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0:00 - Segment 00C: Interview Identifier

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Partial Transcript: "All right. OK, so our counter is moving, and we are recording. And it is 10:23 on the 1st of May, 2015. And I’m Tacey Ann Rosolowski. Today I’m on the 18th floor of Pickens Tower in the Office of Medical Affairs, or actually in the Physician in Chief’s Office."

Segment Synopsis:

Keywords:

Subjects:

0:32 - Segment 16: The Office of Medical Affairs: Credentialing, Quality Indicators, and Building a Culture of Improvement and Quality Care

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Partial Transcript: "We started talking last time about—well, we talked about the survivorship program, which I guess is part of the Office of Medical Affairs. But we hadn’t really talked about the office in general. And so I wondered if you could start off that discussion by telling me what’s the mission of Medical Affairs, and what’s your philosophy, what was your philosophy as you took the office as a Vice President."

Segment Synopsis: Dr. Rodriguez explains a key function of the Office of Medical Affairs: to credential all individuals at MD Anderson to ensure their competence.

She next explains that, since 2009, MD Anderson has been involved in developing performance and quality indicators for professional practice. She explains this history of this focus and the different reactions of clinicians to professional evaluation, given that most evaluation is perceived as adversarial and punitive, rather than part of a culture of self-awareness and self-improvement.

She comments on Texas requirements that support a culture of improvement.

Dr. Rodriguez then talks about how the Office of Medical Affairs created an infrastructure to shift to quality indicators.

Keywords:

Subjects: 1. Segment Code - B: An Institutional Unit 2. Story Codes - A: The Administrator B: Building/Transforming the Institution B: Growth and/or Change B: MD Anderson and Government B: Multi-disciplinary Approaches C: The Life and Dedication of Clinicians and Researchers C: Understanding the Institution D: On Care D: The History of Health Care, Patient Care

20:51 - Segment 17: The Office of Medical Affairs: Patient Concerns, Patient Advocacy, Conflict Resolution

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Partial Transcript: "That’s our responsibility. Secondly is to ensure that we are also providing our patients with the opportunity to voice their complaints or their dissatisfaction, and that we also support patients when they have concerns about whether their care has been appropriate or ethical. So to that end, I also oversee the Clinical Ethics Group, the Physician Advocacy Group—"

Segment Synopsis: Dr. Rodriguez discusses another important role of Medical Affairs: to provide support for patient who wish to voice complaints. This segment covers sources of patient complaints and distress, the importance of communication, the role of Patient Advocates and the sources of stress in that role. (She notes that patients can become abusive because they would like a second opinion to be a different, hopeful opinion, but often a lack of options is confirmed.)

She notes that having an Advanced Directive conversation is a quality indicator and explains the issues that this raises. She notes that there is more emphasis now on selecting health care providers who have communication skills.

Keywords:

Subjects: 1. Segment Code - B: An Institutional Unit 2. Story Codes - A: The Administrator B: Building/Transforming the Institution B: Growth and/or Change B: Multi-disciplinary Approaches C: Cancer and Disease C: Offering Care, Compassion, Help C: Patients C: Patients, Treatment, Survivors C: Understanding the Institution D: The History of Health Care, Patient Care

38:29 - Segment 18: Creating MD Anderson’s Practice Algorithms; On Blending Art and Science in Medical Practice: Practice Algorithms and Targeted Therapy

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Partial Transcript: "Yeah. Interesting. Other areas of function within Medical Affairs—"

Segment Synopsis: Dr. Rodriguez tells the story of MD Anderson’s 147 Practice Algorithms beginning with the origin of this initiative in the 1990s movement to define “pathways of care.” She talks about the process of establishing an algorithm and discusses the effects. She also notes the different reactions of clinicians, who may immediately adopt the algorithm or who may take convincing.

Dr. Rodriguez talks about the dangers of dogmatism in medicine. She notes that medicine is both an art and a science, but the poles need to be harmonized in order to be humane.

Dr. Rodriguez notes that limits of targeted therapy and sketches an emerging view that this approach will be replaced by a focus on failures in the body’s surveillance and regulation mechanisms.

She notes committees in place to support clinicians as they self-monitor the quality of their practice.

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: Professional Practice C: The Professional at Work C: Understanding the Institution

63:35 - Segment 19: Integrating Advance Practice Providers into Care Teams; Training Program for Physician Assistants

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Partial Transcript: "I have, I mean, I’m about ready to shift topics right now, if that’s OK."

Segment Synopsis: Dr. Rodriguez talks about the increasing reliance on advance practice providers in medicine and in oncology. She notes that, at MD Anderson, General Internal Medicine is a hold out.

She sketches what an APP can bring to a care team. She talks about her own experience working with a Physician’s Assistant. She explains why she shares oversight of Advanced Practice Nurses with the Division of Nursing.

Next Dr. Rodriguez talks about the Physician’s Assistant Oncology Fellowship Program, started in 2008. She sketches differences in the education of MDs and PAs and explains the need for an oncology fellowship. She talks about the impact of the program and an e-course developed for fellows at a distance.

Keywords:

Subjects: 1. Segment Code - B: Building the Institution 2. Story Codes - A: The Administrator B: Building/Transforming the Institution B: Institutional Processes B: MD Anderson Culture B: Multi-disciplinary Approaches C: Professional Practice C: The Professional at Work

79:41 - Segment 20: The Office of Medical Affairs: Job Satisfaction Survey of Mid-level Providers

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Partial Transcript: "Can you tell me, I mean, I’m sort of wondering if there—since the Office of Medical Affairs has been in existence for a decade now, were there some important landmarks in its evolution? I mean, that’s—"

Segment Synopsis: After sketching changes to the office of medical affairs in the last ten years, Dr. Rodriguez discusses the purpose and results of the regular survey of mid-level providers at MD Anderson. She notes that, in general, the workforce is very stable, but the institution wants to monitor reasons that pockets of high turnover exist.

She notes results of the survey: everyone at MD Anderson is committed to the job; some fear retaliation if they voice complaints; many feel they are not paid enough. Dr. Rodriguez stresses that employees’ pay is in line with other state institutions.

She talks about requests for mentoring made via the survey and how that was acted on and to what affect.

Keywords:

Subjects: 1. Segment Code - B: Institutional Processes 2. Story Codes - C: Understanding the Institution B: MD Anderson Culture B: MD Anderson History C: Mentoring C: The Institution and Finances

0:00

ROSOLOWSKI:

All right. OK, so our counter is moving, and we are recording. And it is 10:23 on the 1st of May, 2015. And I’m Tacey Ann Rosolowski. Today I’m on the 18th floor of Pickens Tower in the Office of Medical Affairs, or actually in the Physician in Chief’s Office.

RODRIGUEZ:

Suite.

ROSOLOWSKI:

Suite, yes, interviewing Dr. Alma Rodriguez. This is our third interview session together. So thanks for making the time.

RODRIGUEZ:

Oh, not at all. My pleasure.

ROSOLOWSKI:

We started talking last time about—well, we talked about the survivorship program, which I guess is part of the Office of Medical Affairs. But we hadn’t really talked about the office in general. And so I wondered if you could start off that discussion by telling me what’s the mission of Medical Affairs, and what’s your philosophy, what was your philosophy as you took the office as a Vice President.

RODRIGUEZ:

Well, the core, really, the core responsibility of the Office of Medical Affairs is to oversee that the Physicians and Physician Assistants, as well as other licensed independent providers who provide the care for our patients are truly competent individuals; that they indeed have the appropriate—that they’re legitimate, that they have the appropriate credentials that they say they do, and that they have a track record of competence. So part of our job, a very core part of our job is to perform the function of credentialing, what is called “credentialing,” and that is to confirm and verify that individuals who are working at this organization, MD—and who are what are called independent providers, that is, the professionals who are licensed to provide medical care, Physicians, mid-level providers, psychologists, physicists, etc., that they’re all, indeed, well-trained, that they meet the competent standards of the organization. That’s step one. And secondly, added onto that, since 2009, we also established a process of what we call ongoing professional evaluation. And so we had to build the infrastructure, measurement of metrics, decision on metrics across the organization to follow and monitor performance, etc.

ROSOLOWSKI:

Why was that—why did that happen in 2009? What was going on at the time?

RODRIGUEZ:

:

Well, the Joint Commission, which is one of the main accrediting bodies for health organizations in the United States, as part of an over—really, it’s a national movement that began even before 2009, even further back. The issues of quality of healthcare were being discussed, that it wasn’t enough to simply provide healthcare, but that we should look at what is the quality of the healthcare we provide. And there are a number of national indicators that apply to general hospitals, cancer care hospitals were somehow exempt from that and still are; some cancer centers are still exempt from that, although that’s changing as well.

