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Four sessions: 22 October 2018, 12 November 2018, 17 December 2018, 26 March 2019
Total approximate duration: 4 hours 30 min.
Interviewer: Tacey A. Rosolowski, Ph.D.
About the Interview Subject:
Charles Balch (b. 24 August 1942, Toledo, OH) was recruited to MD Anderson in 1985 to serve as Head of the Division of Surgery and Anesthesiology and Chair of the Department of Surgical Oncology (1985-1993). He went on to serve several administrative roles, including VP for Hospitals and Clinics (’93-‘94) and Executive VP for Health Affairs (‘94 – ‘96). Dr. Balch was instrumental in reorganizing breast cancer care as the first multi-disciplinary organ site clinic in the institution and the US. He left the institution in 1997 to serve in executive leadership roles in other institutions, then returned in 2016, when he focused on mentoring. Dr. Balch is also founding Editor-in-Chief of the Annals of Surgical Oncology.
Major Topics Covered:
Personal background and education
Research: tumor immunology, melanoma, breast surgery, T-lymphocyte differentiation
Surgery at MD Anderson: history of; key figures in early years; shifting focus to subspecialization, surgical oncology perspective, and evidence-based practice; recruitments; training programs; and evolving strength of Division
Division of Surgery, creation and evolution
Department of Surgical Oncology: evolution of, development of research mission within
Prevention: creation of Division
Charles LeMaistre: vision for MD Anderson; strategic plan; working with Texas Legislature; legacy
Fiscal crises: managed care, changing healthcare environment; role of Texas laws and regulations; institutional responses to
Leadership: traditions of at MD Anderson; personal experience of; executive roles beyond the institution
About transcription and the transcript
This interview had been transcribed according to oral history best practices to preserve the conversational quality of spoken language (rather than editing it to written standards).
The interview subject has been given the opportunity to review the transcript and make changes: any substantial departures from the audio file are indicated with brackets [ ].
In addition, the Archives may have redacted portions of the transcript and audio file in compliance with HIPAA and/or interview subject requests.
The views expressed in this interview are solely the perspective of the interview subject. They are not to be interpreted as the official view of any other individual or of The University of Texas MD Anderson Cancer Center.
Interview Session One: 22 October 2018
How a Son's Career Can Parallel a Father's
Creativity, Leadership, and Choosing Medicine
Medical School and Other Training: Breaking into Opportunity
Work in the Emerging Fields of Immunology and Surgical Oncology
Melanoma Research and Comments on Research Disappointments
Surgical Oncology at MD Anderson, Part I: Changing Surgical Tradition
Surgical Oncology at MD Anderson, Part II: The First Multi-Disciplinary Breast Center and the Success of a Surgical Oncology Approach
Surgical Oncology at MD Anderson, Part III: Creating a Fellowship Program
Interview Session Two: 12 November 2018
Transforming the Division of Surgery, an Overview
Transforming the Division of Surgery, Part of the Institution's Strategic Plan
Subspecialization: The Key to Building a New Division of Surgery
Building the Division of Surgery: One Precursor to Disease-Site Reorganization
Interview Session Three: 18 December 2018
Head of Hospitals and Clinics: Managed Care and the Origin of the National Comprehensive Cancer Network;
Comments on Leadership
Creating the First Prevention Program
Interview Session Four: 26 March 2019
Addressing the Managed Care Crisis (mid 90s) with HR 192 and Other Legislation
A New Chapter as CEO at City of Hope and Other Roles
A Return to MD Anderson in 2016 and Reflections on a Career
Interview Session One: (listen/read)
Chapter 01 (Personal Background)
How a Son's Career Can Parallel a Father's (listen/read)
In this chapter, Dr. Balch talks the choices his father made while developing a career as a chemist. He observes that his own career path paralleled his father's track: entrepreneurial, research based, and academic. Dr. Balch keys on the fact that his father's entrepreneurial initiatives involved vision, a key leadership quality. Dr. Balch then talks about the leadership qualities that have been important in his own career. Next, Dr. Balch talks about R. Lee Clark's vision for MD Anderson. He describes how he met Dr. Clark.
