Christopher Rose, MD, FASTRO

During the 2017 ASTRO Annual Meeting, Dr. Rose spoke with Dr. Gressen on video about the following interview.

The following interview of Christopher Rose, MD, FASTRO, was conducted on February 28, 2017, by Adam Currey, MD, and Theodore Phillips, MD, FASTRO.

Adam Currey: All right. Well, Dr. Rose, thank you for doing this. I think maybe the best thing to do is just to start with some basic stuff. Where were you born?

Christopher Rose: I was born in Brooklyn, New York in 1949.

Adam Currey: Did you grow up in Brooklyn?

Christopher Rose: I stayed in Brooklyn until I was about 12 years old. My father was an obstetrician and my mother was his scrub nurse. I led a kind of idyllic urban upper middle class bourgeois life until, unfortunately, my father began to develop the signs and symptoms of multiple sclerosis. He was an incredibly strong man and refused to stop working.

His friend was the, what they used to call, the commissioner of mental health in New York. So at age 45 he rethread himself as a psych resident in one of the rural snake pits that patients went to before phenothiazine. This was a town that was about 70 miles out on the North Shore of Long Island called Kings Park. It had two industries - taking care of chronic schizophrenics in a 10,000-person hospital and growing potatoes. So it was night and day from Brooklyn.

As he got sicker though, the town took care of me. The town was only about 4,000 people. The postmaster, the principal of the high school, the English teacher, and the barber became surrogate fathers. The town had really limited educational opportunities, but the teachers all handed me various books to read and that supplemented my education. Unfortunately, my father passed away the week that the college admissions came out and I was a bit distraught. I had no desire to pick a college. My guidance counselor had never gotten anybody into MIT, so he decided I should go to MIT which was good actually in retrospect. So that’s where I went to college.

While there I met a gentleman who had recently arrived from the National Institutes of Health by the name of Richard J. Wurtman and he was a physician. He was a neuroendocrinologist and I worked in his lab the four years that I was there. I didn’t want to be a doctor. I mean my father even before he was sick said, “Don’t be a doctor.” Don’t be a doctor.” So I wasn’t going to be a doctor, but Dr. John Standsbury, the Professor of Thyroidology at Massachusetts General Hospital who was also a professor of physiology at MIT, taught an elective the second semester of my freshman year called Introduction to Experimental Medicine. As part of the course he took the four students over to the Mass General Emergency Room. And the experience of spending the night there changed my mind.

It wasn’t really the sights or the sounds. It was olfactory. It was the smell of the emergency room. It reminded me when I was such a little boy sitting in the surgeon’s lounge waiting for my father to be done with his cases on Saturdays so that we could go out and spend time together, and somehow that was very comforting.

Theodore Phillips: Where had your father done his medical training?

Christopher Rose: My father went to Michigan. He was a genius. He went from high school to a six-year med program. He completed college and medical school in six years. This was about 1944, and although he volunteered he was preventing him from going into the army due to color blindness!! So instead he did his training at what became SUNY Downstate and was the professor of what would have been called reproductive endocrinology, but they didn’t call it that. It was the rudimentary service for women who were having a hard time getting babies.

I remember him running around with these little specimen bottles that had uterine scrapings that he made pathology slides and tried to dertermine whether it was secretory endometrium and whether it was time to try and have the woman try to conceive. I mean this is all in retrospect. All I remember was that he was always running around in his surgical blues with these little bottles in his pocket.

Adam Currey: Did your mother work outside the home?

Christopher Rose: She was initially his scrub nurse and after they got married she would cover for his office nurse.

Adam Currey: Ah, I see. I see. Okay. So you mentioned going to the ER and the smells. Did you initially think about a career in emergency medicine?

Christopher Rose: No. No. I didn’t know what the heck I wanted to do. In 1970 when I got to Harvard Medical School the implication was that the intellectual apex of medicine was internal medicine. So those were the guys who I emulated and that is what I wanted to be. Unfortunately, what I didn’t realize was being an intern was not the same as being an internist. The chief of medicine at Beth Israel was, as far as I’m concerned, just was not particularly empathic, or if he was his concerns were not the same as mine. I was trying to do the best I could but never got good advice about therapeutic distance.

I went through internship and the junior medicine, year at the Beth Israel, the JAR year. Towards the end of the internship year, maybe the 8th or 9th month, after a very busy night, the eighth admission -- this was at a time when the call schedule was every other, right? You’re on for 36 hours and off for 12. After the eighth admission and patients were going sour and into in the ICU, I was feeling rather inadequate. I just put my head on the desk, totally expended and started to cry. It was the middle of the night, maybe 2 AM. The poor 3rd year medical student doing his junior medicine rotation with me saw the chief and brought him over. Why the heck he was there in the middle of the night, I don’t know. The student pointed at me and the chief kind of shook his head sadly and said, “Too bad, my internshio year - the best year of my life.” I just wanted to kill him.

Theodore Phillips: It sounds like The House of God.

