Chapter 05: Evaluating the Division System (1985-1995)

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Chapter 05: Evaluating the Division System (1985-1995)

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In this final chapter, Dr. Roth and Dr. Balch discuss the impact of the Division system (instituted 1985) on the growth of surgery and the interrelationships between surgery departments. Dr. Roth begins by talking about the initial resistance to the restructuring then offers his view of its value and the common resources that were created for use by all surgery departments. He talks about the philosophy of servant leadership that Dr. Balch brought to the institution and gives an example of how the division system enabled surgical departments to grow and improve function: hiring advance practice nurses to address patient safety; reorganizing care delivery around disease sites; building new operating rooms with advanced technology; supporting translational scientists. Dr. Roth next observes that the division maintained the same focus after Dr. Balch left the institution –a testimony to the success of the system. Dr. Balch provides an overview of what was achieved under his leadership.

Identifier

RothJ_01_20190314_C05

Publication Date

3-14-2019

City

Houston, Texas

Topics Covered

Building the Institution; Leadership; On Leadership; MD Anderson Culture; Technology and R&D

Transcript

Charles Balch, MD:

Jack, in our remaining minutes, I wondered if we can talk about the Division of Surgery as an organizational structure. You remember, when I came as the head of the division, this was a new organizational model that was met with some resistance in some circles. I wondered if you could just review the evolution of the division from your perspective as a chair and your role in the division as we worked together to define what are the core facilities, both in education, clinical research, information systems, administration and so forth, that enabled the division to survive and is still there with Steve Swisher as the division head who you recruited as a fellow. But I wondered if you could go back to some of those early years, from say 1986 to 1990, and how it evolved into finding its niche, which people eventually got comfortable with, between the departments in the institution.

Jack Roth, MD:

Well you know, my impression when I got here was that if there was a need for a department, a department was set up. So there were lots and lots of different departments but very little interaction or coordination among those departments, even though they might have very common goals, or if they organized, they might be able to have more resources or useful common infrastructure. This was very unusual because in most medical schools there’s a department of surgery and there’s a department of medicine that brings specialties together that have some commonalities, into an organizational structure, and enables people to interact and work together productively. That was missing here until Charles came. I don’t recall, was the Division of Medicine set up first?

Charles Balch, MD:

Yes, in 1984.

Jack Roth, MD:

In ’84. And of course if you’re a department chair and somebody comes in and says oh you know, we’re going to put somebody above you, there’s going to be some resistance there. You know, I’m losing my autonomy, I don’t have a direct line to the president’s ear, this can affect me negatively. So there clearly was resistance. That was part of the cultural resistance, this new administrative structure. For me, it made absolute sense because we have all these surgical departments which have a lot of things in common in terms of training fellows and residents. These departments, we hoped, would set up research programs, and those research programs could potentially interact, and they could go as a unit to the institution, and say, we need more resources for this, whereas an individual department might not be able to do that successfully. We had division executive committee meetings monthly, I believe.

Charles Balch, MD:

At least, every other week.

Jack Roth, MD:

Maybe it was every other week, yeah, yeah. So all the department heads would come together, and of course there would be administrators and one of the things you did was to bring in a really well defined administrative structure for the vision, there’s an administrative head for that. I can’t remember all the other folks that were brought in. There was a finance person I think.

Charles Balch, MD:

IT.

Jack Roth, MD:

Oh of course, IT, which was absolutely key.

Charles Balch, MD:

This was a time where information systems and computers were still evolving.

Jack Roth, MD:

There was really no IT support. You had to do your own thing with your desktop computer, and I think that was a major contribution because now we have this IT setup where you can get—you can have help almost immediately if you needed it, with your IT.

Charles Balch, MD:

We had a division IT system.

Jack Roth, MD:

Yeah, that’s right, and we had no institutional email at the time.

Charles Balch, MD:

That’s right.

Jack Roth, MD:

Can you imagine without email? So Charles set that up. I remember getting a call—

Charles Balch, MD:

People were using typewriters.

Jack Roth, MD:

I remember getting a call from you and you said, “Hey, we’ve got our email working,” you know, and so that was a big step forward. The addition of the IT is absolutely necessary, not just for the financial and administrative aspect, but also for the research aspect, it’s key.

Charles Balch, MD:

And then we had core laboratory research facilities.