Chapter 02 (Personal Background)
Creativity, Leadership, and Choosing Medicine (listen/read)
In this chapter, Dr. Balch notes that he played jazz trumpet and focused on music during high school, then reflects on the importance of creativity to both leadership and research. He describes the mental process of playing jazz.Next he explains that an experience working with a physician on his first aid merit badge while in the Boy Scouts convinced him to go into medicine. He attended the University of Toledo [Toledo, OH: BS conferred in 1963], where he was able to work as a surgical assistant in the Toledo Hospital. He explains he was particularly intrigued by the heart surgeons and the challenge of "making irreversible decisions quickly."
Chapter 03 (Professional Path)
Medical School and Other Training: Breaking into Opportunity (listen/read)
Dr. Balch begins this chapter on his medical training by noting that the process of applying to medical school was a "breakout moment" when he was encouraged to apply to top schools rather than setting his sights on a regional medical school. He talks about the culture shock he experienced going to New York City to attend the Columbia College of Physicians & Surgeons (MD conferred, 1967). He explains that he focused on cardiac physiology and was able to begin conducting research. Dr. Balch notes that he wanted to be in an academic medical center and explains his motivations: to focus on creating new knowledge and teaching.Next, he talks about the prominent physicians who mentored him and his ambition to become a cardiac surgeon. He mentions his internship in surgery at Duke University Medical Center (1967-1968) and his clinical residency in surgery at the University of Alabama in Birmingham (1970-1975).
Chapter 04 (Professional Path)
Work in the Emerging Fields of Immunology and Surgical Oncology (listen/read)
In this chapter, Dr. Balch talks about how his involvement in two evolving fields, immunology and surgical oncology, influenced his career path. He notes that based on his strong record during his residency and his fellowship [1971-1973 Research Fellowship, Immunology, Scripps Clinic and Research Foundation, La Jolla, CA], Drs. Durrant and Cooper hired him into the faculty at the University of Alabama, where his work in surgical oncology evolved. Dr. Balch describes his growing experience working on clinical trials and his research on adjuvant therapies and monoclonal antibodies. Next he speaks about his role as Associate Director of Clinical Studies and then interim Director of the Cancer Center at the University of Alabama. He also describes the unique characteristics of surgical oncology as oncology management and comments on why it succeeded as a field.
Chapter 05 (The Researcher)
Melanoma Research and Comments on Research Disappointments (listen/read)
In this chapter, Dr. Balch talks about his research. He begins with comments about the balance he had to find between his surgical interests and research and administrative commitments. He notes that general surgery training enabled him to take on a project of being one of the first to insert chemo infusion pumps via abdominal surgery, and that his later research led him to focus on melanoma and breast cancer. Dr. Balch talks about his work on melanoma staging. He describes how the project came about through a desire to create a database and then evolved into new criteria for staging melanoma because of the involvement of statistician Sing Jaw Son, PhD. He talks about his sabbatical year in Australia (1983) at the Sydney Melanoma Institute, a collaborator in the melanoma project and where he wrote a book on melanoma. Next Dr. Balch talks about lessons learned from two studies that did not yield real results.
Chapter 06 (Building the Institution)
Surgical Oncology at MD Anderson, Part I: Changing Surgical Tradition (listen/read)
Dr. Balch begins this chapter by explaining how his research on melanoma raised his visibility and brought him to the attention of other institutions. Eventually he received a call from Bob Hickey at MD Anderson, and Dr. Balch explains that he developed a vision and plan for the evolution of surgical oncology. He describes the situation in surgery at that time (mid-eighties): excellent clinical surgery, but no academic programs, no research, no clinical trials, and a traditionalist approach that created a gap between the "MD Anderson way of surgery" and advances being adopted at other institutions. Dr. Balch explains that he presented a plan for super-specialization (to also guide recruiting), for database development, management, and biostatistics to support clinical trials, for multi-disciplinary care, and active competition for grant dollars. He also observes that he and his plan were not well-received in the Department of Surgery, explaining why. He give examples of the traditionalist approach in the department and the generalist focus. Next, Dr. Balch outlines his first steps in implementing his vision, first reorganizing the Department of Surgery as the Department of Surgical Oncology and tracking patient outcomes to set in place a system where "outcomes should be the same regardless of who did the surgery." He talks about individuals he recruited.