Christopher Rose: Oh. Oh. Oh, Teddy. Well, you know, that that book was written by -- 

Theodore Phillips: Yeah, and I’ve read it several times.

Christopher Rose: Well, what you don’t know about that book is that it was written by Steven Bergman. And Steven Bergman, his nom de plume was Samuel Shem. That - I’ll say guy sat in the top biunk. He was a great writer but again no empathy. He made characer sketches out of all of the people that he interacted with that year. I am Levy, the BMS in that book.

Theodore Phillips: So you were in the book?

Christopher Rose: Oh, yeah.

Theodore Phillips: Oh, okay. Okay. It’s incredible.

Christopher Rose: “Listen for hoof beats, think zebras.”

Theodore Phillips: The movie was quite good.   

Christopher Rose: Every civilian who read that book laughed. Those of us who lived it cried.

Adam Currey: It’s a little too close to home, huh?

Theodore Phillips: It’s one of the wonderful books I ever read.

Christopher Rose: Well, the one who really cried was this poor nurse who was the chief nurse, the head nurse in the cardiac care unit who was the most sweet and pious woman. She would go to mass every day. Of course, you know the predominately male interns and residents were all twisted, and Bergman was the probably the most twisted one of all. And so he took - what’s the right word - he expanded the truth and she went from her being just sweet and kind to the young doctors to being promiscuous. I mean it killed her. He was not a nice man, Bergman, but he was a great and wicked writer. 

Theodore Phillips: I hate to digress here. Who was the guy that was the GI guy?

Christopher Rose: “The Fat Man?”

Theodore Phillips: The fat man, yeah.

Christopher Rose: The fat man. That was Jerry Dubnoff. The fat man was a composite of two senior residents. But Jerry, he finished his residency and went off to Cedars to do a GI fellowship, you know, in the book, “Colonoscopist to the stars.” That was true.

Theodore Phillips: If you haven’t read that book, Adam, you’ve got to get it.

Adam Currey: It’s called The House of God? Is that what I heard?

Christopher Rose: Yeah.

Theodore Phillips: The House of God, yes.

Adam Currey: Oh, my gosh. I’ve never heard of it. I should check it out.

Christopher Rose: Yeah. So the internship that I had was at the Beth Israel. Beth, house, Israel. I guess, house of Israel, house of God.

Adam Currey: Okay.

Christopher Rose: Anyway, we wasted too much time on this.

Theodore Phillips: That’s a wonderful part of your background. I didn’t know you were in The House of God.

Christopher Rose: So at the end of my JAR year I was just so distraught. No one had straightened me out and said, look, the life of an internal medicine doctor is not the life of a house officer. I didn’t understand that. So I had done a rotation in radiotherapy as my first rotation as a junior in medical school simply because I couldn’t get junior medicine or junior surgery. I found such a convivial group of residents and fellows who cared for each other, and laughed, and smiled, and were smart and a wickedly genius group of physicians who were the attendings at the Joint Center.

To top all of that, I had a kind of third cousin once removed relationship with Sam Hellman. What I didn’t remember was I was a bit of a rabble-rouser with a very long beard as a first year medical student and Sam was the associate dean of medical students, as well as the head of the Joint Center. So apparently I walked into his office and started screaming at him about the lack of student housing. He sort of remembered that so when I came back as a second year medical house officer pleading to be let into the residency program, he said, yeah, but not next year, the year after. So that’s how I ended up in radiotherapy.

Adam Currey: Wow. So you sent that great photograph. It was fun to read about that. Just so that it’s on the audio recording, can you tell us a little bit about who was your chairman when you first started residency and who your fellow residents were?

Christopher Rose: Right. By the way, that picture is going to be on the cover of the Red Journal probably in July or August.

Adam Currey: I feel like I had seen that before. I was trying to think of where. I don’t know if it was when Joel Tepper got a gold medal or something. I don’t know. I couldn’t remember.

Christopher Rose: So let me ask you, did you ever interact with Bob Goodman?

Adam Currey: No.

Christopher Rose: The original was –- so the story about that painting and the story about those people is that the chief therapist, Leon Graff, who was really happier to be an artist than a chief therapist but excellent with that too, designed Simon Kramer’s department at Jefferson Medical School in Philadelphia. Then he went to the Joint and helped Sam Hellman with the architecture of those hospital programs. Then went with Goodman, did the same thing with him at Penn. Then ended up with Zvi Fuks at Sloan Kettering.

Theodore Phillips: When did Goodman leave the Joint?

Christopher Rose: He left the Joint, that would have been I would say in 1977 or 1978.

Theodore Phillips: Okay. I was there in 1974. You were probably a medical resident. 

Christopher Rose: I was a medical intern.

Theodore Phillips: You were an intern in ‘74?

Christopher Rose: I was a medical intern then. It was in 1972 that I did my junior rotation there.

Theodore Phillips: Yeah. I was there in ‘74. I might have bumped into you in the ER, but I don’t remember.