ROSOLOWSKI:

Why is that? I mean, I don’t, I hope that’s not too much of a [inaudible].

RODRIGUEZ:

Well, cancer hospitals are not general hospitals.

ROSOLOWSKI:

Oh, OK.

RODRIGUEZ:

We have a very unique and different category of patients, or sub-type of problems with our patients that are not common in the general population. I mean, and general hospitals deliver services that are mostly directed at the more common illnesses; cardiovascular disease, diabetes, infections and other conditions of aging, as well as healthcare for delivery of babies, etc. So we are sort of a bit off the beaten track. And also you must remember that until the 1960s, most patients who had cancer died of the disease, so it was considered a terminal condition anyway. And how do you build quality indicators around terminal conditions, you know, and so on. So for the longest time, now that we are successful, and now that we know that there is a significant probability of survival for many, many patients with cancer, now the question is, are you doing curative treatments, you know, what are the best standards for curative treatments? Are you doing them according to the standards, and so on and so forth. So in any event, they are now—there’s now this movement to apply what are called “quality indicators” to all providers across all professions, regardless of the specialty, and we are not exempt from that. So we monitor, like I said, ongoing professional performance indicators. It’s one of our requirements for credentialing from the Joint Commission. That’s part of our job, as well. That’s one of our tasks. And it sounds very simple, but it’s not. It’s rather complex.

ROSOLOWSKI:

What are some of the complexities that arise in that kind of valuation?

RODRIGUEZ:

Well, where do you get the data? That’s complexity number one. How do you measure these endpoints? Which are the valid endpoints to measure? What are the appropriate endpoints to each specialty? What are appropriate endpoints that apply across the board to everyone? So a very simple measure that applies to everyone across the board is, do your patients complain about you? (laughs) And how often, how many times? That’s one, for example. So in any event, so there’s—another one is, what’s the—for surgery, what’s the mortality of your surgical interventions? How many of your patients die from the surgical interventions? How many of your patients have infections after surgery? How many of your patients—in general, across the board, how many of your patients that you admitted to the hospital that are discharged, how many end up coming back into the hospital within forty-eight hours, meaning probably there was a bad judgment call on their readiness to leave the hospital. So those are—I’m just explaining, you know, the—but it takes a lot of dialog, a lot of discussion, a lot of soul-searching, quite frankly, on our part, as well as the part of administrators, to say what really does matter.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

What is the—you know, what matters when you give healthcare?

ROSOLOWSKI:

Well, I was going to ask you, because it sounded, with some of the issues that you were raising, that by asking those questions, you’re starting to create kind of a cultural change in an organization that delivers healthcare. And I’m wondering, you know, has there been resistance to that? Have there been philosophical discussions? You know, what’s been the reaction, you know, of different generations of care providers here at MD Anderson, as they have engaged with those questions?

RODRIGUEZ:

Right. Well, it depends, as you said, on the specialty and on the generational boundaries, if you will, of the groups that are engaged. Some sub-specialties have been, by the nature of their specialty, are very familiar and very engaged, and in fact welcoming of indicators. One specialty that, for really decades, has been striving to improve its outcomes is anesthesia. You know, they have to shepherd the patient, if you will, through the whole process of the surgical intervention. They must keep them free of pain, but yet they must keep their vital signs and their vital organs functioning properly and appropriately. They must bring the patient out, hopefully with not too many side effects from the anesthetic. So they’ve been monitoring that for a long time, I mean, literally decades, have had internally-driven quality endpoints that they measure.

But for other organizations, for example, medical oncology, it’s very difficult to determine, or it has been difficult to determine what are best measures. One of the national organizations called the American Society of Clinical Oncology recently, over the last ten years, finally started to establish some endpoints of quality through a program they call the Quality Oncology Performance Initiative. And they’ve, again, had their own committees internally to decide what might be indicators and so on, but it’s not a widespread practice. And some institutions have embraced that, others have not. For us, for example, we have not been following those indicators for medical oncologists for the main campus, whereas in the community clinics, our outreach clinics, do follow those indicators. So even within an organization you can have subsets of individuals who embrace the culture, if you will, of self-measurement, versus others resist it. Our surgical colleagues, there’s been a national movement to measure surgical endpoints, and again, initially, very resistant. Our internal culture was very resistant to it.

But we had some young people within the organization who had had experience with the national indicators at their own training programs outside of MD Anderson, and they championed it. They said, “Oh, this is good for us.” And now that we’ve had the so-called National Surgical Quality Indicator Program, the NSQIP program, embedded in the organization, now everybody wants to know what their NSQIP indicators are in the surgical world. So it’s interesting. I mean, it does take time. It takes having champions, people who understand the objectives, the goals of such processes, and who are able to speak to them and speak about them in a way that is not threatening, in a way that is supportive of the practitioners, in a way that really empowers the practitioners to look at their own practice. The whole field of quality endpoints is supposed to have underlying it a culture or a philosophy of improvement, not of punishment. Not of punitive measures, or rather self-assessment and self-improvement. Having said that, the tradition in medicine for many generations has been one of, for lack of a better word, you know, of shaming and punishing those that don’t perform up to standards. And so, I mean, it’s also embedded in our culture, the whole litigious environment of malpractice. It’s not about ‘let’s learn from this unfortunate adverse event,’ it’s ‘let’s see how much money we can milk out of the hospital and the doctor’ kind of attitude. So it’s not, for better or worse, a culture in the United States does not support, you know, this whole movement of self-improvement and quality. Having said that, there have been some—in some states, there have been seminal legislature that is helping to support that. And Texas is one of those states. It’s not well-known, but it is one of those states; it has tort reform, it limits amounts of malpractice. For example, it limits—in general, it has moved towards a culture of supporting physicians’ improved practice, rather than just have punitive outcomes. But nonetheless, that still has not left us, I mean, it still exists. You know, the whole negative attitude still exists.

ROSOLOWSKI:

When I was doing your background research, I’m trying to remember, I know I was doing some work with someone’s background, and I read the phrase “appreciative inquiry.” Were you the person who was work—were you working at all with appreciative inquiry, and—I was just curious because that’s obviously very much based on self-improvement—

RODRIGUEZ:

Correct.

ROSOLOWSKI:

—and self-evaluation moving to self-improvement.

RODRIGUEZ:

Correct. I mean, that essentially the intent of, we hope, of the entire, if you will, culture of medicine, moving forward. It has to shift, really, from this adversarial relationship between society, the environment, the patients and the Physicians. And what is most—what is really tragic and what is very paradoxical is that most patients do not want to have an adversarial relationship with their Physician or with the healthcare institution that provides care for them. And but it always—it’s just the negative few, or the few rotten apples, so to speak, that can spoil the entire barrel.

ROSOLOWSKI:

Right.

RODRIGUEZ:

You know, so—

ROSOLOWSKI:

It’s also a mindset, you know?

RODRIGUEZ:

It’s a mindset, yes.

ROSOLOWSKI:

I think there are some people who, just as individuals, you know, don’t have that mindset to say, well, I’m going to take some kind of negative event and then turn it around and learn and forward from it.

RODRIGUEZ:

Correct.

ROSOLOWSKI:

They process that information differently.

RODRIGUEZ:

Differently.

ROSOLOWSKI:

Emotionally, in terms of data, I mean, all kinds—

RODRIGUEZ:

Intellectually, and so on.

ROSOLOWSKI:

Yeah. Yeah.

RODRIGUEZ:

Yes, of course.

ROSOLOWSKI:

Yeah, very interesting. Now, I kind of derailed you with that discussion about culture. Were there more things evolving from that initiative that this office has taken on to create those measures, just so we complete that story at the administrative level?

RODRIGUEZ:

Well, so we created—I mean, to do all of that requires, you know, really a large infrastructure; you have to have, as I said, data sources. So we had to look at our data sources. I had to build partnerships with the Office of Performance Improvement, because the measurement engineers are in the Office of Performance Improvement; they don’t report to me. So looking, or building alliances with the right groups of people was important, and then realizing again that there is no one individual that can truly understand the complexity of each of the domains of medical practice. Essentially, within each of the domains of practice, there have to be internal content experts, or experts in what matters to that profession. So we also developed policies and processes and established, implemented, the development of a Quality Officer role within each of the clinical departments, so that those individuals would carry out, then, this function of oversight of specific indicators.