Chapter 07 (Building the Institution)
Surgical Oncology at MD Anderson, Part II: The First Multi-Disciplinary Breast Center and the Success of a Surgical Oncology Approach (listen/read)
In this chapter, Dr. Balch explains his move to organize sections around organ based leadership, highlighting multi-disciplinary care as a guiding philosophy. He talks about starting the first multi-disciplinary breast center in the U.S., noting that MD Anderson faculty in urology and head and neck were also using this approach. Dr. Balch explains that he used patient outcomes as evidence to advocate for the value of this system. He also explains that the multi-disciplinary approach saved the institution money. He notes that younger faculty supported the changes, as did Dr. LeMaistre. He notes that Dr. LeMaistre was a visionary and supporter of patient-centered care.
Chapter 08 (Building the Institution)
Surgical Oncology at MD Anderson, Part III: Creating a Fellowship Program (listen/read)
In this chapter, Dr. Balch talks about the academic dimension of his vision for the Department of Surgical Oncology: to create an education and research focused center to enhance patient care and train leaders for MD Anderson and other institutions. He sketches how the training program evolved, discusses the T32 training grant from the NIH, and notes that around 90% of the Department's trainees went on to positions at academic medical centers. Dr. Balch talks about how training was delivered in each content area and notes his own commitment to providing Saturday sessions on the qualities of leadership as well as good writing and presentation skills. He tells the story of Dr. Michael Henderson, an Australian surgeon and former trainee, to demonstrate the success of the program and the evolution of surgical oncology as a field.
Interview Session Two: 12 November 2018 (listen/read)
Chapter 09 (Building the Institution)
Transforming the Division of Surgery, an Overview (listen/read)
In this chapter, Dr. Balch provides an overview of how he went about transforming the Division of Surgery when he arrived at MD Anderson in 1985. He explains the scope of his responsibility, which included the entire Division, its core resources, its clinical trials office, and the database management. Next Dr. Balch explains the rationale for the division system that had been set in place by then president Dr. Charles LeMaistre [oral history interview]. He notes that his mandate was to unify disparate surgical departments into a single division with strong academic grounding and a research purpose. He acknowledges the challenges in demonstrating the value of this administrative restructuring. He notes the role of Donna Sollenberger [oral history interview], his administrative assistant, in helping him achieve this goal. Dr. Balch explains how the current administrative state was preventing the institution from recruiting quality individuals. He discusses his key recruits (Jack Roth and Elizabeth Grimm) in his attempt to build both surgical excellence as well as research. Next Dr. Balch discusses how the Division developed a training program in support of a new Department of Thoracic Surgery, with the assistance of Dr. Denton Cooley of The Texas Heart Institute, and chief of Cardiovascular Surgery at clinical partner Baylor St. Luke"s Medical Center. He mentions some other new departments created as well as his role in creating the first ambulatory surgery space.
Chapter 10 (Building the Institution)
Transforming the Division of Surgery, Part of the Institution's Strategic Plan (listen/read)
In this chapter, Dr. Balch explains that Dr. Charles LeMaistre allowed the Division heads to drive the institution's strategic plan and touches on the range of institutional goals that were to be addressed by transforming the Division of Surgery. (Dr. Balch was a member of the Executive Committee for the Strategic Plan from 1988 to 1996). He explains that Dr. LeMaistre's vision built on decisions made by R. Lee Clark to eliminate economic competition among specialties and reduce economic silos. He notes that the Division heads prioritized doing prospective clinical trials. Next, Dr. Balch explains why he wanted to build subspecialization in the Division of Surgery as a support for both patient care and research. He discusses how developing new training programs in surgery for fellows supported these goals.