Christopher Rose: So, Adam, the story of the residency was there were a number of seminal places at the time and one of them was UCSF and one of them was Stanford and Yale, and the programs in Philly and Wash U in St. Louis. We were the Stanford of the East in Henry Kaplan’s eyes. Hellman had gotten there in 1969. He was trained by Morton Kligerman at Yale and was young. I think he was either 33 or 35 in ‘69. He gathered around him, the guy who was doing radiotherapy at the Longwood Hospital, at the time a fellow by the name of Martin B. Levene who tried at MGH with CC Wong, and a private practitioner from Milwaukee who wanted to go back into academics named Abraham Marck, John Chaffey - who was at Yale with him and James Belli who would come from MD Anderson, and was also the radiobiologist studying potentially lethal damage repair and Adriamycin-radiation sensitization. Later, J. Robert Cassady came from Stanford. It was a very small department, and then it grew, like all of those departments by taking the residents and keeping them as staff.

So when I was there as a medical student in ‘72, there was the residents. The youngest residents were Leslie Botnick and Jay Harris. Leslie has been my friend and partner now for 40 -- that’s more than 40 years, right? That’s 44 years. Jay Harris became the vice chair and a great breast doctor. Then a year ahead of them was Anatoly Dritschilo who’s now the chair at Georgetown, and Ralph Weichselbaum who’s the chair at University of Chicago. Then a year ahead of them, the third year resident was William D. Bloomer. Bill was chair of Mount Sinai in NY and then University of Pittsburgh. Now he’s in private practice in Evanston, Illinois. Peter Mauch and Joel Greenberger were a year ahead of me. Peter stayed at the Joint and contributed greatly to our understanding of lymphoma. Joel is the chief at Pittsburgh now and has the sort of triple threat—teaching, clinical, and research department that everyone tries to emulate.

The other resident of that vintage was Eric Weber. Tony Piro was a staff man there and then became the chair at Tufts. But then Piro and Weber went out to the North Shore of Massachusetts. Weber’s claim to fame was that he went to Hellman and said we have a small group of patients who were treated with lumpectomy and radiation for breast cancer and they all seem to be doing rather well. He went to Marty Levine. Marty was supportive of it and they wrote it up and showed it to Sam. The data was exactly as Weber had suggested, and that was the original paper from the Joint Center. I believe that was 1973. Ted, you would know better.

Theodore Phillips: That was right. When I was there in ‘74, Sam said I have no local failures. That was his mantra about that theory. It stayed that way for quite a while.

Christopher Rose: Well, we kind of thought that all we needed to do was to get good gross margins and not worry about microscopic, and use the boost to take care of things. That clearly was not right. But subsequently Leslie Botnick and Jay Harris teased that out.

But, anyway, that was the group that I was privileged to learn from and it was so exciting. I mean the intellectual fervor was amazing. While I was there everyone had gotten everything and there was not a heck of a lot of leftover, so my research was on the internal mammary lymph nodes. To this day thankfully, thanks to the Canadian randomized trial, it has been resurrected and is an important reservoir of occult disease in a subset of patients,I think. At least that’s how I treat. I mean not everybody. But if you’ve got positive axillary nodes and you’ve got a substantial primary, the risk of internal mammary nodes is high.   

Gilgert Fletcher simply said you go three centimeters lateral and three centimeters deep, and you’ll get those nodes. I was working with the nuclear medicine person at Harvard. The two of us developed this technique called lymphoscintigraphy. I pointed out that about a third of the nodes were outside of the hockey stick portal. I remember, the first time I presented at ASTRO I got up there and I’m presenting the data. Dr. Fletcher and Dr. Montague get up in the middle of the talk and Dr. Fletcher exclaimed, “Lymphoscintigraphy? Lympho-stupidity” And then he walked out. As a young resident, that was very bad.

Adam Currey: How did you respond to that?

Christopher Rose: I stood there speechless, my mouth was open. So I closed it, swallowed and I said, “Next slide please.” But Sam was very, very supportive and wanted everyone to do research. After my time as a resident was up, I said, look, I want to go to Britain because that’s where the nitroimidazoles were really being studied. Roche Products, Limited in Welwyn Garden City outside of London was making the drug. Both at the Institute of Cancer Research in Sutton and up at Mount Vernon Hospital, those were the two places where it was being studied.

Hellman had actually done the same sort of study at the beginning of his career at the Institute of Cancer Research. He seconded me to Michael Peckham in the clinic and G. Gordon Steele in the lab, and that’s where I was trained to be a laboratory researcher.

What I thought I wanted to do was to isolate the toxic intermediate that was being made by hypoxic tissues because I figured that not only were the nitroimidazoles sensitizers but they were cytotoxins, and this was interesting to me. But the problem was that the conditions that you had to have whole animals – mice - and to make a lot of the toxics intermediate was so stressful that the animals kept dying. Four months into the year it looked like I was going to come up empty.

