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0:00 - Segment 00B: Interview Identifier

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Partial Transcript: "OK, we are officially recording. And today is the 6th of March, 2016. The time is about twenty minutes after ten."

Segment Synopsis:

Keywords:

Subjects:

0:36 - Segment 09: Learning Administrative Approaches by Leading the Myeloma Clinic

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Partial Transcript: "And we strategized a little bit beforehand, and decided it would make a lot of sense to start now talking about your administrative experience. And I know that last time you mentioned your first experience with administration, which kind of let you know that you had a gift in that area. So if you could tell me about your next significant experience, which I believe was in 2005, you were Director of Clinical Investigation for Lymphoma/Myeloma?"

Segment Synopsis: Dr. Rodriguez begins this segment by explaining that the Myeloma Clinic was originally jointly managed with Transplant Leukemia services. She served as Clinic Chief of the Lymphoma/Myeloma Section from 1994−1996. Dr. Rodriguez explains what she learned from working in this environment of shared resources and how she acquired basic knowledge of how to assess patient volume and flow and determine hours of clinic operation.

Next Dr. Rodriguez explains how the administrative issues shifted once the Myeloma Clinic became autonomous in 2003 and was stressed with challenged of internal utilization of resources. At this point she began her habit of writing reports to ensure transparency. (She notes that she used to have access to downstream revenue reports, but these have since disappeared.) She talks about the biggest lesson she learned at the time: how an individual’s work has an effect on the whole. As an example, Dr. Rodriguez explains that she became aware that the Myeloma Clinic was one of the biggest customers of the CT Scan Unit. She details how this effected operations of the CT Unit and had an effect on other services. She explains that this refined her thinking about how to strategize care delivery in an arena of low resources. Dr. Rodriguez also notes that most physicians tend not to see the big picture in which the deliver care and use resources; she gives examples of stresses to the system that can result.

Dr. Rodriguez observes that she began to attend administrator education courses around this time. As an example of slow administrative development at MD Anderson, Dr. Rodriguez notes that she never filled out a for-service charge form until the 1990s. She talks about issues that arose once billing forms were introduced.

Keywords:

Subjects: 1. Segment Code -A: The Administrator 2. Story Codes - A: The Administrator A: Professional Path B: Building/Transforming the Institution B: Devices, Drugs, Procedures B: MD Anderson History

12:26 - Segment 10: The Role of the Physician-Leader at MD Anderson

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Partial Transcript: "It sounds to me like a good part of what you’re describing is also a communication problem; you know"

Segment Synopsis: In this segment, Dr. Rodriguez talks about the important role that physician-leaders can serve in an organization. She explains that a primary responsibility is to explain the need for institutional changes in terms that clinicians can understand. She stresses that physician-leaders must be able to listen, have a toehold in specific services, and demonstrate that they share common experience with clinical peers. She returns to the example of the Myeloma Clinic’s heavy use of the CT Scan Unit and the pressures that created among all services. She notes that she was first made aware of this resource issue by listening to clinicians vent their frustrations about difficult access to the Unit.

Next Dr. Rodriguez explains that physician leaders must be able to explain a larger reality to data-driven MDs who generally have a much narrower focus. She talks about why, traditionally, there has been a gap between clinical and administrative levels of an organization.

Dr. Rodriguez next talks about the history of physicians and leadership at MD Anderson, beginning with the first president, R. Lee Clark, who went to hire other clinicians with leadership abilities. She explains that in academic institutions, most physicians assume leadership positions that carry academic titles and that reflect their knowledge rather than specific skill at administration or leadership. Dr. Rodriguez believes that today one cannot excel as a clinician and administrator and this is why one is now seeing different titles for physician-leaders.

Keywords:

Subjects: 1. Segment Code: A: Overview 2. Story Codes: A: The Administrator A: Definitions, Explanations, Translations A: Overview B: Building/Transforming the Institution C: Leadership C: Understanding the Institution D: On Leadership D: On the Nature of Institutions

24:41 - Segment 11: Today’s Medical Paradigm Shift

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Partial Transcript: "I have another general question. When I was doing my background research, I read somewhere that you had said that medicine—the entire environment of medicine and healthcare was really poised for what you referred to as a “paradigm shift.”"

Segment Synopsis: In this segment, Dr. Rodriguez provides perspective on what she calls “the medical paradigm shift” that currently challenges everyone in healthcare. She begins by sketching how landmarks in the history of research into causes of disease created paradigm shifts in the pass. She begins with the long period in which doctors learned their craft through apprenticeship to other individual physicians. She then explains that a paradigm shift occurred in the 19th Century, when hospitals became the primary setting for acquiring this training. She notes that the growth of nursing also had an effect on the practice of medicine. She then talks about the technical developments of the 20th century that led to another paradigm shift.

Dr. Rodriguez explains that the current paradigm shift is not focused on technology, but on how care is delivered and diseases managed. She stresses that the new paradigm focuses not merely on the doctor-patient relationship, but on the management of relationships between teams of providers and the institution to deliver optimal care.

Dr. Rodriguez says that MD Anderson is still in the investigational paradigm and may not have the skills to engage patients in being their own health care advocates. She explains that there is a great deal of data available to help individuals prevent cancer and that nearly seventy percent of patients survive for five years. Dr. Rodriguez cites several MD Anderson initiatives that focus on prevention.

Keywords:

Subjects: 1. Segment Code - A: Overview 2. Story Codes - D: Understanding Cancer, the History of Science, Cancer Research C: Research, Care, and Education C: The Institution and Finances C: Understanding the Institution D: On the Nature of Institutions D: Technology and R&D D: The Healthcare Industry D: The History of Health Care, Patient Care

40:46 - Segment 12: The Survivorship Initiative

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Partial Transcript: "And would you like to talk about survivorship in detail now? I mean, that’s certainly a really important topic."

Segment Synopsis: In this segment Dr. Rodriguez talks about MD Anderson Survivorship initiative, which began to take shape, she explains, after the Institute of Medicine released its presidential report From Cancer Patient to Cancer Survivor: Lost in Transition (November 3, 2005). This report, she says, detailed why care for survivors was lacking. Dr. Margaret Kripke, PhD [Oral History Interview] had been appointed to the president’s Committee on Cancer and became aware of the issues. She brought this information to the president of the institution, Dr. John Mendelsohn, who decided to integrate survivorship into MD Anderson’s care delivery system. A committee was formed and Dr. Rodriguez took on implementation of their plan in 2006.

Dr. Rodriguez explains the process she and her committee went through to determine how to implement survivorship care, a process that began with listening closely to all constituents. She summarizes: they build the survivor care clinics in the same way they build acute care clinics.

Next Dr. Rodriguez sketches why a focus on survivorship was controversial when it was first proposed. She touches on bond that forms between the patient and the physician and notes that a primary concern was survivorship programs would ask the patient to divorce him/herself from the main oncologist. Dr. Rodriguez notes that this break can sometimes be more painful for oncologists, who say they enjoy seeing well patients –often the high point of their day.

Dr. Rodriguez explains that they finally settled on a model where one supervising physician determined the activities of mid-level providers in a situation that de-escalates the intensity of visits by focusing on wellness. Dr. Rodriguez sketches the approach.

She notes that a key issue they had to consider: at what point does the primary oncologist see the patient as a survivor? This question will be answered differently in each treatment area and the committee built algorithms to determine the transition point to survivor care, when the risk of relapse is nil. The entire care model for each service is built around four common domains: Surveillance, Prevention, Monitoring for Late Effects, Psychosocial Health. Dr. Rodriguez explains how this model works using the example of lymphoma. She confirms that all the survivorship services are amassing a great deal of knowledge about survivor care.





Dr. Rodriguez notes that MD Anderson began transitioning patients to survivorship in 2010. There is now a significant body of patients and Dr. Rodriguez says her next step is to leverage the information that has been collected.

Keywords:

Subjects: 1. Segment Code - B: Building the Institution 2. Story Codes - B: Building/Transforming the Institution B: Growth and/or Change B: Multi-disciplinary Approaches C: Dedication to MD Anderson, to Patients, to Faculty/Staff C: Patients C: Patients, Treatment, Survivors

61:27 - Segment 13: Aimed Toward an Interest in Survival; Survivorship Care and the Affordable Care Act

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Partial Transcript: "Well, I know—so I said that I wanted to talk about the Affordable Health Care Act."

Segment Synopsis: Dr. Rodriguez begins this segment by sketching how the Affordable Care Act has an impact on care for survivors. She focuses on the assumption payers make that it’s most cost effective to transition patients to their primary care physician after treatment, as oncologists are expensive. She says that is premature for patient who have had aggressive tumors or treatments.

Dr. Rodriguez notes that she spoke at ASCO about MD Anderson model of survivor care. She communicated that the four domains MD Anderson uses to structure a care plan is relevant at all stages of cancer care.

Dr. Rodriguez then explains that her interest in survivorship was a natural extension of her work with lymphoma patients, as lymphoma was one of the first malignancies that could be cured. She understood early the four domains of Surveillance, Prevention, Late Effects Monitoring, and Psychosocial Health.

