhD:

I was going to ask you about that. What were the themes that you were hearing, why people were suspicious or resistant?

Jack Roth, MD:

Well, individuals here had based their entire career on a certain way of approaching cancer patients. For example in surgery, Cliff Mountain was very interested in staging, which was good, but still the focus was on classifying patients, not really developing novel treatments.

Charles Balch, MD:

That’s a very important part. This was about translational research and how it led to novel treatments such as I’m sure you’ll get into, going into such sophisticated things as gene therapy, which was only being done in a very few places in the world.

Jack Roth, MD:

So particularly in the --I guess it was called the Division of Surgery then, when you took it over, it was the Division of Surgery-- most of the surgeons there were very tied to their approach of seeing the patient, operating on the patient and taking out the cancer as much as possible, without really thinking about is there something we can learn about this, can we enter these patients into clinical trials. We used to have executive committee meetings in surgery, and you can remember the people who were involved in those executive committee meetings, and many of them were simply not either knowledgeable or in some cases actually hostile or not supportive of this type of approach. They thought that we were diluting patient care, you know? If you’re going to do research, how can you take care of patients?

Tacey A. Rosolowski, PhD:

Interesting.

Charles Balch, MD:

This is a very important part but for both me and Jack, we were the only people there at the time who were both NIH funded and operated. Part of the culture was you can’t do both. Either you’re in the lab or you’re an excellent clinical, and you can’t rise to a level of being really excellent clinicians if you have funded research. That was part of the culture we had to break to show yes, we can do that and we’re going to recruit more people who can do excellent research, clinically and laboratory, but who are also excellent clinical surgeons.

Tacey A. Rosolowski, PhD:

Were there other sources of resistance? I mean you’ve kind of outlined a couple themes, you know what were some other things you were hearing?

Jack Roth, MD:

Well, I think there were some administrators. I’m kind of hesitant to name specific names here in a transcript like this.

Tacey A. Rosolowski, PhD:

You don’t have to.

Jack Roth, MD:

But there were some administrators, for example, who kind of felt the same way but in sort of a mirror image. So you’ve got the clinicians who say well, you’re either a clinician or you’re not, and then there were some scientific administrators who would say well, you’re either a scientist or you’re not, you can’t have a foot in both areas.

Tacey A. Rosolowski, PhD:

Isn’t it true that, I mean this was really the period when that odd entity, the physician-scientist, was starting to coalesce, and nobody knew what to do with that person. Am I correct in that?

Jack Roth, MD:

Yes, you’re right. This was an idea that came actually from NIH, to develop this physician scientist program, and they had specific grants for this, training grants were being issued, medical schools were developing MD PhD programs and so forth, to train the physician scientists. It was recognized that this was a very important concept and these individuals would be key in advancing medicine in the future.

Tacey A. Rosolowski, PhD:

But crossing boxes has never been easy for institutions.

Jack Roth, MD:

But how do you do this, where does this individual fit in administratively, how do we get the resources and so forth.

Tacey A. Rosolowski, PhD:

Absolutely.

Jack Roth, MD:

Keep in mind that the 1980s and the 1990s were the golden years for NIH funding, a lot of dollars coming from the NIH. So as this money came in, we had to put it into the best use possible, but at the same time there were real opportunities here to extend the research, advance the clinical trials, with this funding that was coming from NIH, if you could get it. That’s obviously another challenge for the physician scientist, the funding opportunities. Let me backtrack a little bit before I get into that, because we can talk about it. I think funding is very important: how we went about it, how we got it, and the types of grants that we were able to attract here, but you know the first days when I arrived here.

Chapter 02: Attracted to the Division of Surgery at MD Anderson

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