Jack Roth, MD:

Yes. Yeah, that was set up later as well, I guess when we moved into the new research building, right.

Tacey A. Rosolowski, PhD:

What was your impression of, did the—what was the atmosphere during the first convening of these divisional executive committee meetings, did the atmosphere change over time, were people suspicious of each other. What was it like? [01:22:26

Jack Roth, MD:

Oh sure, well I think we mentioned that before, that there were people that were hostile to this situation and they expressed their opinions, their hostile opinions during the meeting. Nevertheless, as the division grew with more recruitments --Ray Sawaya, in neurosurgery.

Charles Balch, MD:

Mark Shusterman.

Jack Roth, MD:

Mark Shusterman in plastics.

Charles Balch, MD:

Who brought micro-vascular surgery.

Jack Roth, MD:

Right, right, and I think when Taylor Wharton stepped down and Gershensen became chair and so forth, these were individuals that were much—that clearly wanted the divisional infrastructure to exist, were supportive of it, saw the advantages of it.

Charles Balch, MD:

And so one other thing historically, at one time Dr. Cox [oral history interview] was the VP who sent out a memo that we’re eliminating the divisions.

Jack Roth, MD:

Yes I remember that.

Charles Balch, MD:

This was right at the time we were recruiting Donna Sollenberger [oral history interview; Division of Surgery Interview] to become the division administrator.

Jack Roth, MD:

I think this was just before—

Charles Balch, MD:

Just to put this in context, in Donna’s oral history she pointed out, when she was interviewed, that one of the Department of Surgery chairs said we don’t need a division administrator because we don’t need a division, but despite that she came. Mickey LeMaistre had a major role in calling her personally and saying, I know you’ve heard this about the divisions going away but yes, they are going to stay here, you have my assurance. And the ladies who were the administrators for other departments, in Radiation Therapy and Medicine really helped a lot, but the point was there was a lot of angst about whether the division was going to stay and be durable and whether it could find its niche. One thing that made it viable was when Donna Sollenberger came with great administrative skills and political skills as well, and working with people and adding value, and working with the administrators in the department. That helped a great deal. That was in the early nineties.

Jack Roth, MD:

I remember that memo. I think it came out shortly before Christmas as I recall.

Charles Balch, MD:

Yes it did and then after, I think it was a painful six weeks or so and Mickey LeMaistre finally sent out a one liner to the entire faculty, “The current structure with the departments reporting to divisions will remain in place.”

Jack Roth, MD:

That’s right, that’s right.

Charles Balch, MD:

It’s just one sentence.

Tacey A. Rosolowski, PhD:

What was your feeling of how the—I mean what the divisional structure does for the departments, but did you have a sense that there was a feedback loop and that departments were contributing something to the division and the evolution of its structures.

Jack Roth, MD:

Well, I think that’s important. A servant leadership structure is usually the most successful. I think greatly to Charles’s credit, he was instrumental in developing that type of administrative structure, you know we’re here, we’re going to help you and we have these resources and let us know what you need. There was a constant give and take, and the departments can certainly bring forward their initiatives and things that they needed in terms of funding space, personnel and so forth, and these would always be considered.

Charles Balch, MD:

For me as a division head, one of the things we did is everything was on the table. Each department chair could see the academic productivity, the surgical cases, the trainings, the grants, the publications. I did that in part because people like Jack were a role model and sometimes, because we’re all goal oriented, when you see what people can accomplish in other departments, you implicitly say well, I’m as good as they are and we’re going to have to rise to a level of having the similar types of productivity, academically and in our clinical work. So there was, part of the philosophy was when you come to the division meeting, that all of the information for all the departments is available. That helped because people like Jack were really bringing a clinical and academic productivity that I think set a good standard for all the other departments.

Tacey A. Rosolowski, PhD:

Did you have a sense about other facets of contributions that the department was making and kind of bringing to kind of push the division, the strength of the division forward?

Jack Roth, MD:

Well, the success of the departments means that the division is successful also, because the division is an administrative structure, it’s providing the support, but the idea is to make each of the departments successful as well. I mean that’s really where it comes down: is our clinical productivity going up? Do we have better outcomes for our patients? Is our research getting funded? All of these things really are done at the department level. So with the success of these departments, that reflects on the success of the division as well.