Now, some departments again have taken it on very, very seriously, versus others. Some departments have extremely robust processes to share the data internally, discuss it amongst themselves if there are adverse events, that there’s a methodology for, if you will, [inaudible], doing a tracer for the events, what happened here, where did things go wrong, what needs to be fixed so it doesn’t happen again. And usually, those have been the procedural departments, if you will, like [Department of] Pulmonary Medicine, [Department of] Gastroenterology, because they have to understand the methodology—you know, what occurred during the procedural care delivery that maybe can be done better. Others have taken a more lackadaisical attitude, and have said oh, well, that’s just a Joint Commission requirement, it’s not about us. You know? (laughs) So we have a very divergent, at this point in time still quite divergent group of quality officers, some of whom are extremely and highly engaged and knowledgeable about what it means to have self-assessment and quality oversight and others that are very peripheral to the process. (pager is heard)

ROSOLOWSKI:

Should I pause for a moment?

RODRIGUEZ:

Let me just see if this is a critical page or not. Message, oh—they’re just telling me I’m covering someone. OK. Somebody else’s pager is being dropped onto my pager. So anyway, so that was another initiative, so getting the department chairs engaged in appointing such an individual. Some department chairs have said this is a waste of time, others have said oh my gosh, it’s about time we did this. So again—

ROSOLOWSKI:

Huge range of reactions.

RODRIGUEZ:

Yes. A whole range of reactions. But slowly, slowly I’m seeing a shift towards a—the number of individuals who say this is important is becoming larger and larger. So that’s encouraging. And it’s very timely, because on the national scale, like I said, you know, starting this year, we will be required to report what are called the Physician Quality Report Indicators, PWRIs. And it will be publicly reported in a federal domain on one of the federal Websites, anybody can go and look at their Physician’s quality scores.

ROSOLOWSKI:

Wow. Wow. Wow, I’m sure that’s making some people mad and leaving them shaking in their boots—

RODRIGUEZ:

Yes.

ROSOLOWSKI:

—or saying OK, huh, good shift—

RODRIGUEZ:

A lot of them are annoyed. It’s going to be a very big challenge. So they’re starting off, of course, first of all, with organizations that have large numbers of physicians in their organization, because they understand that those are the organizations that are likely going to have the measures or the numbers or the data sources to measure. But it’s gradually moving to every single Physician in the United States, even if they have a single office, single Physician, single office practice. They’re going to have to figure out how they’re going to track their own measures of practice quality—

ROSOLOWSKI:

Interesting.

RODRIGUEZ:

—to report.

ROSOLOWSKI:

Wow.

RODRIGUEZ:

So, more to come.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

It’s a shift in the national healthcare scene, as well as a change in the internal environments of all organizations that deliver healthcare.

ROSOLOWSKI:

Very interesting story.

RODRIGUEZ:

So that’s, you know, that’s a core function of our organization, do we have the right people delivering the right care? And are they doing it well?

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

That’s our responsibility. Secondly is to ensure that we are also providing our patients with the opportunity to voice their complaints or their dissatisfaction, and that we also support patients when they have concerns about whether their care has been appropriate or ethical. So to that end, I also oversee the Clinical Ethics Group, the Physician Advocacy Group—

ROSOLOWSKI:

And that’s all part of this office?

RODRIGUEZ:

Mm-hmm [affirmative]. I have a Conflict Resolution Advocate. And we also formed a group called—a council called the Psychosocial Council that brings to the table, really, all the domains of practice that somehow touch on psychosocial care. For example, psychiatry, psychologist or behavioral medicine, social workers, patient educators, integrated medicine services, etc. So we bring all these individuals to the table and we talk about, you know, what would be important processes for us to improve; what’s a key issue that we should be addressing. And again, from the national perspective, one of the endpoints of quality, actually, that organizations are going to be asked to report is on whether we are assessing patients for distress, and how we are addressing distress. Now, that’s a very—the word “distress” is very general. I mean, people can be distressed due to physical symptoms, but they can also be distressed due to emotional issues or economic issues or social issues, or their transportation—so it is so broad, that it is very hard to put one’s arms around it. But nonetheless, you know, there’s some—there’s some initiatives that have attempted to build, if you will, boundaries around what—how do you ask patients about distress, and what might be some of the domains of distress that are most common that should be addressed? It turns out the most common domain of distress is usually the patient has anxiety about their test reports. And once they’ve seen the doctor and gotten their test reports, they feel better. But then there’s the others that have true emotional distress or spiritual distress, or socioeconomic distress. And those domains of care really are not—you know, the Physicians are not going to be the best to provide support for those initiatives, or for that category of distress. So integrating what we call psychosocial services into the delivery paradigm in cancer care is important. So—

ROSOLOWSKI:

Have you seen, with the issues of patient distress and psychosocial issues, have you seen changes in the issues that are stressing patients over the course of ten years that you’ve been with the office?

RODRIGUEZ:

Not really. So, I’m going to talk about the complaints more than the distress issue, because the distress question is something we push out to the patients. The complaints are something the patients initiated.

ROSOLOWSKI:

Yes.

RODRIGUEZ:

So those are more, if you will, objectively measurable. So the most common, and still persistent issue with patient complaints is communication. And despite the fact that we now have all kinds of devices to communicate, it still remains the same thing. And part of it is—paradoxically, I think what may be happening is that the expect—people, the expectation that people have now, given that everybody emails and texts everyone everywhere on the planet, the expectation is almost that there will be an immediate response. Well, we wish we could respond to everyone, but the truth is, I am sitting here right now talking to you. If this had been somebody just wanting to know am I going to be at such-and-such a meeting at such-and-such a time, I’m not going to call them back.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

I’m not going to answer to them. I’m here to talk to you. I’m here for you. You’re here. They’re not. They’re home or at another office, or whatever. So the social expectation of what is appropriate timeliness to communication has eroded. I mean, people used to be patient and thoughtful, I think that that’s eroding. (laughs) I think patients and thoughtfulness are eroding in our culture. And so how are we going to resolve that? I don’t know. I don’t think that there are any good solutions to that. And what is unfortunate is that this continuous barrage of asking, asking, asking puts those individuals who truly should be listened to immediately, puts them at risk.

ROSOLOWSKI:

Yeah, because they’re just lost.

RODRIGUEZ:

They’re lost in the noise, OK?

ROSOLOWSKI:

Yeah. Yeah.

RODRIGUEZ:

And we have not yet come up with a good solution to the true triaging, if you will, of what requires immediate response, versus not. I think this will only—I mean, this will take some time, some evolutionary process, I think, that we’ll leave the communication experts to tell us, to look, perhaps, for certain clues, certain terminology. But it’s interesting because patients get wise to that. And we knew this even way—I mean, it’s well-known in the pain literature, for example, so there are people who have true pain, and then there are people who are drug seeking. And how do you distinguish? I mean, it’s really very difficult, because pain is a purely verbalized—there’s no objective measure of pain. Although I have to say people who are truly in pain also have vital sign changes that go along with that. But then there’s also the so-called adaptation to pain, so over time, the body becomes adapted to pain. And then the vital sign signals are not there.

ROSOLOWSKI:

Yeah, that’s the normal.

RODRIGUEZ:

So how do you know when people are really in pain? You have to go by what they say. And so again, in the noise of the saying, the pain seekers or the drug seekers versus the truly ill patients—you know, the signals are very difficult to interpret. So we know from that discipline that it is very, very difficult to separate signals of true distress from just demanding people. It’s going to be difficult. So that’s one of the challenges we face, quite frankly. That is still the number one complaint. And true complaints about the quality of care are relatively small, compared to the volume of just the “You didn’t answer my phone call,” “You didn’t tell me about this,” “The timing on my card for the appointment was wrong,” I da da da da, da da da da da.”

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

It’s continuous, continuous—

ROSOLOWSKI:

All the little things that seem overwhelming to people when they’re going through the cancer process. But not really, in the grand scheme, essential—

RODRIGUEZ:

Correct.

ROSOLOWSKI:

—situations.

RODRIGUEZ:

Correct. And that, unfortunately, can derail a relationship.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

It can derail, if you will, the harmony of relationship between the patients and the providers.

ROSOLOWSKI:

Yeah. Yeah.

RODRIGUEZ:

And that’s unfortunate.

ROSOLOWSKI:

What about on the issue for advocacy for Physicians?

RODRIGUEZ:

Very interesting question. Are you asking do we have a body of people who advocate for the physicians? Or—

ROSOLOWSKI:

Yeah. You said that there was a Physician Advocacy Group.

RODRIGUEZ:

No. It’s a Patient Advocacy Group.

ROSOLOWSKI:

Oh, a Patient Advocacy Group. I’m sorry.

RODRIGUEZ:

Yes.

ROSOLOWSKI:

So that’s why—but maybe we could talk about the two halves of that coin.

RODRIGUEZ:

Well, you know, they are an incredibly important group of people. And they put up with a lot of stress. I mean, they face a lot of stress.