Chapter 11 (Building the Institution)
Subspecialization: The Key to Building a New Division of Surgery (listen/read)
In this chapter Dr. Balch explains why his desire to subspecialize surgery at MD Anderson was key to his mission of developing the Division. He comments on the challenges of getting tradition oriented departments of surgery and notes that his mission to change traditional thinking was controversial. To demonstrate how he was holding traditional practice up to scrutiny for quality outcomes, he tells a story about suspending limb perfusion until consistency of the practice could be demonstrated. Next, Dr. Balch talks about how the division went about establishing practice guidelines, noting that this was precursor of the current system of linking quality and safety to evidence. Next, Dr. Balch comments on the complexity of the change process he had set in motion and its success as measured by the number of faculty and trainees who have risen tot leadership in their specialties. He makes comments on his participation at national meetings then discusses how his own laboratory became involved in sending experiments into space.
Interview Session Three: 18 December 2018 (listen/read)
Chapter 12 (Building the Institution)
Building the Division of Surgery: One Precursor to Disease-Site Reorganization (listen/read)
In this chapter Dr. Balch provides an overview of what he accomplished after five years of service as Head of the Division of Surgery. He explain that his division focused on developing multi-disciplinary collaborations in treatment, a mindset evolving in parallel with the Divisions of Medicine and Radiation Oncology. This positioned the institution to reorganize patient care delivery around disease sites, becoming the first institution in the US so organized. He also emphasizes how R. Lee Clark's decision to pay all MD Anderson faculty on one practice plan laid the groundwork for this.
Chapter 13 (Building the Institution)
Head of Hospitals and Clinics: Managed Care and the Origin of the National Comprehensive Cancer Network; (listen/read)
In this chapter, Dr. Balch focuses on two main challenges he faced as Vice President of Hospitals and Clinics: the impending managed care crisis and the institution's initiative to develop a network of affiliates. He begins by explaining how he was asked by Dr. Charles LeMaistre to serve in this new leadership role. He discusses the context in 1993 and explains the measures taken to ensure that the institution worked more efficiently with better margins. Next, Dr. Balch tells the story of secret discussions with leaders at Memorial Sloan Kettering to join efforts in negotiating aggressively with managed care and how these conversations led to the creation of the National Comprehensive Cancer Network, a body that still establishes guidelines for standards of care in cancer treatment. Next, Dr. Balch talks about Charles LeMaistre's vision for a national and international network of institutions delivering MD Anderson care. He discusses the creation of the Tex Moncrief Cancer Center –one of the first affiliates, located in Fort Worth, Texas.
Chapter 14 (Overview)
Comments on Leadership (listen/read)
Dr. Balch begins by talking about his scope of responsibilities while he was VP of Hospitals and Clinics and then EVP of Medical Affairs. He then explains that he took on these roles out of loyalty to Charles LeMaistre and to MD Anderson, though his "core values" lie in teaching and clinical work, not in administration. He talks about the need for physicians to have leadership training and the perspective they bring to administration. He also comments that leadership training can prepare researchers to lead team scientific efforts.
Chapter 15 (Building the Institution)
Disease-Site Reorganization; (listen/read)
In this chapter, Dr. Balch focuses on the reorganization of patient care around disease sites and the creation of Rotary House, also an addition to patient care. He first sketches how Eva Singletary, MD and Gabriel Hortobagyi, MD [oral history interview] in Breast Medical Oncology asked patients to wear pedometers and discovered how far they were required to walk to circulate among the various specialists involved on their teams. He explains how this led to the decision to reorganize Breast Medical Oncology as the first multi-disciplinary breast center. He then talks about the building of Rotary House from funds from the Rotary Club and explains how it fit into Charles LeMaistre's vision of using hospital services for intensive and intermediate care. Next, he returns to the disease-site reorganization and explains how it led to specialization of the staff, cost-savings, and reduction in staff. Dr. Balch also notes that MD Anderson ran the largest pharmacy in the world, which could generate income that could be put back into clinical research for innovative therapy.
