Two interview sessions: 27 August 2012, 28 August 2012
Total approximate duration: 4 hours 30 minutes
Interviewer: Tacey A. Rosolowski, Ph.D.
About the Interview Subject:
Helmut Goepfert (b. 13 September 1936 in Santiago, Chile) first came to MD Anderson in 1967 as a research fellow. In 1974 he joined MD Anderson as a part-time associate professor (while serving as the first Chief of the Otolaryngology Section in Dept. of Surgery at University of Texas Health Sciences Center Medical School. Dr. Goepfert is a Professor Emeritus in the Department of Head and Neck Surgery. He has provided clinical support to clinical research addressing chemoprevention w/ derivatives of Vitamin A and combination therapies and to preserve larynx functionality. He served as Chair of the Department of Head and Neck Surgery from 1982 until his retirement from clinical practice in 2003.
Major Topics Covered:
Personal and educational background
Head and Neck oncology: evolution of; patient experiences of; special challenges
History of head and neck surgery; evolution into multi-disciplinary team collaboration
Section of Head and Neck Surgery
Research: combining surgery with chemotherapy and radiation therapy to preserve laryngeal function
Interdisciplinary care for head and neck cancers at MD Anderson
Biomedical publishing; ethics
Biomedical/clinical education, educational publications
The Physicians Network
MD Anderson presidents
MD Anderson culture
Interview Session One: 27 August 2012
Head and Neck Oncology and Related Specialties
Chapter 01 / Overview
An Overview of a Surgeon’s Education
Chapter 02 / Educational Path
Friction in the Evolving Field of Head and Neck Surgery
Chapter 03 / Overview
Farming or Medicine?
Chapter 04 / Personal Background
Surgery in Transition to Multi-disciplinary Collaboration
Chapter 05 / Building the Institution
An International Pathway back to MD Anderson
Chapter 06 / Professional Path
Laryngeal Preservation Studies
Chapter 07 / The Researcher
Financing Clinical Research
Chapter 08 / Overview
Chapter 09 / Building the Institution
A Summary of Research
Chapter 10 / The Researcher
Interview Session Two: 28 August 2012
Patient Reactions to News of Speech Loss
Chapter 11 / Overview
A Brief History of the Section of Head and Neck Surgery
Chapter 12 / MD Anderson Past
Chair of the Section of Head and Neck Surgery
Chapter 13 / Building the Institution
MD Anderson Publications and Publication Ethics
Chapter 14 / Overview
The First Web-Based Textbook
Chapter 15 / The Administrator
Accrediting Head and Neck Services
Chapter 16 / Professional Service beyond MD Anderson
The Physicians Network
Chapter 17 / Post-Retirement Activities
MD Anderson Presidents
Chapter 18 / Key MD Anderson Figures
A Career Devoted to Interdisciplinary Teams; Earning the name, Dr. Fixit
Chapter 19 / View on Career and Accomplishments
Interview Session One: 27 August 2012 (listen/read)
Interview Identifier (listen/read)
Chapter 01 (Overview)
Head and Neck Oncology and Related Specialties (listen/read)
In this segment, Dr. Goepfert explains that Head and Neck Oncologists work in concert with Radiation oncologists and Medical oncology in order to address the challenges of cancers of the head and neck. “Head and neck” specialists address any cancer occurring between the chest and the brain, and Dr. Goepfert lists the organs, tissues, structures, and functions that cancer can attack. Dr. Goepfert notes that Head and Neck is an “abundant field,” that draws on additional specialties, such as pathology, imaging, oncologic dentistry and such rehabilitative specialties as speech pathology.