ROSOLOWSKI:

I mean, are you talking about the p hysicians?

RODRIGUEZ:

The advocates.

ROSOLOWSKI:

The advocates. OK.

RODRIGUEZ:

And the advocates have to balance between what is a legitimate issue that the patient is facing, that we, you know, that requires immediate attention, versus what might be unrealistic expectations, what might be, in fact, what make—and it does happen—what might be in essence, unfortunately, an abusive patient that is making unrealistic demands of their provider, in which case, then, we have to take a stance for advocating for the Physician rather than the patient. And that’s incredibly—that’s an incredibly tough job, and requires a number of processes of discourse within the advocacy group. Some of them float up to my office personally, some of them—most of them, actually, they resolve themselves. There are some really interesting issues in oncology. I mean, it’s true in healthcare in general in our country. But oncology, in particular, and for our organization, because we get referrals of patients who have been treated already by their community oncologists, and they’re failing treatment. Well, I’m going to rephrase that, because the patients, obviously, would never want to fail the treatment. But their cancer is not responding to the treatment.

So the patients get sent to us, and the patients expect, or hope, that we’re going to tell them differently, that there is something else that can be done, and that it will work. But unfortunately, that is not the case for many, many, many patients that are referred to us. I mean, that’s just a reality. And often, these individuals have invested a great deal of resources, both emotional psychological and economic to get here, and to hear the same narrative from us as they heard from their oncologist at home sometimes makes them very unhappy. Sometimes, frankly, abusive. And it makes, then, the dialog difficult. It makes the experience very difficult. If you ask any of the physicians here what is their biggest stressor, it is that. How to have the difficult conversations with patients who are not ready to hear that their disease is not going to have a favorable outcome. And although, there’s a lot of literature about how we should and must be having these poor prognosis conversations with our patients. In fact, one of the quality indicators is, have you discussed with your patient within the first three office visits about advanced directives?

ROSOLOWSKI:

Right.

RODRIGUEZ:

Which the patients immediately interpret as, “You’re telling me that I’m dying, right?”

ROSOLOWSKI:

Right.

RODRIGUEZ:

Which is not the case. For newly-diagnosed cancer patients, that’s not the case. You know, more than two thirds of newly-diagnosed cancer patients are going to be well. It’s the patients who come with recurrence of disease and/or multiply treated—multiple treatment events, those are the patients who really are not likely going to do well.

ROSOLOWSKI:

Well, with any, you know, with any topic that has a really big emotional charge to it, you have to plan very carefully how you situate that conversation in the midst of many other conversations.

RODRIGUEZ:

And that’s the interesting thing. And so it is why it’s so interesting to me that there is now almost a mandate that we must do this. And the mandate is being placed upon the physicians. I don’t know if the public knows that, but it’s one of the national quality indicators for oncologic care. And so, as you said, you know, how do you do that in the midst of time pressure, volume pressures? You must—you know, patients have to be seen within a certain timeframe because there’s only so many rooms, right? So many hours in the day. And there are twenty patients who expected to be seen today by you, so how do you carefully orchestrate, and time, and so on? That’s the biggest stressor for Physicians today in our practice. How to have the time to have the meaningful conversations when they are appropriate, how to deal with the patients who are not ready to hear them. And how and where are those conversations best done when we do have certain external pressures.

ROSOLOWSKI:

And I’m even thinking, you know, backing up a few years and saying, well, how do you get the skills to have them? I mean, those are special conversations. And you know, you have to be able to bring those issues up and read people’s body language cues and all those non-verbal cues in a conversation that can help you help a person process that information. And—

RODRIGUEZ:

Well, and that’s even a larger and more complex issue, which goes back to how do we select individuals for healthcare professions. And up until now it has been, or even now in most medical schools, the overriding criteria are about academic performance, they’re not about communication skills or personal skills.

ROSOLOWSKI:

Right.

RODRIGUEZ:

Personal interaction skills. And yet, progressively, or most critically, that’s going to be an essential element.

ROSOLOWSKI:

Interesting.

RODRIGUEZ:

So very challenging.

ROSOLOWSKI:

Yeah, very challenging, but a fascinating area that’s emerging. And this role, these advocacy groups, they were formed when?

RODRIGUEZ:

Patient advocacy has been around for a long time. They precede me. When I joined MD Anderson, we already had Patient Advocates in this organization. I don’t know exactly the history as to how far back it goes. But I know it was well—you know, I came in here in the late 1980s, they were already here.

ROSOLOWSKI:

Yeah. I see.

RODRIGUEZ:

So—and over time, we have expanded the numbers, obviously, as the organization has grown. And we are focusing more and more, as you said, on the issues of how do we select, you know, personal communication skills, if you will, certain philosophical perspectives. I mean, these are individuals who have to be well—for lack of a better word—well-balanced. They have to have some skills for self-care, so that they are not overwhelmed by the task at hand, and so on.

ROSOLOWSKI:

Yeah. Interesting. Other areas of function within Medical Affairs—

RODRIGUEZ:

Well, you mentioned the issue of the algorithm. So of course, you know, I said it’s really important that we have the individuals with the right credentials and the appropriate competence to perform the job. We also want to provide them with the right tools to perform their job.

ROSOLOWSKI:

Hmm, OK.

RODRIGUEZ:

And so it became apparent, even predating my coming into this role, somewhere in the 1990s, there was a movement nationally as well to establish what were called “pathways of care,” and this was particularly true in surgery where, again, organizations, just HMOs [Health Maintenance Organizations], and so on, were pushing for the delivery of care within X-number of days, within X-number of hours, and you know, the whole trend to efficiency in how patients were moved through, if you will, moved through the system of the hospital or the clinics.

ROSOLOWSKI:

And I guess standard it too—

RODRIGUEZ:

Standardizing it—

ROSOLOWSKI:

So you realize what you’re paying for.

RODRIGUEZ:

Exactly. Exactly.

ROSOLOWSKI:

Yeah, OK.

RODRIGUEZ:

So even back then, there was some movement to start to begin to look at the processes of delivery within the organization. Nothing much happened out of that, other than some groups did map out what their care processes were. But eventually, when I was assigned to this role, I realized that on a national scale, we also were beginning to talk about algorithms of care, actually they were called “guidelines,” guidelines of care. And there’s a whole debate around the terminology, what is a true guideline, what is a pathway? We chose to call our maps of care “algorithms,” because essentially, it was, like, if this, then that. If that, then this. You know, so it gave essentially a map. Essentially we mapped out processes of care. And within those maps of care, there were unique focus areas that we felt needed a deep dive in, particularly all the domains that had to do with the delivery of chemotherapy.

ROSOLOWSKI:

Can you give me an example of what one of these algorithms might look like?

RODRIGUEZ:

Oh, I can show you on our Website—

ROSOLOWSKI:

Oh, sure.

RODRIGUEZ:

If you want to see them.

ROSOLOWSKI:

And then actually, if you could, then maybe I could ask—I’ll remind you to maybe send me a shot of it so that we could—

RODRIGUEZ:

So when will—

ROSOLOWSKI:

And ooh, so we’re worried about our recorder, here—

RODRIGUEZ:

Well, I think this one has a—or some of these [inaudible]. So let me show you here in this book, textbook that we published on cancer survivorship— We developed algorithms for survivorship care, of course. So today, we have algorithms of care for several domains of care; for cancer treatment, for survivorship, for prevention and for what we call “supportive care,” or, “medical supportive care,” I forget what the subheading is. But it’s about managing other associated problems, such as preventing thrombosis, prophylaxis for deep vein thrombosis, management of pneumonias, whether they are related to community infections or hospital-acquiring infections. Management of chest pain and myocardial infarction, and so on, so that we are taking into account the more common complications we see, as well as the actual treatment of the cancer itself. So this is what they look like. I mean, essentially, they’re a map. And the map says, “If this, then you must do that.”

ROSOLOWSKI:

OK, so myeloma post-treatment and NED, which means--?

RODRIGUEZ:

No evidence of disease.

ROSOLOWSKI:

Oh, OK. Yeah. So then you go through surveillance, oh I see. And then it’s, like, selecting from a flowchart.

RODRIGUEZ:

Exactly. Exactly. And so every map--

ROSOLOWSKI:

Wow, one year of age and up, four years of age and up—

RODRIGUEZ:

But this is [inaudible].

ROSOLOWSKI:

[inaudible] diagnosis. OK. Got you. OK. Interesting.

RODRIGUEZ:

So many—so—

ROSOLOWSKI:

I can’t even imagine the database that you would require to put together something like that.

RODRIGUEZ:

So we have that. (laughs)

ROSOLOWSKI:

Yeah. Yeah.