Keywords:

Subjects: 1. Segment Code - A: Overview 2. Story Codes - D: Fiscal Realities in Healthcare C: Discovery and Success C: Patients C: Patients, Treatment, Survivors D: The Healthcare Industry

72:12 - Segment 14: Lessons in Administration as Ad-Interim Chair of Lymphoma/Myeloma

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Partial Transcript: "Well, tell me about, well, there’s the Director of Clinical Investigation and then there’s the Office of Medical Affairs. How do you want to continue your story? You kind of gave me the background about the change in your perspective. What really was kind of a next big landmark in the evolution of your administrative work and perspective?"

Segment Synopsis: Dr. Rodriguez begins this segment by explaining how her view of the institution changed as she stepped into the role of Ad-Interim Chair of Lymphoma/Myeloma when Dr. Cabanillas retired. She sketches her new areas of responsibility and how this changed her view of operations and the institution as a whole.

Next, Dr. Rodriguez explains that traditionally, a Department Chair is seen as an “erudite expert,” but to be successful a chair must let go of her/his ego and bring forth future leaders in the field.

Keywords:

Subjects: 1. Segment Code - A: The Administrator 2. Story Codes - A: Professional Path C: Leadership D: On the Nature of Institutions

81:42 - Segment 15: Vice President of the Office of Medical Affairs; the Value of Faculty Credentialing

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Partial Transcript: "So I sort of came to this, my current job, in a roundabout way, and that once I stepped down, you know, after having been in this very intense furnace of the interim chair role, and I suddenly was—they hired the new chair, although I did become the Director of Clinical Research, and that in itself was—clinical investigation within the department, that in itself was another set of lessons. I really have always had my heart in the hospital side, in the operation side, and the professional aspect of medicine side. So I simply had had a conversation with a person who, at the time, was the Physician in Chief. And I had said, you know, there are opportunities for operation leadership. Keep me in mind, I’d like to step back into leadership in operations."

Segment Synopsis: Dr. Rodriguez begins this segment by explaining how conversations with the outgoing and incoming physicians-in-chief around she came to her role as Vice President of the Office of Medical Affairs. When Thomas Burke, MD [Oral History Interview] became physician in chief in 2004, her role was expanded to include medical affairs functions. She was officially named in 2005 with service to the present.

Next Dr. Rodriguez notes that learned a great deal about Texas law and regulations of medical practice. She also had to familiarize herself with the roles of Physicians Assistants and Advanced Practice Nurses.

Next, as an example of a function within Medical Affairs, Dr. Rodriguez talks about the process of documenting the credentials that physicians present for employment. She explains why this process is key to the reputation of MD Anderson. She also notes that employees have occasionally falsified documents.

Keywords:

Subjects: 1. Segment Code - B: Building the Institution 2. Story Codes - B: Institutional Processes A: The Administrator B: Institutional Mission and Values B: MD Anderson Culture B: The MD Anderson Brand, Reputation D: Ethics D: Fiscal Realities in Healthcare D: On Texas and Texans

0:00

ROSOLOWSKI:

OK, we are officially recording. And today is the 6th of March, 2016. The time is about twenty minutes after ten.

RODRIGUEZ:

Two thousand and fifteen.

ROSOLOWSKI:

Two thousand and fifteen. What did I say?

RODRIGUEZ:

Sixteen.

ROSOLOWSKI:

Oh, my gosh! That—I usually don’t do that one.

RODRIGUEZ:

You’re time traveling.

ROSOLOWSKI:

(laughs) I know! I am time traveling. Thank you for catching that. And I’m on the eighteenth floor of Pickens Academic Tower today in the office of the Executive Vice President, talking my second session with Dr. Alma Rodriguez. So thank you very much for making time for me again today.

RODRIGUEZ:

Not at all. Thank you.

ROSOLOWSKI:

And we strategized a little bit beforehand, and decided it would make a lot of sense to start now talking about your administrative experience. And I know that last time you mentioned your first experience with administration, which kind of let you know that you had a gift in that area. So if you could tell me about your next significant experience, which I believe was in 2005, you were Director of Clinical Investigation for Lymphoma/Myeloma?

RODRIGUEZ:

Right. So, before getting to that—

ROSOLOWSKI:

OK.

RODRIGUEZ:

There were several stages, if you will, in the evolution of the Lymphoma/Myeloma clinic.

ROSOLOWSKI:

Oh, OK.

RODRIGUEZ:

Because initially, we were included in or jointly managed with leukemia and stem cell transplantation. We were a single, if you will, operational unit, and we shared resources. We shared space, nursing assignments, funding, etc. And it was very interesting, quite frankly, to be in an environment of shared resources where each one of the participants felt they were entitled to more than the other.

ROSOLOWSKI:

Huh. What did you, what did—

RODRIGUEZ:

So, and this was a very—pardon me?

ROSOLOWSKI:

What did you learn from that experience?

\

RODRIGUEZ:

Well, what I learned from that experience was that one had to be very well-prepared, first of all, in understanding the fundamentals of how resources are allocated and distributed, according to need. So you had to—so I learned how to assess patient volumes, patient flow, how to assess nurses to Physician ratios, hours of operation, etc. And being well-informed certainly lends credibility to one’s claims on, or requests for, resources. And that’s a very fundamental principal in operations. You have to justify cost for the operation.

ROSOLOWSKI:

And just to refresh the memory of the listener, this would have been when you were Medical Director of the lymphoma section?

RODRIGUEZ:

Correct.

ROSOLOWSKI:

From 2000 to 2003.

RODRIGUEZ:

Well, it was even earlier than that—

ROSOLOWSKI:

Oh, really? OK.

RODRIGUEZ:

—when we were still joined. Now, we were eventually, if you will, divorced, or separated. Each of the clinics was then separated, which then comes to the period of 2000 to 2003 when we are our own freestanding clinic.

ROSOLOWSKI:

Oh, OK. So the joining that you were talking about had always—I mean, that was pretty much how it was conceptualized.

RODRIGUEZ:

Mm-hmm. Mm-hmm.

ROSOLOWSKI:

In that joint operation.

RODRIGUEZ:

But as we were the separated, and each of us were allocated our own resources, it was interesting because there’s always—at every level, there are different challenges. So now it was not so much paying attention to how we competed, if you will, for resources with the other two groups, but in fact it was the competition within the group. I want to work with this nurse, I want my clinic on these days.

ROSOLOWSKI:

Right.

RODRIGUEZ:

You know, I do not want to be here on Fridays—so the process then became more one of analyzing internal utilization; how is work distributed internally within our own work group? By this time we were a much larger operation, as well within lymphoma.

ROSOLOWSKI:

How had it grown in terms of faculty numbers and provider numbers?

RODRIGUEZ:

I can’t tell you the exact numbers. But we certainly—I can tell you by this time, we had probably nearly doubled the number from when—way back when, we had been joined with leukemia and stem cell transplant, which is one of the reasons why the three clinics were separated, because the operation had gotten so large. It was not possible to efficiently manage all three together. And so in internal resource management, people are much closer to you, if you will. So it becomes necessary to be far more transparent. So I began to create reports that would display how many patients were seen by each of the providers, what their clinic days were. Back in those days, we would also be provided with sheets of downstream revenue that the whole clinic had generated, and at some point, those disappeared, and I’m not sure why. But it used to be that we would know how many—you know, what the revenue to lab, what the revenue to diagnostic imaging and the chemotherapy areas had been from our referrals to those areas, or generating, if you will, business for those areas, for lack of a better word. How many x-rays we ordered, how many chemotherapy cases we had treated, and so on.

So it was a learning period for me as well, obviously, in that I began to understand then the effect that the work of individual has on the whole. I mean, we, in essence, like all other clinics, we were driving downstream benefits and work and workload. So, for example, we became aware that we were one of the biggest customers, again for lack of a better word, of the CT scan unit, I mean patients with lymphoma for staging purposes require that you image the entire lymphatic system. So we had to do CT scans from head or neck, thorax, body. And so we were a big customer of theirs. So we then began to ask that they participate more actively in helping us to plan and strategize for the growth of the clinic. If we’re going to generate so many—if we’re going to be asked to increase the number of new patients that we’re seeing by so many percents, what is that going to mean for CT scans? And if you can’t manage that volume, what are we going to do? So, for example, sometime in this period of time, somewhere in this period of time, there were not enough CT scan machines in the organization to handle the volume that not just us, but the entire clinical operation was generating for diagnostic imaging. So we had to think of alternatives, such as negotiating with St. Luke’s at the time. They had started to build some of their external or ambulatory CT scan units. If we send our patients there, will you send us the reports in a timely fashion? How will we communicate with you? So thinking strategy for care delivery under stress of low resources, I mean, that’s very challenging. And that was another learning point for me.

ROSOLOWSKI:

Yeah, after we turned off the recorder last time, you were saying that every time you reached another administrative level, you realized that you were operating in an entirely different institution. And I—

RODRIGUEZ:

Correct.

ROSOLOWSKI:

—can kind of see how this is an example of that.

RODRIGUEZ:

Correct.