Chapter 02 (Educational Path)
An Overview of a Surgeon’s Education (listen/read)
In this segment, Dr. Goepfert sketches his surgical training in Chile, the U.S. and Germany. He explains that he “fell into” surgery as a result of his training in his native country of Chile in the 1960s, where he started as a general surgeon. His interest in cancer grew just as the American Society of Clinical Oncology was being created (1965), and chemotherapy was generally put in the hands of surgeons. He describes how he received a fellowship in 1964 to go to UCLA to train in the chemotherapeutic management of solid tumors, then extending his visa to come to MD Anderson to train under Drs. John Stahling and Dr. Richard Jesse. He spent four years in Stuttgart, Germany, setting up a radiation therapy unit at a the Katherinenhospital, then was offered a job at MD Anderson by Richard Jess. Dr. Goepfert had to pass his board certification, and so became a Resident at Baylor.
Chapter 03 (Overview)
Friction in the Evolving Field of Head and Neck Surgery (listen/read)
In this segment, Dr. Goepfert explains the debates in the 60s and afterward, over how to divide conditions of the head and neck between general surgeons and those trained in Otorhinolaryngology (Ear, Nose, and Throat). He talks about the friction between the Society of Head and Neck Surgeons (mostly general and plastic surgeons) and the American Society for Head and Neck Surgery, founded by ortolaryngolosts. He gives an example of the Mayo Clinic, where (in the 1080s) cancer was treated by a Head and Neck surgeon and a general surgeon performed necessary neck dissections. He also discusses the debates over which field should handle surgical reconstruction after procedures to address cancer –plastic surgeons or the head and neck surgeon. He notes that, at MD Anderson all plastic surgeons are trained in that specialty, not in head and neck surgery, then lists various plastic surgeons at the institution, beginning with Margaret Sinclair, the first reconstructive surgeon at MD Anderson.
Chapter 04 (Personal Background)
Farming or Medicine? (listen/read)
In this segment, Dr. Goepfert explains that his father, Pablo Goepfert, was a surgeon and had a strong influence on his choice of career. Nevertheless, Dr. Goepfert recalls how much he enjoyed working on his uncle’s farm during the summer, helping with farming, taking apart engines, driving a tractor at age nine and then a track at twelve. Though he enjoyed biology, geometry, and algebra in school, he thought of farming as an alternative career. He ends this Chapter with a funny anecdote about taking his medical school admissions test.
Chapter 05 (Building the Institution)
Surgery in Transition to Multi-disciplinary Collaboration (listen/read)
In this segment, Dr. Goepfert observes that he came to MD Anderson during a time when cancer treatment was expanding beyond surgery to include chemotherapy. He gives a brief overview of the treatment practices at the time and notes that specialties debated who would administer chemotherapy. While Dr. Goepfert was a Senior Fellow in Surgery at MD Anderson, he observed that hematologists were activity involved in redefining who administered treatment (not the case at UCLA). (He also notes that he wanted to leave Chile for a fellowship in the US because of the “dismal state” of cancer therapy.) He witnessed the evolution of multi-disciplinary cancer treatment while working with Dr. Gilbert Fletcher. Dr. Goepfert notes that he established the “Thursday Afternoon Planning Conferences in the Department of Head and Neck Surgery in 1982, where multidisciplinary treatment plans were created. These sessions became a model for the entire institution. Dr. Goepfert then shares memories of Dr. Fletcher’s influence on his own thinking about how disease processes respond to radiation, how important give and take is in interdisciplinary care, and how critical it is to establish liaisons with basic scientists. He notes that he took part in the initial efforts at MD Anderson to establish a track for physician-scientists, mentioning the key roles of Dr. Garth Nicholson and Dr. Josh Fidler. He explains how a tone was set for the interdisciplinary management of head and neck cancers. He describes the working relationship between Dr. Fletcher and the gifted surgeon, A.J. Ballantyne. He notes that the process of establishing multidisciplinary care was not as “bumpy” at MD Anderson as in other parts of the country. He credits R. Lee Clark’s vision in setting up the remuneration system at MD Anderson for smoothing this process.