Charles Balch, MD:

And this in turn allowed us, as a division, to really compete for resources, laboratory space, state funded positions, for nurses in research personnel and so forth. Because the division as a whole, and each of its departments --we could demonstrate our track record, our productivity, the improvements that we were making. Therefore, the need for more resources that could be justified when we go for institutional budgets.

Jack Roth, MD:

Just an example is that, one of the major problems we had in clinical care was that our faculty and our fellows were in the operating room so much that patients on the floor did not have the contact with the physicians that they needed. Sometimes the clinics are shortened because you have to run off and do cases and so forth. We were having not very good relations with a lot of our patients, because of this lack of contact. So one of the things we could show with the increased clinical volume that we have, was a need to bring in really, a new type of individual, that’s the advanced practice nurse. Bringing that individual in on the floor, on the wards and in the clinic, the patient satisfaction and the quality of the patient care just went up exponentially with this program. These were new resources we had to ask for, we had to justify, and I think the division played a big role in our ability to be able to get these advance practice nurses in. Now we have oh, we have about six or seven in our clinic. We have another five or six on the floor. These folks have increased our ability to do cases and maintain a high level of clinical care, and at the same time the patient satisfaction just goes way up, because they love contact with these individuals, they’re there to help them every step of the way, from admission to discharge to clinic appointments. So that was a big step in improving the overall care of patients in the hospital, and again, something you can attribute to the division.

Charles Balch, MD:

This is something I started. I hired the first physician assistant, named Carol Lacey, who worked in our department but showed her value early on. Now the cultural change was she reported directly to the doctor, not to the chief of nursing. There was some resistance about having somebody who is not a clinical advanced nurse but a physician assistant. There are now 300 PAs and next month there will be an entire conference of physician assistants in oncology, attracting people from all over the nation, because MD Anderson is the leading place for physician assistants in oncology, which actually started in the surgery departments.

Tacey A. Rosolowski, PhD:

Gentlemen, let me just say we’re almost at our time and I didn’t want to let things go without asking about kind of the next big transition.

Charles Balch, MD:

I have one more thing just for you to talk about, Jack. When Donna and I went up to the hospital, one of the things that I think was transformational was the establishment of the multidisciplinary disease-oriented clinics.

Jack Roth, MD:

Yes.

Charles Balch, MD:

[01:31::44] And I wondered if you could talk about the impact of that, which we take for granted today but essentially, we eliminated the surgery clinics and repositioned the entire patient care delivery system around doctors of different specialties, but who had the same disease site areas of interest. I wonder if you could talk about the impact of that.

Jack Roth, MD:

No, that’s had an incredible major impact. Our clinic houses medical oncologists, radiation oncologists and surgeons all in the same space and now, we do see the patients individually, not necessarily together but we have a conference every week where everybody gets together to discuss all the cases. This enables optimal care for the patient, once again it’s a question of the best care. Not just the care that I’m able to give but what’s the best care for the patient. Secondly, it’s enormously helpful in terms of getting patients on clinical trials, because we identity which patients are eligible. We have our advanced practice nurses, our research nurses, all with the protocols and we can just immediately, even in clinic, determine if a patient is going to be eligible for a protocol that might involve radiation therapy, medical oncology, as well as surgery, and where that’s going to fit, and then have this at the conference. So, a dramatic increase in the quality of patient care and a dramatic increase in our ability to do clinical research.

Charles Balch, MD:

So Jack, the other part in those last years, from ’90 to ’95, we built a new hospital with new operating rooms, we built a new building for clinical research so that the clinical departments could have laboratory research space and we built a hotel connected to the hospital. I wonder if you could just talk about the impact in your department, of those things, including technology in the operating room.

Jack Roth, MD:

Well, the new operating rooms were much needed, and we need more actually. The technology has advanced in different directions. Minimally invasive technology has become much more prevalent now than it was back in 1995, it was just starting back then. I think we were beginning to use video scopes for thoracic surgery, and of course the robotics have come along now as well. These are technologies that need more space and more sophisticated space in terms of the electronics, in terms of the computer screens, the computers, and all the things that are needed here. So building those new operating rooms was a huge advance in being able to adapt that technology and we’re currently evaluating it now, to see how useful it’s going to be and what the impact is going to be on patient care. Just because it’s new technology doesn’t necessarily mean you’re going to have a better outcome.