ROSOLOWSKI:

And you’d just seen an entirely new—it’s like putting a different lens up to the Institution.

RODRIGUEZ:

Correct. Correct.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

And, you know, being in that particular scenario, for example, of the CT scanners, understanding who else needs the CT scanners, the sarcoma, thoracic, GI service—you know, understanding how the other services whose clinical work demands that they also have access to the same imaging resources makes one aware of how we’re not the only fish in the pond, if you will.

ROSOLOWSKI:

Right.

RODRIGUEZ:

And I can tell you that the individual Physician providers do tend to be very ingrown, if you will, and view the world only as within the boundaries of their own life. Like I said, you know, it can get fairly—it can get into a sibling rivalry situation, almost, where people are competing for the same day, or I want to work with Nurse So-and-So, well, so do I. So-and-so is my mid-level provider, well, I want to work with them, too. You know. And so, the management and distribution of work internally, but then also proceeding how the internal work affects the external operation of the organization. That was an important learning curve for me.

Also, sometime around this time, and I have to look at all my different diplomas, some of which are hidden by now, were put away. I attended so many administrative educational courses this time to learn more about operations, to learn more about how budgets are done, how forecasting of business is done, how or why third party payers view services rendered, why documentation is so important, why the appropriate billing structure was so important. I know that it astonishes many people when I tell them that when I first arrived at MD Anderson, we didn’t even drop bills. We never filled out a charge form, ever. As a Physician, I never saw a charge form, probably until the ‘90s, the late ‘90s, the mid to late ‘90s. We became aware that, oh my gosh, we get paid for what we do! (laughs) And we introduced the billing forms, and oh my God, you would have thought that this was a revolution. People were not used to seeing those forms, so they conceived of that as just more added paperwork. And then even within the forms, the rules about how we were reimbursed changed, and you had to explain the complexity of the visit. And there were rules about how you calculated the complexity, etc. So there have been many evolutionary changes that have occurred.

ROSOLOWSKI:

It sounds to me like a good part of what you’re describing is also a communication problem; you know—

RODRIGUEZ:

Yes.

ROSOLOWSKI:

—you have the individual providers and then you have a person like you who’s in the administrative function, and has a much broader, more nuanced perspective on these operations. What have you discovered about communicating across that gap, to try to ease some of this?

RODRIGUEZ:

Well, I think that that’s—I mean, you’ve hit on a key issue about administration. I think one of the most important roles of Physicians and administration, but administrators in general, is that you have to communicate in a way that is relevant to the listener why it is that change—how and why certain changes are important, and why it is that the individuals who are affected by the change must engage in the change. So for example, when—and it’s also important to listen. So for example, the issue with the CT scans, initially, my perception was that I was just hearing, because I started to hear from one or two individuals how hard it was for them to get their CT scans. They happen to also be very busy, have very large patient numbers, and they were very vocal individuals. So my thought was, OK, they’re having a bad day, you know?

But then, and again, this is another one of the important reasons why I think Physicians who are in administration have to have some sort of toe hold, if you will, into clinical work. I began to notice I was having trouble getting my CT scans scheduled, as well. So having a shared experience does give one a more realistic perspective on why there’s dissatisfaction, or why the complaints are coming up. So I began to realize, look, I’m not one of the busiest clinicians, and yet I’m having difficulty with this. So these individuals, who have many more patients than I do, must be desperate, trying to get these results back and trying to get the tests scheduled in a timely fashion for their patients. So there’s then a shared reality, if you will, a shared experience, and a validation of the reality of what the individuals are saying. And I think that that’s important. So it’s important—so if the individual—so if the administrators are not clinicians, they at least need to do experiential rounds, for lack of a better terminology. They really should go to the front lines, spend time experiencing what it is that people in the front lines are experiencing, because I don’t think that—there is really a difference in the perceived urgency, I think, of complaints, when you are experiencing the problem yourself. So that one aspect of communication that’s important; being there, experiencing it, so that one understands the reality of what is happening. But then there’s the other side; the explanation of the larger reality. And in general, Physicians are very data-driven. We understand information that is, if you will, factual, informational, graphic.

ROSOLOWSKI:

Mm-hmm.

RODRIGUEZ:

So, sharing that information with people is very important. So, saying to my colleagues, well look guys, we had X-number of CT scans, these five or six CT scanners have to fulfill the needs of not just lymphoma but thoracic oncology department, the Sarcoma Department, the X, Y and Z department, the neurosurgery, etc. So when you add up all the numbers, then you begin to realize, if you total up the number of cases per day that these six machines are handling, it’s not possible for them to fulfill. And if you take into account that each test will take a minimum of X-number of minutes or hours, there are not enough hours in the day for them to fulfill the needs of all of these demands. So let’s talk about alternative solutions. So that’s when we came up, OK, let’s start to talk organizations outside of MD Anderson. Now, here comes the rub though—I had to have approval from the higher ups to say it’s okay to go outside of the organization, to negotiate for your patients to get tests, because obviously, that’s a revenue loss for our organization. So again, appealing and making the case known to higher level administrators on behalf of the group one is representing is also—you know. So it’s up and down. So in a way, you know, if the mid-level or mid-tier administrators, particularly if they are Physicians such as the Medical Directors, their role is really to advocate up and down. You know, to sort of be the conduit from the larger group to the front-line group, and from the front-line group to the larger group. That’s really the key to the job, in my opinion.

ROSOLOWSKI:

There’s so much discussion now about the importance of having physician leaders.

RODRIGUEZ:

Yes.

ROSOLOWSKI:

And I can see that, you know, the contours now of why that’s so key. Are there other things besides being able to create a shared reality, you know, understand the clinical needs? What are some of the other reasons why Physician leaders are so important in an organization like this?

RODRIGUEZ:

Well, I think it’s just the psychology of groups. I mean, we tend to trust the people who are more like us, right? So I think gaining trust from Physicians is perhaps, to some degree, not always, but again it depends on the skills of communication and other interpersonal qualities. But it is much easier for a Physician to have credibility with Physicians than a total stranger, in the eyes of the Physicians, a total stranger that comes and tells them this is how it is. And it’s no mystery that there is a dichotomy in the culture of hospitals; there are the suits, those are the administratives and the coats, and the coats are the Physicians. So there’s that perceived dichotomy of culture. So the coats would listen to another coat. More than they’ll listen to a suit. That’s the bottom line.

ROSOLOWSKI:

And, I mean, traditionally, there has been—or maybe I’ve not been asking that question correctly, you know, what has been the kind of history of having physician leaders in a setting like this? Is it a new thing? What are the impediments or challenges of getting people to take on that role?

RODRIGUEZ:

Well, I mean, it’s not a new thing. Obviously, MD Anderson was established by a Physician, a surgeon, specifically. And of course, he had to assume administrative responsibilities once he came on board as the leader of the enterprise.

ROSOLOWSKI:

And we’re talking here about R. Lee Clark [MD].

RODRIGUEZ:

R. Lee Clark, yes. And then, of course, he on-boarded other individuals that to whom he then delegated responsibilities and authorities, and in turn, they became leaders of other operational aspects of the organization. So, it’s not unknown. But there are distinctions, if you will. And these are—and again, looking in from the outside, they may seem subtle or irrelevant, but they’re really critical and key. And that is that most Physician leaders assume responsibility or take on that leadership role under the auspices of academic titles; the provost, the dean, the chair, the deputy chairs. Those titles in those designations are under academic format. And those are individuals that are assumed to have gained that title and that authority through the acquisition of knowledge of that specialty, or that area of work. You know, so the chair of radiology will be seen as an expert, an utmost expert in radiology, right? But in today’s reality where—at least in our organization—where we are really one entity, the academic and the operational and [inaudible] enterprise, they’re one big pot. We really have to do both well. But the truth is, one cannot do both well. It is not possible to be an expert and the leader, and the most grant-driven leader in a specialty, and at the same time be the most expert and best at safety, quality, financial, organization, operational expertise, that is required to run the organization well. That’s—it’s not possible. Those are two huge jobs, in and of themselves. So—

ROSOLOWSKI:

And that’s aside from, you know, the problem of assuming that just because a person has acquired great knowledge and specialty, that they will, therefore, have a great ability in admin.

RODRIGUEZ:

Exactly.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

Exactly. That’s a huge and inappropriate assumption, we’re learning, now, in the current reality. That might have been very feasible and workable twenty years ago, like I said, in the early 1990s, where we didn’t even know about billing. (laughs) But it’s not an acceptable reality today. And so this is why now you’re beginning to see more titles for Physician leaders that are different, such as Chief Medical Quality Officer, such as myself, the Vice President of Medical Affairs, and so on. The Directors of the various clinics who progressively now are being relied on much more by our Executive Vice President for Operations, because that’s where the rubber meets the road in the clinics. So you have to have somebody who understands how the clinic runs to help run it. So—

ROSOLOWSKI:

I have another general question. When I was doing my background research, I read somewhere that you had said that medicine—the entire environment of medicine and healthcare was really poised for what you referred to as a “paradigm shift.”

RODRIGUEZ:

Yes.