We all took care of each other in that lab. One of the other doctors had experiments that had to do with diurnal rhythmicity and cyclophosphamide toxicity, so we all took turns dosing up the tumor-bearing animals. Just by happenstance, there were about ten tumor-bearing animals left over and they were going to have to be sacrificed. I had the cyclophosphamide in one hand and I had the misonidazole in the other hand, and I gave half of the mice cytoxan, and the other half cytoxan and misonidaole. To the extent that anybody still remembers what I had done in the lab, it’s that. I showed that nitroimidazoles were synergistic with the alkylating agents.

The interesting thing was - and I just love this – is that at the same time as I was doing the work on chemical sensitization of chemotherapy, Ted was doing the same thing with WR-2721 and alkylating agents showing that not only was Ethifos a radio-protector, it was a chemo-protector. So that’s the funny story, Ted.

Theodore Phillips: Yeah, I remember that.

Christopher Rose: I come back and I’m going to get you in trouble now. I come back from that year. It was time to take the board and I had six examiners. I didn’t know that you knew me. I didn’t even know how that happened. I walk in to be examined by you for breast cancer and you’re not allowed to ask me who I am, just where I’m from. Right? So you said, where did you train? And I said, well, the Joint Center. Obviously you knew. So you said, “Well, I’m not going to examine you on breast cancer. That’s like taking coals to Newcastle. But I hear that you’re doing some interesting stuff in the lab over in Britain. Could you tell me about it?” And that’s why we spent a half hour talking.

Theodore Phillips: I didn’t waste time talking about breast cancer.

Christopher Rose: No. Listen, I mean all I knew was that you were a big professor and that you were so kind and generous to me to talk about science. It was great. I think we became friends after that.

Adam Currey: That’s great.

Christopher Rose: So I don’t know. That takes me back to so I was done with the -- I presented that data at the Clearwater Conference in Florida. In the early days all the people who were working on radiosensitization and chemical modification of radiotherapy action presented once a year at this conference. I think half of the people didn’t believe me, but a couple did. That was my lab when I came back. Then I worked in the clinic with Les Botnick. Goodman had left already and Leslie was the paradigm of -- you know, Les had a big, big lab himself and was doing amazing things in terms of isolating CFU-S stem cells with Hellman.

Adam Currey: This was back at the Joint Center?

Christopher Rose: Back at the Joint Center, that’s right.

Adam Currey: Okay. Go ahead.

Theodore Phillips: And you went back there on the faculty, right, for several years?

Christopher Rose: Yes. Yes. Right. So I worked with Leslie. In the clinic, back at the House of God, my home before that, I just liked taking care of patients more than the lab stuff. I always felt like I was counterfeit in the lab, that the post docs who spent all their time there were much smarter and much more focused. As little as I was making in terms of dollars, they were making less. The whole system seemed wrong. In retrospect, I was immature. The system was as it was and I should have accepted it. I would have stayed there in academics and that would be very convivial for my whole career.

But I just enjoyed taking care of people. So after three-and-a-half years in the clinic for me and five-and-a-half years for Les, we took off to the West Coast together and ended up at a community hospital in Burbank, California that lied to us about how long it would take for them to build a cancer center. We did the best we could.

The other thing I guess that I was interested in when I was in Boston because of my prior experience at MIT was computer control of radiotherapy. Bengt Bjarnga, who was the chief of physics, had a big program with computer control. So they had these minicomputers, VAXes that were huge rooms of computer, and then the MicroVAX which you downloaded the information into. Then we would push this thing about the size of a refrigerator into the treatment room.

Siemens had prepared a LINAC with digital-analog potentiometers, so it really was digital-controlled. I mean you apply the voltages and they turn motors. That allowed the voltages to change and allowed about six to eight motor controls to be modified all at the same time on this LINAC. Mechanical engineers, and computer scientists, and physicists were getting that thing ready. Hellman I guess needed to have a junior faculty guy to be treating the patients, so that was my job. The plans that we worked on were cervix cancer, paraaortic lymph nodes, and pelvis. It took about a month to prep the plan. We created essentially a 3D plan. It wasn’t an IMRT plan. It took about an hour to treat the patient. The whole thing was desperately ahead of its time, but it was exciting.

When I got to Burbank, I knew that if I couldn’t replicate what was being done at Harvard, at Memorial, and at Michigan, I was doing second class work. So I went up to Varian. I was always talking to them about making a computer-controlled radiotherapy machine and Dick Levy kept saying, no, it will never sell. One day I was walking around up there and I walked into the wrong test vault. I saw this young engineer typing on an IBM console and the linac responding. I said, “Holy cow, they’ve made one of these things.” And that was the C-series and it was all hush, hush. But at that point they were making a multileaf collimator and they were thinking of using it purely as a cerrogend replacer, to make apertures that could be set-up automatically and to treat either two fields or four fields with custom apertures.