Chapter 06 (Professional Path)
An International Pathway back to MD Anderson (listen/read)
Dr. Goepfert begins this Chapter by describing his activities on returning to Chile in 1968, after finishing his research project in the Section of Head and Neck Surgery at MD Anderson. He practiced general surgical oncology at the Instituto Radium in Santiago and also created a multidisciplinary pediatric tumor clinic at the Hospital Roberto del Rio. He explains that Chile was in political turmoil with coming elections and anticipated the election of a Socialist government that would not put a high priority on cancer treatment. He took his family to Stuttgart, Germany and went to work at the Katherinenhospital (’70-’71). He did not flourish in the rigid work environment in Germany, and he returned to Houston for a residency in Otorhinolaryngology at Baylor College of Medicine and was a research project investigator in the Section of Head and Neck Surgery6 at MD Anderson. In 1974, as he says, he walked out of his residency and became Chief of Surgery in the Otolaryngology under Dr. Stanley Dudrick at the University of Texas Health Science Center Medical School. He describes how he met his main goal: finding a way for a range of specialties (general surgeons, plastic surgeons, dentists, etc.) to collaborate in handling trauma of head and neck surgery. He also talks about the first resident in the Head and Neck section, Pedro Jimenez. He did not “give up” MD Anderson, but was appointed Associate Surgeon and Associate Professor in the Section of Head and Neck Surgery. He then describes the process of becoming Chair of the Head and Neck Section of MD Anderson, the first board-certified otorhinolaryngological surgeon to take on the role.
Chapter 07 (The Researcher)
Laryngeal Preservation Studies (listen/read)
In this Chapter Dr. Goepfert describes his long-term work on laryngeal therapy and survivorship (protocol 91-11). He begins by briefly characterizing the perspective that otolaryngeal specialist brings to cancer of the head and neck. He then notes that, at the beginning of his career, most of his research was retrospective (he conducted such studies with Gilbert Fletcher on effects of radiation therapy). Then he describes the context of the Protocol 91-11 study, beginning with a landmark article that demonstrated that the survivorship rates were identical, whether a patient was treated with a laryngectomy versus intravenous chemotherapy plus radiation therapy. With the second course of treatment clearly better for the patient (as it preserved the voicebox and, thus, the ability to speak), Dr. Goepfert explains that Protocol 91-11 looked at whether chemotherapy was essential to preserve the larynx or would radiation alone suffice. He some advances in radiation therapy that presented some stumbling blocks to initiating the study (launched in 1991), and MD Anderson provided the largest percentage of patients (10%) to this nationwide study.
Chapter 08 (Overview)
Financing Clinical Research (listen/read)
In this segment, Dr. Goepfert describes the difficult finances of clinical research in an environment where academic clinicians compete with private practitioners for patients. He broadens his focus and speaks about the country’s need for a “social network” system that covers all individuals, noting that Scandinavia and many European nations have “socialized medicine” systems and the highest rates of satisfaction with their health care systems. He notes that though MD Anderson offers some of the best health care, that level of are is not necessarily available to the general community. He notes that rising health care costs effect cancer care and also the viability of research. He observe that in the journal, Head and Neck, fewer and fewer innovative articles are published by American researchers; more authors come from Asia and Europe.
Chapter 09 (Building the Institution)
Supporting Physician-Scientists (listen/read)
Dr. Goepfert begins this Chapter by noting any physician-scientist must have passion in order to succeed. The idea that time can be protected for research in the current work environment is a myth, and research simply has to be added to the long list of activities demanded of the academic medical professional. A main question for administrators planning support systems for surgical physician-scientists is When does one begin the training? Absence from clinical practice can compromise a surgeon’s skills. In the Head and Neck Department, physician-scientists spend 1-2 years in a lab before their advanced training, and it’s key that a department have a team of faculty who believe in the principles of translational research. He mentions Jeffrey Myers and J Freireich as true physician-scientists. He explains that the program for physician-scientists in Head and Neck began in the mid eighties, when the chief of surgery, Charles Balch, arranged for a outside review of the Department and received feedback that they needed a basic scientist on the faculty to encourage translational research. Dr. Goepfert sketches how this idea developed and the involvement of Garth Nicholson and Joshua Fidler. He notes that it has been difficult to fund head and neck research because the cancers are diseases of the working class. He mentions that he approached the president of the institution, John Mendelsohn, to establish the Helmuth Geopfert Society to train physician-scientists. He notes that Dr. Mendelsohn did not offer practical support, and the Society eventually was only able to support a lectureship.