Tacey A. Rosolowski, PhD:

There was an article in the Times, just—

Jack Roth, MD:

In fact in some cases, it may be a worse outcome.

Tacey A. Rosolowski, PhD:

Yes, I was reading it in the Times.

Jack Roth, MD:

So it’s very important that this be evaluated critically, rigorously, and in randomized trials, and they were done here at MD Anderson, in the Surgery Division, and so I think that speaks very highly to this group and obviously, we’re trying to do this as well in our department. Now the new laboratory space again, was greatly needed and was extremely helpful. Again, this is technologically sophisticated space that requires very expensive equipment and the laboratories have expanded. They’ve expanded off campus, in the South Campus --I shouldn’t say off the Main Campus-- the South Campus. But the laboratories here in the Main Campus are very important for the translational research, because you want to have the scientists close to the clinicians, interacting with them closely and we want to be able to get specimens from the patients, that we’re able to take directly to the laboratory, so that’s very helpful as well. So all those laboratories, I think contributed greatly to the overall success of the program.

Charles Balch, MD:

And do you remember when the Rotary House opened?

Jack Roth, MD:

I don’t remember that exactly.

Charles Balch, MD:

But it enabled you to have patients who might be across the street, you wouldn’t necessarily send across the state.

Jack Roth, MD:

No, that’s obviously a great addition. Prior to that we had, it was kind of in a converted apartment building that was torn down, I can’t remember. We actually stayed in that when we arrived in 1986.

Tacey A. Rosolowski, PhD:

Was that called the Mayfair?

Charles Balch, MD:

Yes the Mayfair Hotel. I was trying to think of that because we stayed there also.

Jack Roth, MD:

Oh did you?

Charles Balch, MD:

The top floor was where R. Lee Clark lived.

Jack Roth, MD:

Oh I didn’t know that, yeah, yeah. Well, it’s very important.

Charles Balch, MD:

The Anderson Mayfair Hotel.

Jack Roth, MD:

Yeah, the Mayfair Hotel. But the new Rotary House is a wonderful facility, and you’re right, I mean we can release patients there that maybe have a chest tube that can’t quite come out yet and those sorts of things, so it’s a very important adjunct to patient care.

Tacey A. Rosolowski, PhD:

Shall we ask about final transitions?

Charles Balch, MD:

Sure.

Tacey A. Rosolowski, PhD:

Okay.

Jack Roth, MD:

Final transitions, that sounds—[very final!]

Tacey A. Rosolowski, PhD:

Well, in the sense that Dr. Balch left the institution and then there were changes when a new president came in. So the question was, were there tweaks to the division system, different relationships between departments. What was the next period of evolution after the era of Charles Balch?

Jack Roth, MD:

Well, I think things have really sort of maintained the same direction and same focus. Let’s see, let me think for a second here. Did Steve come right after you or who was in between?

Charles Balch, MD:

Helmut Goepfert actually had the job for a year as an interim.

Jack Roth, MD:

Helmut was there, he had it that’s right, and then Raph [Raphael Pollock; oral history interview].

Charles Balch, MD:

And then Raph and then Steve.

Jack Roth, MD:

Raph and then Steve.

Charles Balch, MD:

Helmut finally got the job he should have gotten in 1985.

Jack Roth, MD:

Right, right, right. So you know, Raph Pollock is a physician-scientist, so clearly he helped to expand the concepts that we’ve been talking about and was very supportive of translational research. Very supportive of physician-scientists, and Steve Swisher the same, so I really don’t see any regression there. Again, the times have become more challenging in that respect and there have been, from time to time, some increased emphasis on patient care and productivity, individual productivity, and of course the finances of the institution have fluctuated. I don’t want to get into all those details, but as you know, when the institution is losing money, there’s a lot more emphasis on seeing more patients and balancing the budget and so forth, and not so much an emphasis on doing good science, clinical trials.