The young engineer who was working for Varian, he didn’t think much of the Varian record and verify system, CMS 2000, which was the original Varian electronic medical record. So that young engineer and two of his colleagues left Varian and went into their garage and they were going to build a billing system. The Varian sales executive had become a Philips salesman. He knew how much I loved computer control. He said to me, “Oh, you won’t get that computer controlled system from Varian anymore because that engineer had left.” So I said, “Well, where is he? He said, oh, he’s up in Mountain View.” Actually it was in Palo Alto at the time.

So I went up and visited with him and I asked him what he was doing? He said, “I’m building a billing system.” I said “Don’t do that. You know how to make the linac sit up in beg. You should do that.” He said, “Oh, would anybody buy that?” I said I would. And that was IMPAC Medical Systems. So Joe Jachinowski, and David Auerbach, and James Hoey had not only an electronic medical record but really the first decent instruction set to make a computer-prepped linac like the C-series accelerator do than just what analog machines could do.

Theodore Phillips: Were you working on IMRT, Chris, at that time? I thought that Peacock was the first to really bring it into the -- 

Christopher Rose: You’re right. So Peacock was the first IMRT, but the folks at Memorial had discovered that the moving window technique for the MLC could also do it. They figured out how to reverse engineer the Varian machine to achieve any custom dose gradient across the entire treatment volume. So it’s just an interesting set of serendipity. For five years I was asking Joe Jachinowski if Leslie and I could be involved. 

I kept saying to Joe, I said we’d like to invest. This is going to be a great company. He didn’t want our money because he was doing so well. But eventually, about five years later, allowed myself and Leslie and a couple of others in. It wasn’t for the money. It was just so that we could formally help them.

About that time, I’m always sponging off other people’s brilliant ideas. Joe says to me, Chris, how come you guys in radiotherapy don’t exercise the same quality control that we used to do when we were building linacs? I said well, what do you mean? And he said, well, the linac goes down the line and you start adding stuff to it. You look for variances in what’s going on in terms of manufacturing. In that way, you couldn’t have good quality control. You know, you guys have all these data in the electronic record and you don’t use it. You don’t use it to try and investigate what processes result in either good outcomes or bad outcomes.

It’s like being Saul on the road to Damascus. I fell on the floor. That became my interest in both electronic health record and in trying to aggregate data from many electronic health records to see if they are structure-, or process-outcome linkages to improve radiotherapy.

Adam Currey: When was that?

Christopher Rose: 1996.

Adam Currey: ‘96. Okay.

Theodore Phillips: I mean you realized that the ultimate source of big data was there but nobody was tapping it.

Christopher Rose: Right. Exactly. So eventually, through the ROI, we tried but it was terribly underfunded and failed. But I’m very excited now to look at what ASTRO would get together, I hope, with ASCO and do it. I mean it’s time. It’s shameful that we’re not doing it. I mean of course the
problem -- 

Theodore Phillips: I don’t understand why it got dropped by ROI. I mean I gave them a nice donation, but I was so disappointed to see them get out of their registry thing and --

Christopher Rose: I mean I can tell you. I think we do have to set the record straight. It’s tremendously more expensive than we understood. We spent $2 million on that. Now how we spent $2 million on that would take more time than I think we can do here. But ROI just didn’t have the money to do it, and neither did ASTRO. I mean the only reason that ROI did it was that those of us who were passionate about it kept going to the people at ASTRO, but ASTRO doesn’t have the money either.

I mean the problem, if there is a problem, has to do with interoperability. That will get fixed now because of meaningful use and the feds. We have to standardize of the data elements. ASCO tried to do it the way that you think that they should do it, with natural language processing of the dictated medical record, but the technology isn’t there yet. What do doctors do? They dictate notes. Well, they used to dictate notes before Epic. Then you think that the artificial intelligence could pull the data elements out of the notes.

But that technology just isn’t ready so therefore, what I assume ASCO is doing - and ASTRO will help - would be to define the data elements and then the manufacturers will create the electronic health records. And that’s how we’ll get interoperability. That was my last foray into organized medicine, the National Radiation Oncology Registry. I do hope that the ASTRO-ASCO cooperation on large scale data mining of the EHR, or the development of Qualified Clinical Data Registries bears fruit.

Theodore Phillips: You organized a fabulous academic private practice with multiple institutions and you’ve made it national. Can you tell us a little bit about McKesson and Vantage and that stuff?

Christopher Rose: Well, I think that Botnick should get most of the credit for that. I mean the two of us just wanted to practice the same way we did back in Boston and we accreted around, like 0-minded physicians. After two years we were working ourselves silly and it was time to get a third. Arnold Malcolm was at Vanderbilt, which was at that time Vanderbilt and Meharry together, and being abused so it was easy for us to kind of seduce him to join us. Arnold had the same -- 

By the way, Adam, Arnold Malcolm was a year ahead of me at the Joint. So Arnold worked with us for 20 years. During that time period, whenever it was time to get another doctor, we would go to the academy and find somebody who was kind of like - I wouldn’t say a clone of us but a person who was intellectually curious, wanted to practice, wants to take care of people as the primary thing that they did. Frankly, money was not the most important thing because we’re lousy businessmen and we never made a heck of a lot of money. What we cared about was to practice in a convivial manner.