ROSOLOWSKI:

And I wondered if you could talk to me about what that involved, and how it connects up with this issue of Physician leadership that we’re discussing.

RODRIGUEZ:

Yes. OK. Well, so I’m going to digress for some time—

ROSOLOWSKI:

Sure.

RODRIGUEZ:

Just so that we have the perspective of what I’m speaking of today. So, up until the 1800s, for example, when scientific inquiry began to revolutionize, truly revolutionize medicine and to make a scientific inquiry into the cause of diseases, and we discover microbes, and we discover principles of immunization, for example, and principles of hygiene and epidemiology, and how those are very critical in illness, up until that point, throughout history and up until the middle ages in Renaissance, medicine was taught pretty much as an apprenticeship, you know. Yes, there was a period or a face of didactic learning, where the Physicians would go to a university and learn about anatomy, and whatever was known at the time about physiology, was a great deal of herbology, and techniques of how to excise tumors, etc. But truly, it was an apprenticeship, and one would seek a practice, a Physician in practice; one would go and be mentored by that individual, who would take the young Physician under their wing, and the Physician would then learn through the older individual and learn their practice. In the 1800s, hospitals became a reality.

And by the way, hospitals, for a long time, were place to go die, not places to go live. And it was the revolutionary changes, again in the 1800s, that were brought about by nursing, you know, when nursing was developed finally as a distinct, professional pathway, if you will, a distinct profession that helped to sustain patients staying alive after surgery, and it was not just, you know, removing their waste and bringing them plates of food when it really became a care profession. Then Physicians and nurses could partner, and then hospitals became the training, the better training places for Physicians to learn acute medicine. So this is the period of the 1800s into the early 1900s, when we see, if you will, the scientific basis of medicine begin to take root. So medicine transitions from an apprenticeship, really, to a more systematically learned practice. I mean, that’s where the term “intern” comes from; an intern was somebody who would literally live in the hospital. They never left. They were left twenty-four hours to take care of the patients. And that’s where the word resident comes in as well, because one would reside in the grounds of the hospital to be available to the hospital.

And so that was the paradigm shift, from an apprenticeship to a truly learned profession, in given environments with a more scientific basis. And then we transition, then, in the twentieth century to highly technical developments; to the introduction of hemodialysis that allows people with chronic renal disorders to live. Heart bypass and organ transplants, bone marrow transplants. So the twentieth century was like an explosion of technical and further scientific evolutions. In fact, medical oncology, as a discipline, isn’t really born until the mid-twentieth century. So we’re a relatively young profession, or arm of medicine. So that’s yet another paradigm shift, you know, our ability to manipulate physiology and technology in such a way that we are now transforming the life expectancy of individuals.

But the new paradigm now is no longer focused so much on the technology, but actually how we deliver care, because for the longest time, again, the assumption has been that medicine’s about the patient-doctor relationship. But the truth is that health and well-being and the management of illness which, by the way, are different issues—everyone thinks that healthcare is health care. No. There are different paradigms and faces within that, as well. There’s the health maintenance, there’s the chronic illness management and then there’s acute illness management. They’re all different. So, but in any one of those faces, it really is no longer about just the patient-doctor relationship. It really is about the patient and medical team, or clinical team relationship.

ROSOLOWSKI:

And about an institution.

RODRIGUEZ:

And institutional relationships.

ROSOLOWSKI:

Yes.

RODRIGUEZ:

And so, what is now, if you will, under what really should become the important analytical—let me backtrack. What really we need to look at critically now, what we need to learn about now, I mean, we were learning—in the 1800s, we were learning about microbes. In the twentieth century we were learning about how to manipulate technology and alter human physiology. This time, we need to learn how we manage ourselves and our systems; how we best deliver in a system. How do we deliver the most optimum care? So medicine itself, the delivery of care itself, is now the subject of inquiry, in my opinion, that’s most fascinating and most challenging. I understand that MD Anderson is still under the paradigm of let’s investigate illness down to the genetic level; but frankly, that is not what’s going to solve the problem of cancer. And I don’t mean that disrespectfully. That is going to solve the problem of certain cancers. But the problem of malignant disease in the larger community is going to be solved by how we address population behaviors, how we address education of individuals, how we engage the individuals to be accountable and to manage their own health most optimally. I truly cannot be at the bedside, or at the table, I should say, in the home of my patients watching to be sure they don’t eat carcinogenic foods. I can’t do that. That’s not possible. I can’t be watching them while they sneak out to have their cigarettes, right?

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

That’s not possible. So the most meaningful preventive health measures are entirely within the domain of individual control.

ROSOLOWSKI:

It sounds like in in some ways you’re revisiting the scenario you confronted in San Antonio, I believe it was, when you were interested in diabetes.

RODRIGUEZ:

In diabetes. Correct.

ROSOLOWSKI:

Yes. And it really now providing mechanisms to support management of individual behavior—

RODRIGUEZ:

Which is another health disorder that is within the scope of individual—largely. Not entirely. There are some individuals who, unfortunately and regretfully, the pancreas just quits working.

ROSOLOWSKI:

Right. Right.

RODRIGUEZ:

But for most people it’s not that the pancreas doesn’t work at all, it’s just that the metabolism in their body has been so altered by their dietary and lifestyle habits.

ROSOLOWSKI:

So what impact—I mean, how is MD Anderson engaging what you see as this new paradigm in any way?

RODRIGUEZ:

Well, we are to some degree. I mean, so remember that I said that, you know, within what people consider to be healthcare, there really are different—there are different domains of healthcare. There is true health management where one does what I just spoke about, one motivates and engages one’s patience as partners in the care delivery. And that’s predominantly a primary healthcare issue, and frankly, I don’t think Physicians are necessarily the best at that. I mean, I think that nutritionists, exercise experts, even behavioral medicine specialists are far more expert at doing that. We’re not trained to do that. We’re not trained to maintain health. We are trained to take care of disease. We are trained to be disease management experts. So for Physicians, chronic illness management and acute illness management are the domains of our education.

So to answer your question, how do we engage people? Well, we don’t do that very well. Nonetheless, we have accumulated a large body of evidence that supports our moving, if you will, the needle towards the domain of prevention, progressively more. And we can do that at two ends. We can do that before people get cancer, but we can also—we also need to do it after people get cancer, because actually, we’re getting so good at the management of cancer that if you look at the statistics for the American Cancer Society and the National Epidemiology Database, the SEER [Surveillance, Epidemiology and End Results] database, you will see that nearly seventy percent of patients who are diagnosed with cancer today will be alive five years or longer from today. So these people are going to have further opportunities for other cancers, OK, so it’s equally important, not just for the people who are pre-survivors, that terminology is now being used, previvors. Previvors, I think, is the actual term. Previvors. And then the survivors of cancer.

So how do we influence those groups, is now coming into our consciousness. There are people who now—you know, there are fellowships now that are being focused more towards prevention, as well as post-cancer management. We are, in fact, engaging with Baylor University to develop a residency program for along the track of internal medicine with a focus on cancer management. And that means helping patients manage their illnesses, such as diabetes, heart disease and so on, probably go through the challenge of being treated for cancer, but then post-cancer as well. So those are changes that I foresee in the future. So one of the ways in which as an organization we’re doing that, for example, is that, you know, we are committed now to the—we have been for a long time committed to a tobacco-free environment, but we didn’t necessarily require that our employees were tobacco-free.

ROSOLOWSKI:

Right.

RODRIGUEZ:

Now we do. We have—

ROSOLOWSKI:

And that was instituted when? Was that earlier this year, or was it last year?

RODRIGUEZ:

Correct. I think it was—well, probably it was last year.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

Sometime last year. You know, we’re also taking that message in our international relationships, that coalition that was established with the National Institute in Mexico, National Cancer Institute in Mexico for prevention of tobacco-related illnesses and tobacco-related malignancies. I mean, sadly, worldwide, the rise of tobacco-related illness and malignancies is rising. But one country at a time, I guess.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

So that’s another strategy. But I think, going back to the larger community, we also collaborate with other institutions across the state in what is called the Texas Cancer Control Plan and, you know, our cancer prevention program is part of that. And we assume a leader—we have, I don’t know exactly how many years, but I know that Dr. Lewis Foxhall, who’s in the Cancer Prevention Department, has a leadership role in that initiative. So those are some of the ways in which we are starting to take some responsibility for that. And then, of course, on the post-cancer arena, we are developing, or we have over the last several years, been developing the survivorship program. And we are—we make ourselves available to anyone who wants to reach out to us who wants to learn how we’re doing it, we freely share our lessons learned. We’ve been developing the program, we share the model that we’ve developed.

ROSOLOWSKI:

I mean, I know that that’s been a major initiative since 2006, and probably even—maybe even earlier, that was also part of your role as Director of the Office of Medical Affairs.

RODRIGUEZ:

Yes.

ROSOLOWSKI:

And would you like to talk about survivorship in detail now? I mean, that’s certainly a really important topic.

RODRIGUEZ:

Sure.

ROSOLOWSKI:

Or, would you like to continue with the administrative story? Up to you.

RODRIGUEZ:

No. I’m happy to do that.