Chapter 16 (Building the Institution)
Creating the First Prevention Program (listen/read)
In this chapter, Dr. Balch talks about Dr. LeMaistre's desire to establish a Division of Cancer Prevention. He then sketches the difficulty of building a new division by taking faculty from other established divisions. He explains that conducting clinical trials to provide an evidence base to justify reimbursement for preventative therapies. He cites a study Bernard Levin, MD [oral history interview] conducted on COX-2 inhibitors and explains why no drug prevention study has been done since that time. At the end of the session, Dr. Balch previews a topic to discuss in the next session: Dr. LeMaistre's strategy of encouraging the Texas legislature to change MD Anderson's status as a not-for-profit.
Interview Session Four: 18 December 2018 (listen/read)
Chapter 17 (Building the Institution)
Addressing the Managed Care Crisis (mid 90s) with HR 192 and Other Legislation (listen/read)
In this chapter, Dr. Balch talks about factors contributing to MD Anderson's financial instability in the mid-nineties: the impending managed care crisis, requirements that MD Anderson care for all patients even though they could not pay (when Harris County could take some of that burden), regulations governing how MD Anderson –as a state institution—could bid for services, and regulations preventing patients from self-referring. He explains that Dr. Charles LeMaistre ordered an analysis to determine how to address these challenges. He says that MD Anderson's major competitors were private institutions and needed to function more like them to create possibilities for success. He discusses Dr. LeMaistre's approach to working with the Texas legislature, and tells the story of a key reception and the day in 1995 when the self-referral legislation was speedily passed and signed by George W. Bush. Next, Dr. Balch explains how he and other administrators prepared for the impact of self-referral and the rapid increase in patients seen as a result. He talks about a new administrative layer of executive vice presidents were created to coordinate budgets and other efforts across the institution to increase revenue and reduce costs. He talks about an innovative practice of closing inpatient floors that were underutilized to save money. Dr. Balch then sketches the organization of the Executive Council in the newly formed Executive Vice Presidents' Office, specifically devoted to financial discipline and strategic planning. He notes that when the Office began, MD Anderson had no managed care contracts. The office was able to secure 90 contracts in the first twelve months. Dr. Balch next describes efforts to expand MD Anderson beyond Houston into other areas in Texas, materializing Charles LeMaistre's vision to create something new multi-disciplinary cancer care, an area where MD Anderson adds particular value for patients. Dr. Balch then explains that these measures decreased costs prepared the way for the growth generated under Dr. John Mendelsohn.
Chapter 18 (Professional Path)
A New Chapter as CEO at City of Hope and Other Roles (listen/read)
Dr. Balch begins this chapter by briefly touching on his candidacy for president when Charles LeMaistre stepped down and reflects on why John Mendelsohn was successful. He explains that the other candidates went on to high level positions at other institutions. Next. Dr. Balch talks about his move to the position of CEO of City of Hope in California, an institution in financial difficulty. He sketches what he accomplished in five years and notes that the job "took a piece of me." He talks about moving next to be EVP and CEO of the American Society of Clinical Oncology, concurrent with an academic appointment at Johns Hopkins Medical School so he could continue his clinical practice. He explains how and why he wanted to develop ASCO's reach. Dr. Balch then explains why he shifted out of administration into a full time role at Johns Hopkins to continue clinical practice, direct research, and create a clinical trials network.
Chapter 19 (Contributions)
A Return to MD Anderson in 2016 and Reflections on a Career (listen/read)
Dr. Balch begins this chapter by explaining why he returned to Texas and then to MD Anderson in 2016, retiring from clinical practice and devoting energy to mentoring young faculty's careers. Dr. Balch next reflects on his contributions to MD Anderson then on the changes to the healthcare environment he has seen over the course of his career. He explains that he had an impact on the field through his efforts to shift the practice of surgery from a reactive intervention to surgical oncology and a treatment development mindset implemented in a collaborative team environment. Dr. Balch then talks about changes to how surgeons develop their careers as researchers and as leaders. He explains that they need special support to develop research careers and this has an impact on how fellows are trained and how surgeons manage their working environments to encompass research. In the final minutes of the interview, Dr. Balch reflects on his legacy and what his long career has done for him.