We always felt that it’s not good to practice alone. Man does not live by bread alone. It’s a hard job. It’s a hard, hard job. So every center that we set up has to have at least one-and-a-half if not two doctors. I mean the problem with quanta of doctors is it’s either zero or one. The quanta of patients is some fraction of that. So sometimes we would have three doctors share two clinics, but mainly it was two. That automatically puts a ceiling on finances.

I have to say that, Ted, in terms of our private practice model, if we had any one of it, it was Gerry Hanks and Scotte Doggett in Sacramento.

Theodore Phillips: That’s what I thought. They had the same kind of thing. They were before you.

Christopher Rose: Right. They came before us. And a funny story. I get to Burbank and my lawyer, the guy who I picked to be my lawyer said, “Oh, you should call up this guy in Sacramento. His practice is similar to what you aspire to.” So I called up Gerry Hanks and I said, “Gerry, is it okay? Is my brain going to turn into cottage cheese?” He said, no, no, you’ll be fine. And two weeks later he left to go with Goodman to Fox Chase. Well, that scared the heck out of me.

Anyway, so what would happen is that hospitals would come to us and they would say can you help us build a program like yours, and we said yes. But the conditions are that we pick the doctors and we - not that we own the physics but that we control the physics. So the physics were standardized at all the places. In that way, we could exert quality control. In that way, if there were chart rounds, they were chart rounds amongst different institutions. Until frankly USC and UCLA and Cedars got better, it was easy. We weren’t geniuses. We were just providing decent care. It’s only in the most recent era where academic institutions are making ACOs that I think that our model is maybe not the model of the future. That’s how we accomplished what we did.

What happened with Vantage was Leslie - again this is Leslie, not me – Leslie had worked with Michael Fiore at Salick Health Care. Bernie Salick was a nephrologist. When his daughter got osteogenic sarcoma, she got treated at Sloan Kettering and Salick said, well, the difference between Sloan Kettering and how it should be is that these are very high fixed cores cost, very little variable cost. So you can do well and do good by running 24 hours a day, seven days a week. That’s what he said. I mean he didn’t really do it that way. But he kept these places open from early morning till late night so that people who were working could work and continue to get their cancer care.

Fiore was his COO and Les Botnick was the chief medical officer of radiotherapy. They were quite successful and then Bernie sold it to AstraZeneca. Then he went on to something else, and Fiore went on to something else. A couple of years later Fiore said to Leslie I had so much fun with you, let’s do it again. And that’s what Vantage was. Vantage was what we had done in California trying to replicate that in other parts of the country.

Theodore Phillips: What happened to Salick? What happened to his centers?

Christopher Rose: All of those centers were bought by AstraZeneca. Ultimately they ended up being pulled away from AstraZeneca. Like for instance, Cedars-Sinai took their center back. Alta Bates took their center back. The University of Kansas took their center back. But what happened was that Bernie, and Mike Fiore, and Leslie, and the medical oncologists working with them made them better programs. Then after the contract was up, they took them back. I guess that wasn’t such a good business model, but it’s interesting.

Anyway, the problem of course with Vantage was the headwinds are all changed. It was great for the first three to five years, but then after that CMS cranked the reimbursement down. Also the academic departments began to emulate us in terms of not just being places where knowledge was acquired but to take good and compassionate care of patients and it became harder to compete. We competed well. After 14 years McKesson bought us. So that’s what I’m doing now. I’m the chief clinical officer for radiotherapy for US Oncology. I guess my terminal job as a radiation oncologist would be to try and rationalize the care that we developed at Vantage Oncology with the care in the US Oncology system in radiotherapy.

Theodore Phillips: What is McKesson’s role in it? They used to be one of the major drug distributors. Did they change completely?

Christopher Rose: 85 percent of McKesson is still a drug distribution business. But I think that they understand that practice management is important and will be important in the future. Frankly this is something -- now I’m at 30,000 feet. If I’m passionate about anything still, it’s I think that there needs to be cooperation. I always felt this. I felt this when I was the president of ASTRO. It came from my role of being a community practitioner.

We and the academic department should not be competitors. We should be collaborators. Frankly I can deliver the care tons cheaper than you can in Wisconsin, Adam. The reason is that I don’t have a bunch of glass towers and a bunch of deans and all that stuff. But on the other hand, the acquisition of knowledge is not going to occur in the community. At least it is not going to be mainly in the community. It’s going to occur in the academy and how we can figure out to have enough patient material for research and teaching. The other thing though that we know is that volume matters. I mean head and neck cancer is the best example of that. So maybe we shouldn’t have as many accelerators as we have in the United States, and maybe the appropriate quanta is 30 to 40 patients per machine.