ROSOLOWSKI:

Talk about survivorship? OK, great. So how did—how did that survivorship initiative begin?

RODRIGUEZ:

Well, for—I’m not quite sure how the Institute of Medicine—where it began for the Institute of Medicine. But as an organization, one of our prior leaders, actually our first female leader at the executive level, Dr. Margaret Kripke, was appointed to the President’s Commission on Cancer. And at that level, she began to interface with other leaders at the national level, and became aware of the issue of cancer survivors. Mr. Lance Armstrong, at the time, was a member of that commission as well. And he has been—was a much well-known advocate for cancer survivors at the time. So Dr. Kripke was very intrigued by this concept, brought it back, shared it with our President, Dr. [John] Mendelsohn, and shortly after that, the Institute of Medicine report was published. It was published in 2005, and it’s called, From Cancer Patient to Cancer Survivor: Lost in Transition, and that’s a heading, Lost in Transition, really is the main message of that report, and that is that patients felt they were lost as they transitioned from having been under the care of an oncologist and being treated for their cancer. Once that experience was over and they tried to reintegrate into a more normal life, they felt that they were lost and excluded, because the health community did not want to take them on as patients. Sometimes the primary care providers were afraid of assuming responsibility for the care of these individuals, because they felt, you know, once you’ve had cancer, God only knows what will happen after that.

ROSOLOWSKI:

Right.

RODRIGUEZ:

They didn’t want to take responsibility for that, for the care of that individual. Or the patients, worst yet, had lost their insurance, which, by the way, was very common, and therefore, they could not access health services, even if they wanted to, even if there was somebody willing to take them on as patients. They couldn’t. They didn’t have insurance. Many lost their jobs, and that’s very well-documented. A diagnosis of cancer is one of the medical conditions that’s most likely to result in bankruptcy. It is one of the conditions that has the highest rates of divorce as the consequence, and therefore, sometimes in a marriage, one partner was the insured partner and if the other individual, the uninsured partner was the cancer patient, well, there goes the insurance once they’re divorced.

So there are many—there were many difficulties that cancer survivors were facing. So this was made public knowledge, so therefore, again, our President, Dr. Mendelsohn at the time, felt that it was important that we integrate cancer survivorship as into our care delivery system. So he charged a committee to take this on. I was not part of that initial committee that formulated the proposal to him. But I was asked to take it on when the implementation phase was deemed to be the right time. Dr. Burke was the Physician in Chief at the time, and he asked that—he delegated that responsibility to me.

ROSOLOWSKI:

And that was in 2006?

RODRIGUEZ:

Correct. So we formed a steering committee, first of all, multi-disciplinary. We began to map out how we would do this. Certainly it was far more than I could handle on my own, so I requested that I have a true operations expert person to help develop this. So we did. And the person who really was instrumental in doing the front-line work, if you will, the operations work, her name is Fran [Frances] Zandstra, she just retired.

ROSOLOWSKI:

Fran—

RODRIGUEZ:

Zandstra. Z-A-N-D-S-T-R-A. She had been the clinical administrator for several clinics; she then had been a Director for Patient Affairs. She was very knowledgeable about how the Institution worked. She had a network of friends and colleagues in the Institution that knew her and respected her. She was very patient, centered in her approach to things. So she and I partnered in this initiative, and kind of building the model and the implementation of the process. And what seemed to work best, again, part of the listening mode and being in the front lines, part of what we learned to work. So we held focus groups, we got input from providers, we got input from patients and their families. In the end, what we heard both the providers and the patients tell us was, the patients were accepting of the idea that maybe their focus—the focus of their care was no longer going to be necessarily the cancer itself. And in fact, many of them welcomed that it would now be more wellness and prevention.

But they did not want to separate from their clinics. They wanted to feel that their oncologist, or the community of oncologists who were expert in their disease, were still linked to that survivor care. So we built the survivor care clinics in the same way that we built the acute care clinics; in other words, the Breast Center had their own breast survivor clinics, the Gynecological Oncology Center has their own gynecologic survivors clinic. Head and Neck has their own head and neck survivor’s clinic, etc. We did find, however, that some clinics really were pressed for space; so, for example, the Thyroid Center felt that they were very cramped for space, and they would welcome transitioning their survivors to a different space. They still wanted to remain linked in providing the services, so they would assign who would go to the survivor clinic, but they couldn’t do it in their own space. So they transitioned their patients to the Cancer Prevention Center, which had a lot of space at that time.

ROSOLOWSKI:

Can I ask a question?

RODRIGUEZ:

Mm-hmm [affirmative].

ROSOLOWSKI:

When this report came down, and John Mendelsohn and then the committee kind of began working and the Institution began to understand this was going to be added to the pallet of care delivery, was it controversial? I mean, what—

RODRIGUEZ:

Yes.

ROSOLOWSKI:

Why?

RODRIGUEZ:

The controversy was that we were, first of all, we were saying the care for these patients is no longer about their primary cancer. So first of all, having had cancer A doesn’t mean that you’re under the threat of cancer A for the rest of your life. In fact, you maybe at higher risk of cancer B or cancer C as you grow older. So that was one message, you know, bringing to awareness of the primary oncologist that, you know, guess what? The disease that you treated and the care for this patient is no longer the focus of this patient’s life, or should no longer be the focus of the care of these patients, moving forward. So that’s a little bit of a threat, right?

But the other more important issue is that we were asking people to, for lack of a better word, divorce themselves from their oncologist. And so, there is, you know, the reason the so-called model of the dyad of the doctor-patient relationship has lasted for such a long time is that that is very inherently basic to human psychology; you know, the healer-healed person relationship. You know, it’s been talked about extensively in psychiatry and psychology, and it’s real. I mean, there is a bond that forms between the Physician and the patient, and particularly in a situation where the patient perceives that their lives have been saved by this individual. And so it is very emotional, it can be very emotional. It can be difficult, both for the patient and the Physician. We found that in some cases, it wasn’t necessarily so difficult for the patients, again, as long as they knew it was within the same clinical environment where they were cared for before, but in fact, it was more traumatic for the Physicians because they felt that seeing these patients who are well from the perspective of the cancer, who had survived the cancer and were still free of the cancer, that that was the height of their day, that was the most enjoyable part of their day, and we were going to deprive them of that. So that was a challenge, the psychological separation.

The other challenge was, like I said, the operations, you know, where do we find the space? Where do we find the rooms? Who is assigned—who is going to be assigned now to do survivor clinic? Will it be one of the Physicians within the clinic, or will it be mid-level providers? Or will it be a Physician supervising several mid-level providers? In the end, it really was more of a model of a supervisory Physician with multiple mid-level—with mid-level providers; sometimes multiple, sometimes one or two at most, depending on the volume of patients’ transition. But it became clear that really, one of the benefits of the survivor care model is that you can deescalate the intensity of the visit to being more health-oriented. And again, remember what I said about Physicians are not always the most well-trained in health and motivation training. Sometimes the mid-level providers and nutritionists and social workers—so we built partnerships of this other tier of providers, who could then help the patients maneuver through these others issues.

ROSOLOWSKI:

So tell me about the stages in setting that up, I mean, like, kind of—I’d like to get kind of more of a portrait of how the survivorship initiative at MD Anderson works.

RODRIGUEZ:

So we started off, of course, doing pilots in a couple of clinics, first of all to test the model to see if it was feasible.

ROSOLOWSKI:

And just for clarity, was this a model that you adopted from somewhere else and then tweaked, or—

RODRIGUEZ:

We designed it.

ROSOLOWSKI:

You designed it. OK.

RODRIGUEZ:

We designed it to fit, like I said, the psychology and the structure and the operations of our own organization. And being that we have multi-disciplinary disease-specific clinics, and that the patients felt most comfortable in that closeness to their primary clinic, we built the survivor clinics for each disease group for patients with certain categories of disease within that same group. So in gynecology, for example, we built a gynecology survivor clinic in the Gynecology Center. How we would start off is simply by looking at their patient populations and saying, you have X-number of patients who come to your clinic on a yearly basis. We notice that X-number of these patients have not had any treatment for the last three to five years. Would you not consider these patients to be well?

ROSOLOWSKI:

Oh, OK.

RODRIGUEZ:

And to be survivors? We didn’t say immediately upon completing chemotherapy you must transition them to survivor, that’s not what we said. We said at what point do you, the clinicians, consider it safe to transition to survivorship? So remember I said that we took into account both patients’ opinions and the doctors’ opinions; the doctors’ opinions were, OK oncologic care does not end, really, cancer care doesn’t end until the patient has reached a point at which the risk of relapse is fairly minimal to nil. That’s when it’s safe for me to say, “You’re a survivor.” So that’s what our community said. You know, and I can talk about what the national discourse is from the Affordable Health Care Act perspective. But from our providers’ perspective, it was, we’re not done until we’re sure that your risk of cancer is minimal.

We want to continue to follow you through surveillance. So again, the cancer care continuum—and there’s my little diagram—what we’re speaking of is, once treatment ends, it ends here. But we have to keep watching for potential risk of relapse. You’re under what we call a surveillance period for potential recurrence of your illness.