Charles Balch, MD:

So maybe when I came and then Jack came right after me, the vision we had, of what we hoped for, really materialized, for me even to a greater extent than I thought possible. A lot of that is because of the support of Mickey LeMaistre and his style of leadership, his ability to acquire developmental money, endowed positions, state funded positions and so forth. I think the other thing you mentioned early on too, that was critical to the success, is we fundamentally changed the training programs to train academic surgical oncologists, most of whom went on to leadership roles, but then they became the people who came on to the faculty and shared our vision that we started out with. So, Raph Pollock I recruited in September, 1985. He came on to the faculty, I helped him and supported him getting a PhD. So like Jack, he had a funded laboratory research program, got his PhD from Eva Lotsova, who was a very tough taskmaster who said I’m expecting you to do PhD work, you don’t get any favors just because you’re a clinician. But I think by training people and changing the training programs early on, it enabled us to identify and develop people who were likeminded to us, who then came onto the faculty and in turn rose to leadership roles.

Jack Roth, MD:

I think some measure of that—

Charles Balch, MD:

Steve Swisher was a fellow under Jack, and so we got to a point you could perpetuate the philosophy of being excellent clinicians but also being excellent academicians in clinical and translational research, because of the change in the training program that allowed us to recruit likeminded people.

Jack Roth, MD:

One good measure of that would be the grants that the institution is receiving, in particularly the Specialized Programs of Research Excellence, the SPORE grants, which are extraordinarily difficult grants to get, they’re very competitive. They were started, I think it was around 1992, at the NCI, with the idea that translational research really didn’t have its own funding mechanism and so John Minna and I were the first actually, here at MD Anderson, to get a SPORE, and that was around 1998.

Charles Balch, MD:

John Minna?

Jack Roth, MD:

John Minna, John at UT Southwestern. In fact, it was the first collaboration between UT Southwestern and MD Anderson.

Charles Balch, MD:

John Minna had gone from the Navy to UT Southwestern.

Jack Roth, MD:

Right, he and Adam Yasgar, [a lung cancer research pathologist].

Charles Balch, MD:

As the director of the cancer center at UT Southwestern.

Jack Roth, MD:

John and I were the first, this was the first SPORE with MD Anderson, but also, I think one of the first collaborations with UT Southwestern [and the first multi-institutional SPORE]. What happened was that to show how this culture expanded and how MD Anderson had changed, at one point the institution had 11 of these SPOREs. So they had gone just from one department, all the way through multiple departments and multiple divisions, getting these highly competitive translational research grants, and emphasizing research excellence and how translational research has expanded. There’s no way these grants would have been possible without them.

Charles Balch, MD:

And a number of these are led by surgeons as PIs or co-PIs, including Jack Roth.

Jack Roth, MD:

Yes, that’s right, and Colin Denney was one, gynecology. I’m blanking on, who is the chair of gynecology now? Karen Lu, Karen Lu was one.

Charles Balch, MD:

Jeff Gershenwald.

Jack Roth, MD:

Jeff Gershenwald, multiple surgeons involved.

Charles Balch, MD:

All of these that Jack is mentioning and those that we can’t remember right now, did their training here and participated in the change in culture.

Tacey A. Rosolowski, PhD:

Well we’re pretty much out of time. I wanted to ask you if there was anything else you wanted to add at this point, final thoughts.

Jack Roth, MD:

Just a big thank you to Charles for recruiting me here.

Tacey A. Rosolowski, PhD:

That’s nice.

Jack Roth, MD:

It worked out well, Charles.

Tacey A. Rosolowski, PhD:

It certainly did. It was supposed to be a short-term thing.

Jack Roth, MD:

It was supposed to be a short-term thing, yeah.

Charles Balch, MD:

We’ll have another story when Liz Grimm comes here, because Liz and I were very similar. We were both doing immunology research. For me to identify two people who had come at the same time, bona fide laboratory researchers, was really, I think one of the most important steps in the success for me personally, as head of the Division of Surgery, to show we could recruit really good people, they in turn could succeed in this environment. I think it set the stage then, for other people. We just had Ray Sawaya come here two days ago and Ray described the attraction for him coming was he saw your success. And so we were able to continue systematically over ten to fifteen years, to grow what is I believe one of the strongest collection of surgery departments of all specialties in terms of their clinical and academic success that meets or exceeds that in any place in the nation.

Jack Roth, MD:

You really need to talk with Liz, she’ll give a great perspective on this I’m sure.

Tacey A. Rosolowski, PhD:

Well I wanted to thank you both for your time this morning.

Jack Roth, MD:

Okay, thank you, we appreciate it.

Tacey A. Rosolowski, PhD:

And let me just say for the record, I’m turning off the recorder at about eight minutes after one.

Chapter 05: Evaluating the Division System (1985-1995)

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