RODRIGUEZ:

And we established some ground rules, so we say, for example, in survivorship, all your algorithms must contain four domains. One domain is the surveillance one, but the other one is also monitoring for late effects, early detection and risk reduction and psychosocial functioning.

ROSOLOWSKI:

OK.

RODRIGUEZ:

You must address these four domains; tell us what you would do for your patients in these four domains.

ROSOLOWSKI:

Right. OK. Did you work with Lewis Foxhall on this? I think he mentioned to me something about he uses different domains—

RODRIGUEZ:

Well, he was a co-editor of this book.

ROSOLOWSKI:

Oh, yeah, there’s his name. Yeah.

RODRIGUEZ:

But the domains of survivorship, we worked with all specialties. Each specialty really designs its own survivorship domains. We took those four domains from the Institute of Medicine report on what constitutes good survivor care. So we said, OK, there are national estab—or national recommendations and what should be the domains of care that survivors receive, so let’s be sure we built our care—models built on those domains.

ROSOLOWSKI:

So I can see the advantage here. Now, I guess I was making the assumption that these practice algorithms were created diving into MD Anderson databases on treating thousands of patients with all sorts of different cancers. Is that the case?

RODRIGUEZ:

No. You’re talking about, then, outcomes analysis.

ROSOLOWSKI:

OK. OK.

RODRIGUEZ:

You’re talking about analysis. This is about simply creating an informational work tool for physicians.

ROSOLOWSKI:

OK.

RODRIGUEZ:

Within those informational work tools, then, there will be areas where you have to do a specific tool for that performance. So again, so if you say for breast cancer, we just updated one, for example, for invasive breast cancer, limited stage. So the recommendation is you must do either doxorubicin or Taxol-based chemotherapy if the patients are hormone receptor negative and they don’t have Herceptin. OK. So for that subset of patients, then you do Taxol and doxorubicin chemotherapy, which regimens, so we create order sets for those regimens that map—then, along with that algorithm.

ROSOLOWSKI:

OK, interesting.

RODRIGUEZ:

So anyhow, so this is a theory—this is part of how one then develops also quality controls and quality measures, because we can then say one of our quality measures can be, do you provide—in fact, this is one national quality measure for patients who have estrogen receptor, progesterone receptor positive breast cancer, do you give them hormonal therapy, which our algorithms say you should. So do you walk the talk of your [inaudible]?

ROSOLOWSKI:

Interesting!

RODRIGUEZ:

So, no, I think you’re talking about measuring outcomes.

ROSOLOWSKI:

OK.

RODRIGUEZ:

Looking at outcomes. That’s the Tumor Registry. And we have a Tumor Registry, the Tumor Registry follows patients for periods, you know, for their lives to find out how they are doing, and have they relapsed, and are they still alive? So, for example, these are the survivors for cervical cancer, early stage, across many decades. You know, you can see that. And what is interesting is that for some cancers, the outcome has always been good, even before—even in the 1940s. And we haven’t made much difference, and for some, we’ve made a huge difference, and for others we have made absolutely no difference, and the outcome is really still horrible, despite seventy years.

ROSOLOWSKI:

Wow, amazing! Amazing.

RODRIGUEZ:

Yeah.

ROSOLOWSKI:

Now, in putting together these practice algorithms, how did that happen?

RODRIGUEZ:

So that, by the way, is run by the Department of Clinical Effectiveness.

ROSOLOWSKI:

OK.

RODRIGUEZ:

They report to me also.

ROSOLOWSKI:

And when was that department established? Is that, did that—

RODRIGUEZ:

Again, it sort of preceded my coming on board.

ROSOLOWSKI:

OK. OK.

RODRIGUEZ:

Because they—once upon a time, they were supposed to be working and developing those pathways. When I took over the office, we tightened up the process. We said we will have institution-wide clinical algorithms, we will have for all the major disease categories, all the major cancers that we see, we are going—you can’t have an algorithm for everything; there are some malignancies that are so rare that you can’t, you know, really—there is no standard, if you will, or no known best strategy for treating them. But for all the more common and more widely-seen malignancies, we have developed algorithms for cancer care. We have over 100 now, 147 algorithms. And—

ROSOLOWSKI:

What’s been the effect of the algorithms?

RODRIGUEZ:

Well, what has been the effect of the algorithms is in—number one, it brings to awareness, to people’s awareness, that there are indeed best practice processes. In a way, it’s an intellectual discipline process, it’s a process of doing a very rational and thoughtful analysis of where should we be? Then it usually piques the interest of people in saying, well, where are we? So some departments have, I would say, the most—the best outcomes have been that some departments have become interested in looking at themselves again, a self-inquiry, looking at ourselves and saying, “Gee, are we really doing this?” And, “Is this what we want to keep doing?” Some of them have questioned, well, you know, just because we have done X, Y or Z forever, it doesn’t mean that it’s the best strategy. What does the data say? And this is where Stephanie Fulton and her group come in, because they support us in doing fairly—very professional intensive literature searches. And they then can give us the objective information that says, well, you know, that’s changed. Other people think that this is better, or they might say, you know, the needle hasn’t moved, it’s still the same, in which case, it might also initiate a different conversation, which is, “Gee, should we start to try something different?” (laughter)

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

So, you know, so that’s been, again, in the best case scenario, it is, and for some departments, this has been a process of self-inquiry, of self-assessment, of updating, renewing, refreshing information on what’s appropriate and relevant to their practice. In others, in many of the supportive care algorithms, for example, the management of deep vein thrombosis, it has initiated major conversations about who are the appropriate patients who should be placed on these prophylaxis modalities of treatment, are we doing it? It generated a whole deep analysis into practices by various groups. And we sort of surfaced, who are the people who really do it, the people who don’t do it, and we fed that data back to them. And they’re like, “Ooh, that’s us, we can’t believe it!” So it again has brought—one department that said, you know, our patients are really high-risk, we understand. And yet we’re seeing this as a complication often. Why is that? So they initiated a research protocol for that. So it can have very positive consequences, depending on the attitude of the individuals who are participating in the process. And again, we don’t expect humans to be uniform. So it’s a good thing. I mean, it has generated a lot of very good things out of the process.

ROSOLOWSKI:

Was there anything in particular you learned from going through this process of working with all of these individuals, and taking this perspective?

RODRIGUEZ:

Well, so I’ve learned that there’s some—well, first of all, I’ve learned that the overwhelming majority of the physicians who practice here care deeply about doing the right thing, and taking the best care of their patients. I mean, that’s been incredibly rewarding for me, to say as a profession, I think we are an outstanding group of people. I’m very proud to work with them and for them, actually, because I work for them. And so that’s been one thing that I’ve learned. The other thing that I’ve learned is that there is always a potential risk in medicine. I mean, this has been true for centuries; we are a profession that is very, for lack of a better word, dogmatic, and that you have to be vigilant to the risk of being purely dogmatic versus quality and safety-motivated, when you say, no, look, this is the best way to do this. It’s not OK to do X, Y or Z, just because you like to do things that way, right? I mean, there is always the—the physician is the artist. I mean, everyone says that medicine is both an art and a science. Well, one has to guard a bit against the over-artistic aspects, as well as the over-scientific aspects, because being at both extremes may not be the most optimal medium for the patient. I think that there is a certain—there’s a harmony to both the art and the science. I think that while the—and patients are very conscious of this, they truly do want the treatment that, according to the scientific evidence is the best, or would be the best. But at the same time, they want the treatment that would be most suited to them as individuals. So there is a—that’s the—I think that’s the most valuable professional skill to have, to have the appropriate judgment to determine the harmony of the science versus the humanity of the decision. If this is the right treatment, is it the best treatment for this individual?

ROSOLOWSKI:

Just the way you phrase that kind of brought to mind the whole issue of targeted therapy. And I’m wondering how targeted therapy fits into the practice algorithms at this point.

RODRIGUEZ:

Well, there are some scientifically-proven targeted therapy strategies. And, in fact, the most general of the targeted therapy principles is that you decide the treatment according to the tumor type; you know, a breast cancer may not necessarily be the same as a colon cancer, as an ovarian cancer, as a brain cancer, and so on. Even within breast cancer now, we know that there are different types of breast cancer. So the algorithms are supposed to align to each of the sub-categories of malignancies. Now, having said that, there is now an expectation that we do the [inaudible], even to the molecular level of the individual. The problem is that only a handful of the specific tumor markers today can be meaningfully addressed, OK? And so to do a whole genome analysis of every single individual is, in fact, meaningless, unless you know that there are useful therapeutics for certain targets.

ROSOLOWSKI:

Right.