ROSOLOWSKI:

Would it be possible for me to have a copy of that?

RODRIGUEZ:

Sure.

ROSOLOWSKI:

I can put it right into your transcript.

RODRIGUEZ:

Oh, OK.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

And you know, for some cancers, that period of risk of relapse may be very short. It may be a year. So maybe the patient can be considered well, and we can bless that they can transition to survivorship in a year. But for other diseases, it might be five years. For some it might be ten years. We don’t know. I mean, so which is why we delegated that responsibility and accountability for determining the time point of appropriateness of transition to the primary providers. And we said it has to be risk-based. So to do that, they built what we call algorithms of transition. So for disease X, when would be the appropriate time point to transition? For disease Y, what would be the appropriate time point for transition? And then we built the actual care model. So in other words, you’re not just going to toss your patients out there. You have to tell us what are the key care domains, or elements without four domains—we built the domains based, again, on the Institute of Medicine report.

So first of all, you have to do some aspect of surveillance for second cancers. You also have to do prevention in early screening. You have to monitor for late effects of the chemotherapy or radiation or surgery, because unfortunately, those will happen and some patients may be at higher risk than others. So we call that a late effects monitoring. And then lastly, psychosocial health. Did these individuals get back to work? Are they OK mentally? Are they chronically depressed? Chronically anxious? What is going on in their lives? So those four domains of surveillance, late effects management, cancer preventions and psychosocial health, those four key areas had to be addressed in every single algorithm. But it was up to the disease sides to tell us what do we put in those boxes. So in breast, for example, under the psychosocial domain, body image was one of the aspects of psychosocial health that sometimes can emerge as an issue in the patient’s mental health. I treat patients with lymphoma patients, they sometimes, particularly if they had radiation in the chest area or in the neck area, they sometimes can develop hypothyroidism later on. So monitoring thyroid function as a late effect was really important, and so on. I’m just giving you those as examples, that each disease category has its own potential late risks, potential consequences from the treatment and from the disease itself. Patients who have had head and neck cancers, for example, are at risk for developing other head and neck cancers. So they have to have a certain type of exam done on a yearly basis, so that they get completely checked to be sure they are not developing other late second or third oral cancers. So there’s all of these disease-specific knowledge that we built into these models of care. So the providers feel comfortable, I’m not just sending these patients to a clinic where somebody’s going to say, “Eat vegetables.” That’s not it. They’re going to have, you know, a delivery of care that is aligned with these concerns that need to be addressed downstream.

ROSOLOWSKI:

I’m kind of seeing, and tell me if this is the case, that charging each one of the disease areas with this kind of activity also perhaps meant it was asking them to regularize and accumulate their knowledge in a systematic way—

RODRIGUEZ:

Correct.

ROSOLOWSKI:

—that maybe was different than what they had done before.

RODRIGUEZ:

Correct.

ROSOLOWSKI:

Did the individual disease area see this as valuable? Has that activity itself had an impact on the Institution?

RODRIGUEZ:

Well, as many years as now we’re in this process, we really didn’t begin to transition patients in significant volumes until 2010.

ROSOLOWSKI:

Oh, OK. Wow. So there was a long set-up time—

RODRIGUEZ:

Correct.

ROSOLOWSKI:

—exactly to create all that body of information.

RODRIGUEZ:

Correct. Correct. So since 2010, however, we now have, I think, a significant body of patients, volume of patients transition that we—that’s my next agenda item, if you will.

ROSOLOWSKI:

Sure.

RODRIGUEZ:

Let’s start to strategically utilize this information, this data, to assess where are we today? What have we learned from our survivorship model of care? And what should we change? Or is it optimum as it is? Or how can we continue to improve it?

ROSOLOWSKI:

Do you have any inklings of this at this time?

RODRIGUEZ:

Well, I know—so I said that I wanted to talk about the Affordable Health Care Act.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

OK. So there’s a movement nationally now that says, well, oncologists are very expensive, and they order too many tests for surveillance. So let’s transition everybody to primary care after treatment.

ROSOLOWSKI:

Oh, OK, right.

RODRIGUEZ:

And that may be appropriate in some, for some diseases, for some types of malignancies. According to our providers and according to our—what I think we’re learning is that that would be premature for patients who have had very aggressive treatment, or who have had very aggressive tumors. And so, if that kind of concept of how care will be delivered in the future for cancer survivors takes hold, I think we will see a lot of patients who, regrettably, will not do well. I think there is merit to having oncologic care still continue for the period of time at which, or during which, the survivor may be at risk for recurrence of the same disease simply because they already have the relationship with the oncologist if early detection of relapse happens, perhaps a more reasonable—more reasonable options of treatment. Perhaps a what we call a first-line salvage treatment strategy would be workable and feasible, versus patients showing up with very late metastatic recurrence. So pros and cons for both strategies. Obviously on the con side of transitioning the patients, psychologically, maybe, it’s an earlier separation from their identity from the prior cancer. I mean, there could be that psychological benefit. From the healthcare account’s perspective, perhaps the primary care providers are going to do less tests. Maybe, I don’t know. To me, the solution is simply to say the oncologists, you’re accountable for the number of tests you do. (laughs) Justify why you’re doing the tests, rather than saying, you know, don’t see the patients. Anyway—

ROSOLOWSKI:

So, I assume that the, you know, frustration about this is that the Affordable Care Act hasn’t been in place long enough to actually accumulate the data—

RODRIGUEZ:

Correct.

ROSOLOWSKI:

—to provide evidence about that.

RODRIGUEZ:

That’s correct.

ROSOLOWSKI:

So is this office, or other groups or initiatives within MD Anderson positioned to collect this information? Keep track of it?

RODRIGUEZ:

Not yet. Because, quite frankly, I think that there’s a great deal of consternation and there’s huge variability as to how people are interpreting this whole process of transition. In fact, I was invited to speak at the American Society of Clinical Oncology this year about our model of care, and to share with other organizations how we had been doing it. We fully acknowledge that, you know, obviously we are quite unique; we have a huge number of resources. We are very blessed to have all of the number of resources we have. But nonetheless, I think that the model of the domains of health that are relevant to healthcare of the providers—of the survivors, rather—is relevant no matter where the survivor is taken care of. People need to pay attention to cancer prevention. They need to pay attention to the psychosocial health of the patient. They need to pay attention to the late effects that are going to happen. And if you don’t know how to do this, then go learn. And whoever it is who’s going to be providing the care, whether it’s an internist or a family practitioner, or even the oncology practice itself, perhaps, may hire on an additional staff member, and they’ll say, OK, now this is the survivor, so your charge—whoever it is that’s doing the care, however you built the model in your own practice, whether it’s a small practice or a large practice, whatever it is, those four domains of health have to be taken care of. It’s just like saying, if you’re monitoring diabetics, guess what? You have to monitor their fasting glucose or hemoglobin A1C. You have to send them to the ophthalmologist and the podiatrist. You know? It’s the same issue. There are certain aspects of health that have to be paid attention to.

And you have to understand which are most important, based on the disease and the type of treatment the patient received. Which is why there is resistance among the internists or the primary care providers, because they said, we don’t know about chemotherapy or radiation. You do. You, the oncologists, do. You are the ones who really should be doing this. And from our perspective, you know, we’re happy to take care of the survivors. It’s just that the pressure is mounting that we not take care of the survivors. And there are pragmatic reasons for that, one, of course, being you’re more costly.

ROSOLOWSKI:

Right.

RODRIGUEZ:

But the other being that there will be fewer of us in the future, it’s predicted that the number of, the ratio of oncologists to the number of patients with cancer diagnoses is going to dramatically shift, and there will be much fewer of us.

ROSOLOWSKI:

Right. I mean, not only are there fewer doctors, but there are increasing numbers of survivors as—

RODRIGUEZ:

Correct.

ROSOLOWSKI:

—treatments become more and more effective.

RODRIGUEZ:

Exactly. Exactly. Exactly.

ROSOLOWSKI:

Right. Huh. Well, I did interview Lewis Foxhall, and he spoke a lot about the community, the education programs for community Physicians, and kind of even attempts to integrate education about oncology care in medical school curricula so that Physicians would have that survivorship and cancer treatment on their radar from the very beginning.

RODRIGUEZ:

Correct.

ROSOLOWSKI:

It sounds like that the initial steps to being able to put oncologists in partnership with physicians in the community.

RODRIGUEZ:

Correct.

ROSOLOWSKI:

Yeah. Really interesting issue, a whole new dimension of activity. Was survivorship—how did you personally become interested in survivorship?