But we in the community can deliver that care much more efficiently. Whether it’s going to be Donald Trump or Keith Ellison, whether it’s going to be single-payer healthcare or whatever system Mr. Trump has for us, under either system we’re going to go bankrupt if 30 percent of the GDP goes to medicine. We just have to figure out a way to deliver the care in a cost-effective and quality manner and not beggar the universities so that they have the funds to continue to acquire knowledge.

Theodore Phillips: What’s happened down here in Arizona is that Banner Healthcare took over the university hospital. They have a network of community facilities and primary care busting out the university. It seems to me that may be a good model for the future to do everything. I get the best amount of treatment for the amount of money.

Christopher Rose: Yeah. So McKesson’s version, the US Oncology version of that is that the Baylor medical system, those doctors are members of the US Oncology team. They’ve got Texas Oncology Clinics and they’ve got Baylor as their academic institution. Again the business model doesn’t matter. Here I stop being the leftist that I was for most of my career. I think competition is good in the sense that it makes everybody better, but at the end of the day we have to have rational care delivery. That doesn’t mean centralized control. It just means thinking about it in a way which is intelligent. 

Adam Currey: So you mentioned your time as president of ASTRO. Can you talk a little bit more about that? That was what? During the late ‘90s, correct, if I remember from your CV?

Christopher Rose: Yeah. Yeah. I remember somebody. I think it was Sarah Donaldson who said, “Oh, would you like to be secretary of ASTRO?” I said, “Oh, I’d love it.” “Well, would you run?” I said, “Sure.” I can’t remember who I ran against. But whoever it was, that person was in an academic department. So she was known and I was not. And these things are not personality affairs but if the electorate knows one candidate and not the other, the known candidate tends to wn. I knew I was just a stalking horse, and that kind of burned me a little bit. But it was okay. One of the things I hate frankly about contested elections is that what it does is it takes the pool of interested volunteers and cuts them in half each time somebody loses and then they lose heart, get sad and don’t come back. I mean I think that’s called exponential cell-kill, right?

In any event, later on Jay Harris asked me if I’d be willing to be the head of the communications committee of ASTRO. I worked with a nice woman by the name of Keri Sperry. We had a lot of fun. In the middle of all of that, Steve Leibel and Jay Harris were having a bit of a fight with the ACR because of a perception that we weren’t getting value for our money in terms of the management of ASTRO by the ACR. And John Curry, who was an exceedingly generous and decent man, he was the executive director of the ACR and I believe either Kramer or Brady - I guess he was Kramer’s chief - either business manager or chief therapist --

Theodore Phillips: He was. He was Kramer’s business manager.

Christopher Rose: He helped organize a strategic planning retreat. He could have turned the dials that nothing happened, but out of that strategic planning retreat came the idea that ASTRO had to move to self-management. So Rich Hoppe was the president when that happened, and then Larry Kun was the year after that. The year that Rich was president, he asked me to stand for president. I did against the person who was my best friend in radiotherapy outside of the people in my practice. And I would say unfortunately I won because it was a bittersweet thing. But Paul Wallner and I remain great friends, and that’s how I ended up being president-elect.

The first years were kind of screwy. I mean what we figured was that there were three full-time employees of ASTRO when we started and the Meeting Management Services were through the ACR. When we did a budget, we said the most we could possibly need, the most we could possibly need are seven employees. Well, look at that building in Alexandria now. But, you know, so what happened was that Frank Malouff was the executive director. The three presidents at that time were Hoppe, and then Kun, and then myself. I mean we really had almost to take a sabbatical from our jobs in order to do the work and to help the executive directors.

Then, a woman came along to be the meetings manager and she was terrific. My meeting I guess was the first meeting that was run by ASTRO. Sheila Aubin, who Ted will remember, ran the two meetings before that. The last meeting that the ACR ran was in Phoenix, and that was Larry’s meeting. My meeting was in San Antonio, and I remember that was the year that it rained and rained and rained in San Antonio. They were building a new convention center. They brought us over there for the meeting. The whole city was like mud and I just cried. I said, “Oh, my God, it’s not going to be ready.”

Somehow they got the new convention center ready although, and maybe Teddy will remember, they had all these plastic runners on all these beautiful oriental carpets because people were still scuffing them up with mud. But they got the place running, and that was our first meeting. At that point ASTRO got the Annual Meeting “heroin,” which was the revenue fro the exhibition hall. We realized what RSNA and ASCO had already realized that there was big, big bucks in medical devices. Frankly, there’s been many reasons why ASTRO has grown. One of them has been obviously their ability to lever the support of the vendors. It’s a wonderful thing.

The other thing which happened during my era was that, from communications, I thought it was very, very important that we get a web presence. Again, there was nobody to help us so we’re scratching our heads. The people from Stanford did the original work. Then a young and exceedingly ambitious and hardworking radiation oncologist from San Diego, he just stepped up and said “I’ll do it, I’ll do it.” That was Prabhakar Tripuraneni. So the original web all came from him. The CME originally at the meetings was if the people who did the educational courses were willing, they would write this stuff up and you’d get a bunch of paper. But Prabhakar organized a way to have everyone at the sessions filmed and have all the slides filmed. We used to give out CDs in the beginning, now it’s streaming video. But that was all stuff that he did and it’s wonderful stuff.