RODRIGUEZ:

And at this point in time, we do have some scientifically-confirmed useful treatments for targets. But, I recently heard a talk from a world-renowned scientist, talk about this issue. He said, you know, even within a single tumor, we are finding that there is huge heterogeneity in the complexity of the gene. You know, so some cells will have this pattern, but other cells will have this pattern, and yet other cells will have this pattern. So which one of the malignant cells are you going to aim your tumor at?

ROSOLOWSKI:

Right.

RODRIGUEZ:

So in fact, we’re shifting now our thinking, well, we haven’t abandoned the concept of targeted therapy. And, in fact, it’s a valid concept for many tumor types, for some tumor types. So for example in breast, we know that the presence of the HER2-neu receptor calls for treatment with the antibody Herceptin, because that helps many of the patients with that marker. It doesn’t help everyone who has that marker, OK, but it is proven to be of benefit to a large proportion of those patients. So therefore, we would use that treatment for that particular tracer marker. But at the same time, you know, what about all those people that didn’t respond to the targeted therapy? So we’re shifting now to a concept of thinking, how does the body fail to recognize that these cells are not normal, or they’re not healthy? Because our body has self-regulatory mechanisms by which, you know, cells that are damaged do autolyze; they kill themselves. So why is it that this control of self-regulation failed? Why did the immune surveillance fail to recognize the cells as essentially rogue individual cells that are doing their own thing, outside of the, if you will, the overarching domain of health control that the body has. So the concepts now are shifting towards, let’s look at the regulations for—let’s look at the mechanisms that have failed in the so-called immune surveillance of tumors, and that’s where all of the novel immune therapies that you probably have been hearing about are now coming to the fore, because that model of care is very attractive, in that it’s generalizable. You don’t have to have a specific gene marker; you simply have to have a recognition that that cell is not normal. And the recognition mechanisms are very generic, they’re broad. They’re not to a specific gene, or more specific DNA marker, or a specific—they simply are to recognizing this cell is not acting normal. And so that’s really the shift in paradigm that we probably are going to be seeing prominently evolve. It’s already becoming prominently recognized. So I think there’s a lot going on right now.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

Yes, indeed, for some tumors, targeting a geno or genetic marker is appropriate. But those tumors are rare, the ones that are really sensitive to the one targeted therapy are rare. So more to come.

ROSOLOWSKI:

Absolutely. Absolutely. Is there more that you wanted to say about the practice algorithms, kind of next steps, or—?

RODRIGUEZ:

Well, in the next iteration of the algorithms, we hope to be able to have more robust capabilities to self-monitor the practices; in other words, to say if you said that this is the best strategy, are you, you know, are you following what you said was the best strategy?

ROSOLOWSKI:

Is there any oversight right now of that?

RODRIGUEZ:

We have the Medical Practice Quality Committee.

ROSOLOWSKI:

OK.

RODRIGUEZ:

That was just named in November—

ROSOLOWSKI:

Oh, wow!

RODRIGUEZ:

(laughs) —of 2014 by the Executive Committee of the Medical Staff. And these are the focus areas that we launched as critical for oversight of this committee are, number one, the access of patients to the Institution, the diagnosis, are we doing the right diagnosis in a timely and efficient fashion, and appropriate fashion? Treatments, treatment decisions based on best evidence and eliminating adverse outcomes for the treatments. So, safety guidelines as well as effectiveness guidelines. And then at end-of-life care, are we having the discussions in a timely fashion, and are we referring patients to appropriate support services? So essentially, you know, it starts from the beginning to the end of our cancer care domains. And we’re looking at the two very—you know, the start and the end, of course, are critical for the patient for their experience perspective. But these, the diagnosis and the treatment are very driven by expertise and appropriateness of care. So these two are huge, huge domains that we’re going to focus on from a medical practice perspective.

ROSOLOWSKI:

I have, I mean, I’m about ready to shift topics right now, if that’s OK.

RODRIGUEZ:

Sure.

ROSOLOWSKI:

OK. Because I had on my list a couple of other things I wanted to ask you about; one was the survey, it was the 2014 BIG survey, but I didn’t want to jump to that if there were other initiatives within Medical Affairs that you wanted to make sure you got on record.

RODRIGUEZ:

Well, the other domain within Medical Affairs that I think needs to—it’s also a major—has been evolving again slowly and organically, over the last twenty years, really, but has taken off really dramatically over the last ten years is the expansion of the physician practice to include Advanced Practice Providers, to include Physician Assistants and Advanced Practice Nurses. And initially, when this work model was introduced, it was mostly the surgical services that embraced it because the model of Physician Assistants in surgery was established in the military during the major wars in the twentieth century, and so it is was not so alien to the surgical specialties. But what has been very, if you will, culture-changing has been their integration widely, now, into the medical oncology practices. There are still—and amazing to me, there are still a few holdouts within the organization; not in medical oncology, but in internal medicine where the Physicians feel very threatened by the medical providers.

ROSOLOWSKI:

Why is that?

RODRIGUEZ:

By the Advanced Practice Providers. I have no idea. I’m trying to wrap my head around that one. I really don’t understand. I just got an email from one of the chairs, one of the departments, saying, “We have no comprehension of why at MD Anderson you think that the mid-level providers can give care of equal competence to the Physicians,” or something to that effect. I was stunned, because everybody works with mid-level providers here, except, like I said, very few focus groups.

ROSOLOWSKI:

Now, tell me how a mid-level provider would be integrated into a care team.

RODRIGUEZ:

They are. (laughs) They are part of the team—

ROSOLOWSKI:

No, meaning just—no, I mean—

RODRIGUEZ:

They just are.

ROSOLOWSKI:

—not to convince me, but what do they do? How do they operate?

RODRIGUEZ:

They do everything the physician does.

ROSOLOWSKI:

OK.

RODRIGUEZ:

Under the physician’s direction, with some exceptions, of course. They cannot initiate the decisions for surgery or chemotherapy, but they assist us in the delivery of that care. They do physical examinations, they do procedures, they call patients, they interface with external providers. They interface with each other. They help us to facili—they help the patient and us to facilitate getting certain things done on time. They essentially are an extension of our brains and our hands. I mean, two hands are not enough to get the work done in a day, bottom line.

ROSOLOWSKI:

So what’s the difference between an Advanced Practice Provider and an oncologist, or--?

RODRIGUEZ:

Well, they are not physicians, first of all. They’re not physicians, they don’t have the training we do. So their privileges are granted only under the approval of the Physician, number one, and secondly, they are limited to what we call the more basic performance of responsibilities, being doing the physical exams, eliciting symptoms from the patients, and driving certain therapeutic interventions. I mean, they can order hydration. They can order electrolyte replacements, they can order transfusions, they can order—I mean, they can order tests. But they cannot generate the oncological care plan for the patient. They cannot write chemotherapy orders. They can help us write the orders, because the orders are already preformatted in our order sets. I mean, essentially, once I make the decision, you are going to get Protocol A—in the clinic, my mid-level provider helps me. He pulls up Protocol A, and he says, oh, this, do you want to give all the drugs? Do you want to delete some of the drugs? I go, “OK, we’re going to do full dose everything today, for starters.” OK, he can help me calculate doses, because our current system doesn’t have the dose calculation capability. But in the future, the future an Electronic Health Record is even going to calculate that. So, will I necessarily have to have assistance from them? Probably not. But anyway, we have two-person check requirements in the calculations. So my mid-level provider has to help me—he does his calculations, I do my calculations, we compare. Did we get the right dose? So that’s how we work together. On the in-patient service, we make rounds. We go over the problems for the day, I say, OK, it looks like the patient needs electrolytes. They need this, they need this, they need this, let’s start to plan for the discharge. Please call the case manager, please call the social worker. Please blah blah blah—they take care of all that.

ROSOLOWSKI:

So tell me about the growth of how this office has worked with developing APPs within the Institution.

RODRIGUEZ:

So we—they report, the Physician Assistants program reports to my office because they’re licensed through the same mechanisms as Physicians, through the Texas Medical Board. So if you go to the Texas Medical Board Website, you will see Physician Licensing, Physician Assistant Licensing, and Acupuncture Licensing. So acupuncturists also report to the Texas Medical Board. Pharmacists have their own board, and nurses have their own board. But the Physician Assistants reside within the domain of the governance of Physicians. So there is a bit of—so the Nursing Advanced Practice Providers do not report to me. They report to Nursing, which is confusing to the Advanced Practice Providers who are nurses, because actually, their practice, as Advanced Practice Providers, their practice really resides under the oversight of Physicians. There’s a huge—and it’s been—in Texas, this is a big political issue. In other states, the Advanced Practice Nurses can set up their own practice. In the State of Texas, they have to have oversight by a Physician.