RODRIGUEZ:

Well, I take care of lymphoma patients. And lymphomas are a group of diseases that, actually, from the early days of medical oncology, were one of the first categories of malignancies to be cured by chemotherapy. And so over the years, I have had a large population who were long-term survivors. And so I just noted these problems, so I’m familiar with the issues of, you know, prevention, second malignancies. I can’t tell you how many second malignancies I’ve diagnosed or picked up on routine monitoring and visits, surveillance visits for my patients. You know, having survived lymphoma which, by the way, is not one of the most common malignancies, it usually ranks fifth or sixth for both men and women, but far more common are breast cancer, colorectal cancer, lung cancer, thyroid cancer in women. All those are more common in women, and breast cancer being, of course, the most common. Breast, colon, lung if they’re smokers, gynecologic cancers, thyroid cancers—all of those rank above lymphomas in women. So being aware of those as possible occurrences over the lifetime of my patients was important. They’re not risk-free, just because they were treated from lymphoma. And it’s amazing how many patients would tell me, “Well, I had chemotherapy, don’t you think that would have taken care of all those cancers?”

ROSOLOWSKI:

Oh, yeah.

RODRIGUEZ:

And I go, “No. Actually, unfortunately and sadly, it might even exacerbate your risk for getting those cancers, because the chemotherapy itself, of course they’re toxic chemicals. We don’t know how much they might influence a late effect risk of getting other malignancies.”

ROSOLOWSKI:

There’s actually an article today in the New York Times about, there was a study done of patient and provider’s perceptions of—actually, patients’ perceptions of the relative health or relative benefits versus risks of having certain procedures done, and how pretty much across the board, patients had no clue of how much value—

RODRIGUEZ:

Risks.

ROSOLOWSKI:

—of how much value they were getting and what the risks were, you know? And, you know, most of it was an emotional component that they were bringing to the evaluation of that. So cancer’s certainly on that list, too. Not in the article, but clearly that’s at work—

RODRIGUEZ:

In general.

ROSOLOWSKI:

—in these assessments. Well, would you like to continue with your story about administration at this point?

RODRIGUEZ:

How are we doing with time, because I—

ROSOLOWSKI:

We’re doing well.

RODRIGUEZ:

OK. Great.

ROSOLOWSKI:

We’re at 11:30 now. What time do you ideally have to break today?

RODRIGUEZ:

Let me see, I think the meeting I have to go to starts at twelve—

ROSOLOWSKI:

OK.

RODRIGUEZ:

—something. Twelve fifteen, twelve—I know we start with lunch, so it’s probably sometime around 12:00, and then we sit down and really do business.

ROSOLOWSKI:

OK, so what time would you like to break off today?

RODRIGUEZ:

Let’s break off at noon.

ROSOLOWSKI:

At noon? OK. Sounds good. So we’ve got about a half hour, that’s great.

ROSOLOWSKI:

Well, tell me about, well, there’s the Director of Clinical Investigation and then there’s the Office of Medical Affairs. How do you want to continue your story? You kind of gave me the background about the change in your perspective. What really was kind of a next big landmark in the evolution of your administrative work and perspective?

RODRIGUEZ:

Well, around the time, around 2000, yes, around 2000, Dr. Cabanillas retired, who had been my mentor and so on. And I stepped in in an interim role as chair of the department. And that was yet another whole dimension of MD Anderson, because although I had had experience in the administration of the clinic, running a department on the academic side, because the chair of the department, as I said, remember I said those titles are aligned with academic responsibilities, then brings in a whole different set of dimensions to the responsibility, which is the funding for research, the oversight of the staff in the office, the administrative staff, the research support staff, of course the Physicians as academicians, not the Physicians necessarily as professionals, which is what I had been doing before in my role as Director.

But as the interim chair I also had to look at them as academicians, and how are they doing in their career progression, who is ready for promotion or not, who thinks they’re ready for promotion but really don’t have the qualifications to be promoted in their academic title, and then how do we talk about that; behavior issues, etc., etc. In addition, of course, now there is a whole set of different peers. You know, as a Medical Director, I and others would interact with each other more on the operations side, you know, I knew the administrative Directors, the nurse managers, etc. On the administrative side of the department, you interface with other department chairs, the division head, the provost. So it’s an alignment of leadership that is different than the alignment of the operations of the organization.

And there is also competition for resources, in a different way. There’s—in addition of the competition for office space, there’s the competition for lab space, for position—for the number of positions, how many Physicians, if you want to hire somebody else you have to justify it on the grounds of this, that or the other, and if you’re onboarding them as scientists then they have to have X-number of qualifications, whatever their level of title is, is how much square feet of space they get, and on and on and on. So that’s yet a different level of administrative responsibility that has its own different view of what MD Anderson, or who MD Anderson is. You know, in that world, MD Anderson may or may not have good standing in the national societies; you may or may not get published by certain journals. You may or may not be excluded, perhaps, by certain funding mechanisms. You may or may not be highly successful at philanthropy, etc. So all of these are metrics that are looked at—

ROSOLOWSKI:

Interesting.

RODRIGUEZ:

—as a point of evaluation of the performance of that department. So in that realm, then, one sees the organization from the perspective or the world view of, well, for lack of a better word from the academic world, from the knowledge world of medicine. You know, are you credible? How credible is your research? How much have you contributed to the knowledge of the larger community of medicine and science?

ROSOLOWSKI:

So what did you take from that—how were you interim?

RODRIGUEZ:

Until 2003, when the new chair—

ROSOLOWSKI:

Until 2003, OK.

RODRIGUEZ:

—came on. I think those are the years.

ROSOLOWSKI:

I don’t actually have—

RODRIGUEZ:

Yeah, 2003, 2004, actually, I think.

ROSOLOWSKI:

OK.

RODRIGUEZ:

Two thousand and four, somewhere in there. Anyway, he, you know, a new chair was brought on board, so therefore, I stepped down in my interim role. One of the things that I learned that was very valuable from that experience is that the people who are chairs of the departments, the traditional model, up until recent years, the traditional model or the historical model of who became a chair was this eruditious expert, you know, best-known, highly-glorified individual. However, again, you know, we have been in a transition period where to really be a successful chair, it’s ironic that the people who are selected for those positions indeed still are the people with the thickest CV. But the irony is that once you step into that role, you have to let go of that ego persona, because the job of the chair really is not to continue to aggrandize your own identity, but rather to bring forth the future leaders of the field, and to ensure that the people who are reporting to you themselves have the opportunities to become great people, great leaders in the future.

So managing other people’s careers is your primary job. Ensuring that they have the opportunities, that you champion them, that you mentor them, or if you can’t, then you find the right mentors for them, that you stay on top of pushing them. Like I said, one of the toughest conversations to have is with people who are not going to make the next promotional step, and they think they deserve it. But what if they don’t meet the watermark? I mean, in some ways, and in some ways, that is not the chairs decision; it’s going to be a committee that’s going to decide that. But the chair has a pretty good perspective, because you know what the career path is for everyone else. And if this individual falls significantly short of his peers, then you know that they’re not going to get promoted. I mean, the committee’s going to look at everybody else’s performance and compare. So it’s an interesting job in that sadly, most people who step into the chair job think that they’re there to get further glorification, but no. They’ve got that job so they can make other people great. And that can be a challenge, if the individual who steps into the role does not have that perspective, the department can falter significantly. Because it’s not about the chair, it’s about the department. It’s about the staff in the department, not the peers within the department. So that’s what I learned from that job.

ROSOLOWSKI:

Sounds like a very important lesson, indeed.

RODRIGUEZ:

So it makes me appreciate how tough the job of the chair is, quite frankly.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

I think it’s one of the toughest jobs.

RODRIGUEZ:

So I sort of came to this, my current job, in a roundabout way, and that once I stepped down, you know, after having been in this very intense furnace of the interim chair role, and I suddenly was—they hired the new chair, although I did become the Director of Clinical Research, and that in itself was—clinical investigation within the department, that in itself was another set of lessons. I really have always had my heart in the hospital side, in the operation side, and the professional aspect of medicine side. So I simply had had a conversation with a person who, at the time, was the Physician in Chief. And I had said, you know, there are opportunities for operation leadership. Keep me in mind, I’d like to step back into leadership in operations.

ROSOLOWSKI:

And was this still Tom Burke at this time? The Physician in Chief?

RODRIGUEZ:

Well, it was kind of a—that was yet another transition period.

ROSOLOWSKI:

OK.

RODRIGUEZ:

The person actually was David Callender [MD, MBA, FACS].

ROSOLOWSKI:

OK.

RODRIGUEZ:

But he knew he was leaving, so he introduced me to Tom Burke.

ROSOLOWSKI:

OK.

RODRIGUEZ:

Who he knew was probably going to be—so that was a very interesting transition experience as well, because Tom Burke’s role was an interim role. And he just asked me to take on some of his responsibilities so that I could help him do both jobs.

ROSOLOWSKI:

I’ll be interested to hear about that! (laughter) So, I mean, just let me ask you question. So you had this conversation with Dr. Callender. You know, obviously, he was very open to the idea of you taking on this role. And why, what did he see in you? I mean, because obviously, I’m sure there could be any number of people interested in this role. So why you at that time?

RODRIGUEZ:

Well, I can’t answer for him. But I can tell you that one of the things that I did, you know, and my relationship with Dr. Callender had been in my job as the Medical Director—

ROSOLOWSKI:

OK.

RODRIGUEZ:

Of the lymphoma section. I think I was the only Medical Director that would, on a yearly basis, send him a report. (laughter)

ROSOLOWSKI:

The importance of documenting.