Chapter 10(The Researcher)
A Summary of Research (listen/read)
Dr. Goepfert notes that he has generally served a supportive role in research studies. He participated in a study of a chemoprevention protocol involving derivatives of Vitamin A (Principle Investigator, Waun Ki Hong, MD [Oral History Interview]). His research in the eighties and nineties focused on the preservation of functionality of the larynx. He notes that his main contribution was to determine how to use chemotherapy in combination with surgery to preserve the voicebox, though that procedure was not long in use due to improvements in treatments using concomitant chemo- and radiation therapy. Dr. Goepfert ends this Chapter with a description of endoscopic surgical techniques and the new robot surgery in use by Dr. Floyd Holsinger.
Interview Session Two: 28 August 2012 (listen/read)
Interview Identifier (listen/read)
Chapter 11 (Overview)
Patient Reactions to News of Speech Loss (listen/read)
In this segment, Dr. Goepfert explains how devastating it can be for patients to receive the news that they will lose their ability to speak because of a cancer of the head or neck. He the field is still struggling to find better ways to both preserve the larynx and its many functions. He sketches how the stage of the cancer determines the treatment that offers the best hope for preservation, but that existing treatments often fall short of what the patient and surgeon both hope for: full preservation of the power of speech. He gives an example of a member of Houston society who refused a necessary treatment, noting that some patients simply cannot “face reality.” He also describes how surgeons must help patients understand their options and how treatment will proceed, especially when they have gotten “second opinions by Google,” sometimes arriving at MD Anderson with stacks of printouts from the internet. Dr. Goepfert gives a final example of a banker from Dallas who committed suicide rather than face losing his voice. Dr. Goepfert offers his philosophy about suicide in the face of such news.
Chapter 12 (MD Anderson Past)
A Brief History of the Section of Head and Neck Surgery (listen/read)
Here Dr. Goepfert sketches the history of the Section of Head and Neck Surgery, officially started in 1952 with Dr. William McComb. He discusses Dr. McComb’s commitment to the principle of radical surgery, noting that during this period there were only limited possibilities for reconstructive surgery. He also talks about Dr. McComb’s collaboration with Gilbert Fletcher to combine surgical intervention with cobalt-60 radiotherapy, also discussing radiation therapy applied via implants. He notes that Drs. McComb and Fletcher published an excellent book in ‘65/65, Cancer of the Head and Neck. Dr. McComb was succeeded by Dr. Richard Jesse, who advocated for surgery combined with radiation and chemo therapy. He worked to define specific treatments for disease sites, using a single treatment when possible to avoid complications. He also implemented blood saving techniques during surgery and started intra-arterial infusions of chemotherapy. He was also a strong proponent of multidisciplinary care during a time of antagonism between surgeons who believed in radical surgery and those advocating radiation therapy. Dr. Goepfert explains that Dr. Jesse should also be remembered for creating the creating the chaplaincy at MD Anderson, an initiative that was fundamental to creating the Lutheran Pavilion. Dr. Goepfert compares the leadership styles of Drs. Jesse and McComb. (Continues, Chapter 13)
Chapter 13 (Building the Institution)
Chair of the Section of Head and Neck Surgery (listen/read)
In this Segment, Dr. Goepfert talks about his leadership of the Head and Neck Surgery from 1982 until 2003. His primary goal on assuming the role was to facilitate multi-disciplinary care practices. He notes that all head and neck patients at MD Anderson came through Head and Neck Surgery, whether they ultimately needed surgery or not, and the Department followed each patient through treatment and aftercare. Dr. Goepfert notes again his role in establishing the Thursday Conferences where thirty or thirty five individuals from different specialties and services would gather to plan multidisciplinary treatment. These sessions served as a model eventually implemented by everyone at MD Anderson. Dr. Goepfert also says that he wanted to train physician-scientists, following the model of Dr. J Freireich in Developmental Therapeutics. He talks about the qualities needed to succeed as a physician-scientist, the need for proper mentors in both the clinical and laboratory science fields, and other requirements to support translational research. Dr. Goepfert sketches the evolution of the physician-scientist role at MD Anderson, and what he did to support this growth.