ROSOLOWSKI:

Interesting. Huh.

RODRIGUEZ:

Yeah. So in any event, I sort of have a co-oversight with the Division of Nursing, but the Physician Assistants report to me directly; their Directors report to me directly.

ROSOLOWSKI:

Now, am I correct, in 2008, this office started an oncology fellowship program for Physicians Assistants?

RODRIGUEZ:

Yes, it did. Yes.

ROSOLOWSKI:

Tell me about doing that.

RODRIGUEZ:

Well, again, so Physician Assistant programs, our Physician Assistant’s education parallels that of Physicians in that the first year of the Physician Assistant’s education is exactly as first-year students, have the same curricula, you know, you have to have anatomy, physiology, pharmacology, etc., etc. Where it deviates is that Physician Assistants immediately move into clinical rotations their second year, whereas physicians don’t until about their third or fourth year, actually fourth year. So physicians have a much longer didactic training period than the Physician Assistants. And furthermore, we are required to do residency programs, training, you know, and some of us even do fellowship programs which are beyond—so for us, our training lifespan is about ten years, if you count starting medical school and residency education and fellowship education. It’s very long, and for some surgical specialties, even longer. Whereas the Physician Assistants, immediately after one year of didactics and one year of what is called clinical rotations, they’re sent off to the job. And so they basically are more in the apprenticeship model. They learn on the job to do what they do.

So many of the Physician Assistants who are going into oncologic practices really felt a bit lost. And we’ve done our own analysis. When we take in Physician Assistants that we hire either fresh out of school or from other primary care practices, it takes them six months to a year to really get up to speed on what they’re doing here. They require very, very close oversight and supervision. So we thought, why would we not prepare Physician Assistants to be more competent in the job force as oncology trained. There is a precedent in that there are, for example, emergency room fellowships for Physician Assistants, where they spend a year in the emergency room as part of their training, and therefore they are competent at, very competent at working in emergency rooms. There are some that are surgical, so once they’ve done their year of surgery fellowship, they’re very competent in the surgical environment. So we felt, let’s do—why do we not train oncology—why do we not train PAs [Physician Assistants] out of school in the oncology environment for a year? So at the end of that year, because it’s how long it takes us anyway, if we hire them.

ROSOLOWSKI:

Right.

RODRIGUEZ:

And we consider that a fellowship; they’re not obligated to work for any one physician. We will expose them to various rotations throughout the hospital. They will do some surgery, they will go to radiation, they will also do medical oncology, hematology practices and see what they like best. So there is an American Academy of Physician Assistant education; they do have criteria for credentialing programs. We were the—and most of their experience had to do, like I said, with emergency medicine, and surgical programs, we kind of an outlier group for them. So it took a while for us to get through that entire process of accreditation as a program. We had to develop curriculum, we had to identify instructors within the organization, or preceptors, rather, within the organization. So Maura Polanski is the lead Director of Education in that program, and I’m the designated Medical Director of the program. Because again, because it’s—because their training is under the guidance of a physician, they have to have a Medical Director for their program.

ROSOLOWSKI:

So that was formed in about, well, about eight years ago. So what are the effects that you’ve seen? Are there many of these fellows who decide to stay at MD Anderson? What’s been the impact of the program?

RODRIGUEZ:

Yes. The impact has been that, you know, some of the best fellows we’ve had have, fortunately, stayed with us, and some of them have gone to really—most of the ones that have not stayed with us have gone to excellent programs in the nation. Dana Farber Memorial and other programs, simply because, you know, family or interest of the individuals leads them to those locations.

ROSOLOWSKI:

Right. Right.

RODRIGUEZ:

We wish that more programs would do this. We’ve had lots of—we’ve been asked by the American Society of Clinical Oncology, our Director, Todd Pickard, has been a member of a committee at the national level for the American Society of Clinical Oncology, because many of the community oncologic practices are beginning to realize we need to have help. And how are we going to do this, and who is capable of doing—who is competent to do it, how do we get people trained to do it? So we’ve developed, actually, an online course for—precisely for those people who cannot physically be here. Because we can’t—of course, we don’t have the funds to have, you know, 100 fellows at MD Anderson. Let me see if I—I used to have a little flyer here for that program. Let me see if it’s still here. Oh, yeah, here it is.

ROSOLOWSKI:

Oh, neat!

RODRIGUEZ:

We have an e-Learning course.

ROSOLOWSKI:

Oh, how neat! Could I take this?

RODRIGUEZ:

Sure.

ROSOLOWSKI:

That would be great.

RODRIGUEZ:

Let’s see if—yeah, Maura Polanski and I.

ROSOLOWSKI:

Neat!

RODRIGUEZ:

And we’ve updated it a couple of times. It requires, you know, when you have online learning courses, you have to—they expire, they have a life span, because knowledge, of course, keeps accumulating, so you have to update them periodically in order to be certified.

ROSOLOWSKI:

And is that the same kind of—I mean, does the person come out with the same kind of status of approval, as if they were coming here?

RODRIGUEZ:

No.

ROSOLOWSKI:

No.

RODRIGUEZ:

Not really. I mean, this is didactic information—

ROSOLOWSKI:

Right.

RODRIGUEZ:

It’s not the same as the—

ROSOLOWSKI:

Not the apprenticeship.

RODRIGUEZ:

Yes. It’s not the same as having your roots on the ground and face-to-face with the patients’ situations, and learning from, again, face-to-face from experts who can explain why this is different than that, and so on. So no, of course a live person-to-person experience always is richer than— But nonetheless, I think, we think that this provides an incredibly rich—this is an incredibly rich source of knowledge that can inform people on how to get themselves prepared, or at least have a basic and working knowledge of why there is a difference between this category of disease and that category of disease; what kind of side effects might you expect from this kind of chemotherapy drug, versus this other drug, and so on. What might be some of the more common complications of surgery, you know, in patients who have had a mastectomy versus a renal removal, or versus a cystectomy, a bladder resection, and so on. So just some very basic understanding, so they are not going into their jobs completely unprepared. Right.

ROSOLOWSKI:

Can you tell me, I mean, I’m sort of wondering if there—since the Office of Medical Affairs has been in existence for a decade now, were there some important landmarks in its evolution? I mean, that’s—

RODRIGUEZ:

Well, let me say that the Office of Medical Affairs has been here forever, I mean this is saying why are—

ROSOLOWSKI:

But I mean you being here—

RODRIGUEZ:

Me as the person here? Yes.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

Oh gosh, everything. We, you know, when I stepped, again, into the role, we didn’t have a Physician Assistant Program’s office with the Director. I mean, Maura was sort of a volunteer Director, if you will, and she was sort of the volunteer Education Director. We established those as formal titles for individuals. We established roles and responsibilities, job descriptions for them. I can say with confidence today that, you know, Todd Pickard is the Director of this office, serves as an invaluable resource to all the departments and processes of evaluate—for starters, you know, how do you do an evaluation that’s meaningful for your mid-level providers, what do you expect of them? We’re right now—we just completed a really important survey looking at job satisfaction of the mid-level providers, and what do they see as [inaudible] their roles are meaningful to them or not, or what kind of disparities do they observe, what kind of dissatisfiers are there that we need to address? It’s very interesting, because they’re all very committed to their job. What we found is they’re all very committed to their roles, but they do observe major inequities in terms of work distribution and in terms of in a significant proportion, and slightly more than a third, they think that they’re not being—their jobs are not fully up to the optimum level of performance they could perform. If you will, they’re being underutilized—

ROSOLOWSKI:

Yeah, interesting.

RODRIGUEZ:

—in their jobs. So, you know, they’re an incredibly valuable resource to the organization, and very—of all the complaints that we get, the group that gets the least complaints and the most appreciative notes is the mid-level providers group.

ROSOLOWSKI:

Wow. That’s amazing. What was the name of that survey?

RODRIGUEZ:

I—it was just a mid-level provider’s survey.

ROSOLOWSKI:

OK.

RODRIGUEZ:

We made it up ourselves. We asked them, what do you want? What do you think? HR [Human Resources] helped us to develop it; it was just a survey of work environment assessment.

ROSOLOWSKI:

Wow. That’s amazing. And how will you use the information that’s come out of the assessment?

RODRIGUEZ:

Well, that’s what’s in discussion right now.

ROSOLOWSKI:

OK. (laughs)

RODRIGUEZ:

What are we going to do about this?

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

Yeah.

ROSOLOWSKI:

Yeah. Well, and it’s always a pleasure to discover a situation when people want to be doing more.

RODRIGUEZ:

Uh-huh.

ROSOLOWSKI:

You know, to feel good themselves, and [inaudible].