RODRIGUEZ:

Yes. I mean, I still have some copies of those reports. I mean, I took my job of, you know, observing what—remember I told you I would prepare these reports for my own peers.

ROSOLOWSKI:

Right.

RODRIGUEZ:

So-and-so, so many patients, so-and-so saw so many patients, this is how many, you know, on Mondays the clinic is overwhelmed with patients, but on Friday we don’t have enough utilization of rooms. So let’s try to reassign people, you know. So I would send yearly reports to him of, you know, this year we met the goal of blah blah, however, we fell short of blah blah. Next year we need more of this, you know, so I was always sending him reports that sort of justified whatever it was we were calling—we were asking for. I kept track of what I did. So I don’t know if that had any influence, but certainly my name was known to him because I was sending him those reports.

ROSOLOWSKI:

Well, so it shows you’re kind of on the wavelength—

RODRIGUEZ:

Yes.

ROSOLOWSKI:

—of sort of seeing things in a big perspective, and understanding the need to document of a wide variety of activities from different perspectives.

RODRIGUEZ:

Yes.

ROSOLOWSKI:

Very interesting.

RODRIGUEZ:

So my guess is perhaps that’s what he thought. I truly don’t know. Also, in my interim role as the chair, the transition for the department was really very challenging. There were lots of disruptions; I kept him and Dr. Kripke, who at the time was a provost, I met with both of them, apprised them of who were being difficult. We had had a challenge in the entire, well, the Leukemia Department had been shut down because their research protocols had been shut down because of some problem. So that brought the big light on lymphoma.

ROSOLOWSKI:

Oh, wow.

RODRIGUEZ:

(laughs) So suddenly all the hematology services are being looked at really critically. So I met with everybody, we sent reports. If there were things that were found wanting, we corrected them. I mean, I was, I think by my directorship role and my obsession for reports served me well in that role, because, you know, I wouldn’t let things just sit. You know, if a response was needed to a certain thing that was brought to our attention, we would respond. I had a good administrator that was also helping me very much, certainly it’s not just me. But we tried to keep things afloat through that transition period of a few years. And the department survived. (laughs) So I think that was—he was also aware of that.

ROSOLOWSKI:

Yeah. Yeah.

RODRIGUEZ:

So my guess is those qualities served to bring me to his attention.

ROSOLOWSKI:

It’s always good to be a cool head in an emergency! (laughter) So you stepped in as interim Director of the Office of Medical Affairs in 2004.

RODRIGUEZ:

Correct.

ROSOLOWSKI:

And what did Medical Affairs look like at that time? Because I assume that in the last ten years, it’s gone through significant changes.

RODRIGUEZ:

It has changed significantly, yes.

ROSOLOWSKI:

Yeah. So in 2004, was it—

RODRIGUEZ:

Well, essentially, I mean, the only charge that, or the aspects of the office that Dr. Burke delegated to me because he actually stepped in an interim role, when Dr. Callender left. He stepped in as the Physician in Chief. He still had the title of Vice President of Medical Affairs. I was only a Director, he delegated to me the title of Director, meaning I wasn’t quite him. But I mostly focused—or he asked me to focus most of my oversight responsibilities to the credentialing privileging of Physicians to the Office of Credentials, and oversight of the Physician Assistant programs, which really there was no such thing as an office of Physician Assistant’s programs, they actually all reported to me directly. And I learned a tremendous amount about Texas law, of which I was very ignorant, I must say. Not mostly, but I had huge gaps in my knowledge; I knew some, I knew enough, of course, to run the department and the clinic. But I learned much more in-depth all the regulations of medical practice, particularly in a hospital setting, which are huge, enormous. I mean, I was just overwhelmed. To this day, I’m still over—I am amazed that we float. (laughs) We float, despite all the regulations. So I did a very in-depth learning of the laws and regulations that govern medical practice, I familiarized myself with what Physician Assistants were, the rules and regulations that govern them. I learned also a great deal about Advance Practice Nurses, because they were also privileged to practice at the hospital, so oversight—they are governed by a totally different board. Both Physician Assistants and Physicians are governed by the Texas Medical Board. But the Advance Practice Nurses are governed by the Board of Nursing. And oh my God, if the Medical Board has complex rules, the Board of Nursing is unbelievably more complex.

ROSOLOWSKI:

Can you give me an example of a rule that’s complex? Sort of amazingly so?

RODRIGUEZ:

For nursing? No, I can’t—

ROSOLOWSKI:

Either one. (laughter)

RODRIGUEZ:

I do not even want to remember reading all of that.

ROSOLOWSKI:

OK.

RODRIGUEZ:

OK? But so, in medical practice, for example, there is a whole list of rules about how Physicians or who is worthy of getting a license in Texas.

ROSOLOWSKI:

Oh, OK.

RODRIGUEZ:

OK? You had to have gone to a medical school that’s recognized by the Board, you have to have had training, post-graduate training completed. You have to have confirmation of that training. In fact, you even have to have transcripts all the way back to high school to confirm you are who you are. You have to be in good standing. You cannot have any criminal activity, you know, etc., etc. It becomes really convoluted for people who come from outside of the state, and most—and largely so for people who are trained outside of Texas, outside of the U.S., OK? There are different kinds of licenses. And each of them has a different set of forms that need to be submitted. We have a number of people who want to come as visiting professors—well, they have to go through a certain set of paper trails that we have to manage for them. On and on.

ROSOLOWSKI:

I mean, I’m sure the legislature has one answer to this question, but I want you to answer this question. Why is that important?

RODRIGUEZ:

Well, it’s important to safeguard the larger community, to ensure that, frankly, we’re not quacks. Because anyone can falsify documents, right? And in fact, it has happened. So I see why they have built all of those rules and regulations; I think in today’s environment of electronic databases and so on, it might make it simpler for the physicians to jump through all those hoops. But it has been rather difficult. I mean, I’m not kidding about you have to have your transcripts, your grades, your original diploma, your etc., to show the Board to get your initial license. Now, one you’ve gotten your initial license, then it becomes much easier. You simply submit a whole pro forma every so many years. It’s still a very large, long document. But thankfully they keep a template of what you submitted the last year, so you can copy it all over again, because things don’t change that much from year to year, right?

ROSOLOWSKI:

Right.

RODRIGUEZ:

So but yes, so all of that. Now, internally, hospitals have to have, and it’s not just from the state, but it’s from the federal government. We have to have oversight of the credentials of individuals. So the state has its own rules for granting licenses and renewing licenses. Internally, each hospital has to have what is called a credentialing process. So that’s the office that I was overseeing, the Office of Credentialing. And we, ourselves, have to do due diligence. We have to track on national databases, the national provider database has to have any actions, lawsuits, loss of privileges, and other adverse events being reported for this particular person. We have to search criminal databases, has this individual been charged, not only criminal in terms of the state, for example, but also at the federal level. We have found cases, for example, where the FBI is investigating someone for fraud, or because of violations of narcotics prescriptions, or etc. You know, so we do occasionally find those. It’s rare, thankfully. It’s rare, but it does happen. We have had people send us false documents, and we confirm all of that. So somebody sends us a certificate for their board certification, we confirm that by going to the Board and saying, is provider so-and-so, certificate number so-and-so, certified by you?

ROSOLOWSKI:

Wow.

RODRIGUEZ:

I this particular case, they said, “Oh my God, we’ve been looking for that certificate for years. Send it to us immediately.”

ROSOLOWSKI:

It was a stolen certificate? Wow!

RODRIGUEZ:

So, you know, it does happen. So that’s the reason why there are rules like that. We wish humanity was peerless, and we wish physicians were above misconduct, but, you know, we’re humans.

ROSOLOWSKI:

Right.

RODRIGUEZ:

So it happens.

ROSOLOWSKI:

And it does seem like it’s remarkably rare.

RODRIGUEZ:

So and then, of course, we also look at the Texas Medical Board to see if any complaints have been filed by patients or peers against that individual. So we do all of that on a continuous—well, not a continuous basis, but on a yearly basis to ensure that everyone’s information is up to date. Now, it is then up to me, if those issues float up, then I communicate that, share that with the chairs of the departments and say, “Are you aware that this is going on?” Because remember I said it’s one of the toughest jobs, it’ll be that chair’s responsibility then to say how they’re going to address that issue. Now, some of those issues may, because of the bylaws or the rules and regulations of the state, or whatever, may end up in termination. That, again, is extremely rare. But it could be a consequence. So we don’t take this as a trivial exercise at all.

ROSOLOWSKI:

Right. Right. And a lot of states—

RODRIGUEZ:

It’s very serious.

ROSOLOWSKI:

—in the United States. Yeah. Well, Dr. Rodriguez, we’re almost at noon, and I want to make sure you get to your lunch and meeting.

RODRIGUEZ:

OK, thanks.

ROSOLOWSKI:

So why don’t we close off for today, and then I’ll look forward to continuing our conversation at a later time.

RODRIGUEZ:

OK.

ROSOLOWSKI:

Thank you very much. And I am turning off the recorder at about 11:58. Thanks very much.

RODRIGUEZ:

Thank you.