Chapter 14 (Overview)
MD Anderson Publications and Publication Ethics (listen/read)
Dr. Goepfert has served on a number of editorial boards and is keenly interested in the educational dissemination of information critical to cancer research. In this section he talks about some of MD Anderson’s publications and also addresses some controversies with publication. He first raises the ethical issue of how authorship is assigned to a manuscript going out for publication. Today there are guidelines for assigning authorship, but twenty years ago, he explains, some department chairs at MD Anderson reviewed all manuscripts going for publication and insisted on being listed as first author of an article, whether they made any contribution to the research or not. Dr. Goepfert contrasts his own practice of putting his name on a paper only if he has contributed. Dr. Goepfert then shifts subjects and describes several MD Anderson educational publications, beginning with Cancer Bulletin, distributed free to all physicians across Texas.
Chapter 15 (The Administrator)
The First Web-Based Textbook (listen/read)
In this segment, Dr. Goepfert describes a promising, but ultimately failed, attempt to publish what was the first web-based text book. In 1997 he secured some funding to set up a team to plan the book and identified companies that could collaborate on design. His vision was to create an entirely web-based and interactive publication that kept text to a minimum, relying instead on multi-media and multidisciplinary training in head and neck surgery. The project was completed in 3-4 years and he presented it to the Vice President of Academic Affairs, Margaret Kripke, who was very enthusiastic. The textbook was launched and housed on the MD Anderson server. Dr. Goepfert then explains that a committee decided that MD Anderson could not pursue any web publishing. He then comments on the difficulty of obtaining high level support for projects. The web-book project closed down when an outside publishing company decided that marketing the book would not be profitable. He then talks about what the web can offer researchers and clinicians, e.g. education via visual documentation of surgical techniques; a forum in which physicians can submit cases and receive input from specialists; a storage bank for cases for future reference. He notes that MD Anderson could be producing educational programs and offered for a fee. Dr. Goepfert first talks bout the family origins of his interest in education and communication. He then mentions his Hayes Martin Lecture on education in ’95, which focused on the fundamentals on what it takes to be a physician scientist.
Chapter 16 (Professional Service beyond MD Anderson)
Accrediting Head and Neck Services (listen/read)
In this Chapter Dr. Goepfert talks about his service on the Joint Council, a combined effort of two societies of Head and Neck surgeons to regularize accrediting of surgical services. He first describes how the two societies came to work together, then notes how rigorous their parameters were for accreditation and the process of making site visits and making reports. (Dr. Goepfert also notes his discovery that some hospitals do not care about accreditation.) He was interested in the training of fellows who assist faculty members and observes that MD Anderson has a very well organized training program: often fellows who come into the program have to be retrained to meet MD Anderson standards.