RODRIGUEZ:

Yeah. Very few of them said that they wanted to do less.

ROSOLOWSKI:

OK.

RODRIGUEZ:

Many of them did say that—well, let me put it this way. They were not dissatisfied with the challenge, the intellectual challenge and emotional challenge their job was offering them. They were dissatisfied with the physical stress of hours. Some of them work very long hours, and that probably is not appropriate. And they feel that there is inequity in distribution. Some of them have physicians who—but what ends up happening is that their job responsibilities are going to more or less mirror the physician’s. Some physicians have huge workloads, others don’t. But—so here’s the thing. If the mid-level providers have inequity, so do the physicians, right? I mean, I have to draw the parallel.

ROSOLOWSKI:

Right.

RODRIGUEZ:

And it’s likely that that’s the case. So the next question is, what are we going to do about the physicians?

ROSOLOWSKI:

Yeah. Right. Right. Right. Now, just to ask the obvious question, I mean, are the mid-level providers paid equally regardless of that workload? I mean, is that part of the stress that they’re talking about?

RODRIGUEZ:

Yeah, they’re paid differently, depending on the number of years or level of competence and experience, and so on. But they’re not paid more if they see more patients, or work harder.

ROSOLOWSKI:

Right. Right.

RODRIGUEZ:

So that’s what—at the core, it’s really an issue.

ROSOLOWSKI:

Money, yeah. Yeah. Now, there was another survey that you did; this is the 2014 BIG survey of employees.

RODRIGUEZ:

Oh, the BIG survey?

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

Mm-hmm?

ROSOLOWSKI:

So tell me about that. Because I was reading a lot about that. What was the motive for doing that? And what was the outcome?

RODRIGUEZ:

Well, I think—so the institution has had this survey for quite a long time, it’s every other year, every third year—

ROSOLOWSKI:

OK. All right.

RODRIGUEZ:

—I forget the time frequency. But it’s been going on for quite a long time. And the intent was simply to look at satisfiers in the workforce; you know, what makes the workforce, in general. And I think overall, we have an incredibly stable workforce. Our turnover rate, as I understand it, is relatively low compared to other organizations. Nonetheless, there are certain pockets of the organization that do have high turnover rate.

So the questions were, you know, where are these pockets? Why is there dissatisfaction? Culturally, what are issues that we face? What I can say overall is that—or, what I’ve learned, and what has been consistent in the survey over time is, number one, everybody knows what our mission and vision are. They’re highly committed to it. Most find their jobs rewarding personally, on an personal level. Many want opportunities for improvement, or promotion that they think we failed to provide them, and that may be the case. I mean, it’s unfortunate, but not everybody can be a Manager or a Director. And sometimes you have to move either laterally to another department to be able to have that opportunity, or you need to go to another organization and move up the ladder there. You know, it’s just a reality. And we can’t have as many chiefs as Indians, you know, for lack of a better metaphor. So there is going to be only X-number of opportunities for promotion up the ladder in any one organization. And so the people who are very highly-driven motivated, ambitious and so on, unfortunately, we may not have an opportunity for all of them.

So we find that consistently in our survey, every time that we’ve done it. The other issue that we find, which is very unfortunate, is that there is a fear of retaliation. If people complain, or at least that’s the perception, that if they bring up issues of things that are not going right that there’s going to be a negative retaliation against them. We’ve tried to do in-depth analysis of that; that seems to be across the board. Oh, and of course the other thing that people consistently complain about is that they’re not paid enough. That, as I understand it, our measurements are exactly the same as the national measurements in all health organizations. Fifty percent, or some of the people, think that they’re not paid enough.

And that’s apparently the national norm. We’re not different than the national norm.

ROSOLOWSKI:

What’s the value of doing a survey of this kind, every two or three years?

RODRIGUEZ:

I have no idea. (laughter)

ROSOLOWSKI:

OK.

RODRIGUEZ:

I truly don’t know.

ROSOLOWSKI:

No big truth from the mount on that one.

RODRIGUEZ:

Well, I mean, there has been some, there have been some things that we’ve done as a result of the survey. So let me say the biggest one is, we’re not paid enough. Well, there’s no way that we can changed salaries. They’re fixed by the state, OK? We paid whatever it is that the other state organizations pay. And then we also usually measure ourselves against—we do what is called a market analysis, and we look at what is it that our competitors are paying, and we try to match those benchmarks. So it’s whatever the marketplace decides and whatever government regulations decide, that’s what we pay. I mean, I don’t know what else we can do about that. So I don’t even know why we ask that question. Because to me, that’s kind of like a silly question. I mean, we should process that continually and proactively assess, are we doing the fair thing? Are we paid the fair salary? And if we are, we are. I mean, what else is there to—why are you asking that? You know?

So the one thing that we did do, that we have done that I think is positive is that some people wanted to have an opportunity for mentorship. So they said you should establish this mentorship program to onboard new employees, or employees who wanted to transition to something else, or who could learn—who wanted to learn about something else. So, for examples, in the survivorship—in the patient—the Physician Assistant programs, we established a mentorship program for employees who wanted to learn about what the PAs do. You’d be amazed how many of the technical staff, like, laboratory technicians and so on, say, “Oh, I could go to medical school,” or, “I could go to PA school.” What they don’t know is that getting into PA school is just as hard as getting into medical school. It’s getting even harder, because there are fewer positions.

So in any event, but so we said, OK, there are probably a lot of very capable people who could possibly be accepted to PA school. Why don’t we just have a program where we talk to them about what is it that we do, how do we do it? And the reason that we wanted to have a formal program is, we didn’t want—what was happening was, you know, a friend of a friend of a friend recommended that so-and-so shadow PA Smith in Orthopedic Surgery. And PA-X in Orthopedic Surgery then felt obligated because their friend, so-and-so so-and-so said that they wanted to have—so they would take this person around. And I said—when I started to discover this, I said, “Wait, time out. Has this person had all the appropriate training? I mean, you are exposing patients to individuals whose job descriptions do not permit that these patients be exposed to them.” I mean, you have individuals in vulnerable situations, maybe half clothed, or you don’t know. And there’s private information that’s being revealed or disclosed to these individuals who have nothing to do with this particular job function, they just want to do it out of curiosity or self-knowledge, or whatever.

Fine. Let’s have a formal vetting process. They have to go through HIPAA [Health Insurance Portability and Accountability Act] training, they have to have ethics training, they have to have—

ROSOLOWSKI:

Right.

RODRIGUEZ:

You know, do you know what I’m saying? I mean, you can’t just—

ROSOLOWSKI:

Absolutely.

RODRIGUEZ:

—have people walk in.

ROSOLOWSKI:

Yeah.

RODRIGUEZ:

Or walk into the OR just because I want to observe what it’s like to do a hysterectomy. I mean, sorry, no!

ROSOLOWSKI:

(laughs) I can see people in the compliance office having coronaries!

RODRIGUEZ:

Yeah, well, I was having coronaries.

ROSOLOWSKI:

And you too, of course!

RODRIGUEZ:

Because that’s inappropriate. That’s—

ROSOLOWSKI:

I’m sitting here thinking, wow, I’m really glad that Dr. Rodriguez stepped in!

RODRIGUEZ:

It’s a violation of patients’ rights.

ROSOLOWSKI:

Absolutely.

RODRIGUEZ:

You know, so, no. So anyway, that’s why we established that. And there’s many other mentorship programs in the Institution. That’s the one positive thing that I’ve seen come out of the survey. Outside of that, honestly, I don’t think that much has happened.

ROSOLOWSKI:

Dr. Rodriguez, I just checked my watch, and we’re almost at noon.

RODRIGUEZ:

Yes.

ROSOLOWSKI:

And I want to make sure—I know you’ve got a meeting. So do you want to close off for today?

RODRIGUEZ:

I—I think we’ve talked about a lot.

ROSOLOWSKI:

We have. And well, what I thought was that, you know, we could probably do one short session for the final things that I have to ask you.

RODRIGUEZ:

Uh-huh. OK.

ROSOLOWSKI:

For follow-up, would that be all right?

RODRIGUEZ:

Yeah. Sure.

ROSOLOWSKI:

OK. Because I don’t want to make you late for your meeting.

RODRIGUEZ:

No, that’s all right. Thank you so much.

ROSOLOWSKI:

So I am turning off the recorder at 11:56, and I want to thank you for your time this morning.

RODRIGUEZ:

(laughs) I’m just curious, have other people said that something important has come out of the BIG surveys? (laughs)

ROSOLOWSKI:

I’ve never asked anybody about it. Actually, it was—you were the only person where it was, you know, in your background research. All right, I’ll be turning off the recorder now.