I guess the last thing that I would talk about from that era, because it’s getting late, is the original Scope of Radiotherapy meeting. The scope of radiotherapy happened under our leadership and I think that’s a very important thing because now, these days, radiation oncologists have got to decide whether they’re doctors or whether they’re just technicians. We pushed hard that they needed to be doctors and not technicians. That there was, and remains in our field, a substantial component on things that we’re just technicians, I think that’s bad. But it’s up to the younger folk to make that decision now.

Adam Currey: Well, speaking of that - we’re running a little short on time - do you have any last words of wisdom for the younger folk, as you say, who are just entering the field now?

Christopher Rose: Well, I think I’m so lucky to have been a radiation oncologist. I think it’s the most, it’s the best career for somebody who’s interested in pathophysiology and physics and computers and also humanism and palliative care - taking care of people, holding their hands at a very difficult time in their life. I think that the more that we can be doctors, be clinical oncologists the more we have a right to remain as partners to the patients. 

I didn’t talk enough about Sam Hellman. I’m sorry. I said that I was a sponge and most of what I accomplished was on the shoulders of giants. As far as I am concerned Dr. Hellman was the defining presence of radiation oncology at the end of the 20th Century. He gathered all of us around him and then sent us out to practice as he taught us. He provided the conditions after he left Boston for Dr Fuks and Dr. Leibel to Clif Ling and physic colleagues at MSKCC to accomplish great things there and then he moved to Chicago to partner with Ralph Weichselbaum. He is a giant. He taught me how to be about a clinical oncologist. I’m an oncologist who uses radiation. I’m not a radiotherapist, and that’s what I think we have to be.

Adam Currey: All right. Well, I think we’re about out of time. Ted, do you have anything else?

Theodore Phillips: Can you say a few words about your family?

Christopher Rose: Sure.

Theodore Phillips: You mentioned your wife. Tell us something about your family.

Christopher Rose: Yeah. I’m going to be retiring soon and I have this woman who’s been waiting for me for the 47 years of our marriage. We’ve known each other for 51 years. She is incredibly patient. My wife, Randi, is a graphics designer. She uses the Middle Eastern edition of Adobe Illustrator to make customized prayer books with linear translation of the Hebrew, English and transliteration so that unaffiliated families can have bar an bat mitzvahs and weddings and the guests who may not be so schooled in Judaism can participate. She is very serious about her faith and her moral integrity grounds me. She makes me smile and punctures my pomposity. My son Alex, 37 is a disaster services coordinator for the National American Red Cross in Washington, DC,. Right now he is in Houston working 16 hour days coordinating the disaster services for the Hurricane Harvey effort. He’s also one of the kindest people I know. My daughter Adrienne, 35, is a bit of a clone of me in hat she is passionate about her work. She prosecutes international drug crime at the Department of Justice in Washington, D.C. Her group prosecutes very bad people with enormous amounts of controlled substances and is right in the thick of dealing with the opioid epidemic just now. I think there is some karma here give that she is interdicting some of the controlled substances that we were consuming in the 1960s. I am so proud of my kids, that they turned out so well is a tribute to Randi.

Theodore Phillips: Great. Anything we forgot?

Christopher Rose: No. Well, the only thing I guess I short-shrifted was Samuel Hellman. Anything that I am as a radiotherapist, I would ascribe to him. Les and I left Boston because we had a disagreement with him about what was important. We thought that clinical care was important, and we thought that he wanted us to spend more time in the lab. At the end of the day we all were right and we all were wrong, and that’s unfortunate. But he’s such a generous man that he stuck by us and he remains a friend.

What he taught me in terms of breast cancer, and Hodgkin’s disease, and computer-controlled radiotherapy, and stem cell, and oligometastases, and on and on and on - I can’t say enough about him. Other than Randi and Les Botnick, that was probably the best and most lucky interaction I ever had in my life.

Theodore Phillips: I assume you’ve seen his new book.

Christopher Rose: Oh, yeah. Oh, yeah.

Theodore Phillips: Learning While Caring. It’s quite good.

Christopher Rose: That’s right. People who don’t know him should read that book. It really sums up many of his own passions.

Theodore Phillips: Okay. Anything else?

Christopher Rose: No. I think we went over by three minutes. 

Adam Currey: Well, it’s been a pleasure. I’ve enjoyed it. Thank you for taking the time to do it.

Christopher Rose: My pleasure. I will red-pencil this like crazy. Ted, I think you should do the same.

Theodore Phillips: I’m leaving the stuff about the board exam in though. I think that’s great.  

Christopher Rose: Okay.

Theodore Phillips: All right.