Chapter 17 (Post-Retirement Activities)
The Physicians Network (listen/read)
In this segment, Dr. Goepfert describes his post-retirement work on the Medical Board of the Physicians Network, a subsidiary of MD Anderson that helps physicians offer better patient care. He explains how a service can be connected to the Physicians Network through evaluation according to MD Anderson guidelines for best practices and standards set by other institutions. (Programs pay Physicians Network a fee.) Right now standards for care in breast, lung, prostate, and colo-rectal cancer are in place and standards are in development to evaluate care for more cancer types. Dr. Goepfert explains that there are nine host programs, and that the Physicians Network link –and the MD Anderson name—helps them with their marketing and funding. In response to a question about the expansion of the MD Anderson name, Dr. Goepfert says that the expansion of MD Anderson standards of care is still not well structured, and not much has been learned from past mistakes. He points out the Orlando, Florida remote site as one that is still very “nebulous” and MD Anderson Espana as a “model of what not to do.” He observes that quality of care relies on the participation of faculty to insure quality in both technical and intellectual components of care, but that faculty are still not clear on how to participate and how they will be rewarded. He explains his concern for the peer review program for Madrid oncology. He says that a strong future for the Physicians Network lies in better cooperation, and notes that while physicians see problems with care in remote sites, administration often does not and does not understand the danger of doing nothing.
Chapter 18 (Key MD Anderson Figures)
MD Anderson Presidents (listen/read)
Here Dr. Goepfert gives his views of the leadership styles of MD Anderson’s first three presidents. He describes R. Lee Clark as a “unique leader” with a strong character and decisive leadership style. (He observes that Clark advocated thinking big, but “built small” when it came to the inpatient unit.) Dr. LeMaistre was a very gentlemanly man, a good delegator, who was able to put smoking cessation at the forefront of MD Anderson’s initiatives and also made the first connections with other institutions such as MD Anderson Orlando. Dr. Goepfert next describes the search process (including some internal political strife) that resulted in Dr. John Mendelsohn’s presidency, describing him as the most “eccentric” of all the presidents and a significant physician-scientist who conducted valuable work on epidermal growth factors and antibodies. Dr. Goepfert notes that Dr. Mendelsohn’s name was associated with an insider trading scandal and that Dr. Mendolsohn did not support him in his efforts to develop the Head and Neck physician-scientist program. He observes that Dr. Mendelsohn was able to stimulate significant philanthropy for MD Anderson. Dr. Goepfert also explains that he advised Dr. Mendelsohn to step away from MD Anderson once Dr. DePinho assumed the role of president (though he notes that Dr. Mendelsohn appears to be reestablishing his connection with the institution). Dr. Goepfert emphasizes his own philosophy and practice of stepping away once an administrative role is done: he could have continued in his department after retiring, but advocates that one should “go before they make you go” and that younger people in “the pipeline” need to have their chance.
Chapter 19 (View on Career and Accomplishments)
A Career Devoted to Interdisciplinary Teams; Earning the name, Dr. Fixit (listen/read)
Here Dr. Goepfert comments on his accomplishments and a significant award and shares some details of his life outside of work. He says that as he looks back on his work at MD Anderson, he says he is very gratified that he got three sons through medical school and a daughter through college with no debt. Taking a more serious tone, he says that he believes he used resources in his Department and Section wisely and made Head and Neck surgery visible enough to be recognized as the number five program nationwide. He is proud of the fellowship program and hopes that his focus on interdisciplinary care will be carried on. He is also proud of the Distinguished Surgeon Award he received from the Association of Operating Room Nurses of Greater Houston in 1999. He notes that he was brought up as a scrub technician in his father’s operating room and knows the value of nurses to a team. Speaking about his hobbies, he immediately talks about his love of riding motorcycles. He only stopped riding about four and a half years ago, when he felt his reflexes were not quick enough to insure safety. Otherwise, he reads and listens to music. He enjoys car trips and looks forward to taking driving trips up both the east and west coasts of the country. He notes that he washes his own cars. He tells an amusing anecdote about fixing bicycles for kids in the neighborhood in Sugarland, Texas, an activity that earned him the nickname, Dr. Fixit.