Robert Sagerman

By Luther Brady, MD, FASTRO, and Gustavo Montana, MD, FASTRO

In 2002, ASTRO established the History Committee for the purpose of documenting and recording the history of radiation oncology in the United States. This interview took place at the 44th Annual Meeting of the American Society for Therapeutic Radiology and Oncology in New Orleans on October 7, 2002.

Question: Now, Dr. Sagerman is having a very distinguished career in oncology and in radiation oncology and currently is professor at the State University of New York upstate in Syracuse, N.Y. So I thought, Dr. Sagerman, I'd start by asking you to give us some basic demographics about you—when and where you were born and what your educational background was so that we get all of that on the record pretty quickly and move on to other areas for discussion.

Dr. Sagerman: I was born in 1930, the son of a physician and what was known in those days as a housewife or homemaker. My father was a family practitioner in Brooklyn, N.Y., and, in fact, that was what I planned to do when I eventually decided that I wanted to be a physician, which wasn't until a major portion of the way through my university studies. Then it turned out that if you have certain ego strength and the ethnic referral patterns—everyone that I saw come into the office always wanted to be referred to some specialist—and so I thought that family practice was not going to be for me, so I then decided that radiology would be like the general practice of medicine except that you would be dealing with physicians from all specialties and not directly with the patient.

Question: But may I interrupt just for a second? We haven't gotten you through university yet, so . . .

Dr. Sagerman: I went to Brooklyn Technical High School, one of the four especially competitive New York City schools. Then I went on to New York University at Washington Square rather than the uptown branch because my high school had 7,000 boys and no girls, and NYU uptown had only boys. I wanted a broader social experience. I graduated in 1951. At that point in time, just after the Second World War and before the Korean conflict, it was very difficult to get into medical school, but I was planning to go to my father's medical school, which was St. Louis University. I was admitted but decided that after three years of university, I would never have another chance to do all the other things in the world that I would like to do, so I spent a fourth year at NYU doing creative writing, fine arts and all the other liberal art things that one didn't have time for while following a scientific curriculum. That experience changed my perspective, so I decided that I would really like to stay in New York City. I was admitted to NYU's medical school and graduated in 1955.

Question: And then you did your internship?

Dr. Sagerman: I did a rotating internship in what was then known as Meadowbrook Hospital out on Long Island. There were two notable things; my first summer as an intern was the last polio epidemic and we were the county infectious disease hospital, so that was a tremendous experience. The other was that at that time you couldn't get into a residency training program because you were military “draft bait” and no one would take you; all the military from the Second World War who had been called back into service were now retiring with the end of the Korean conflict. The radiologist was Herbert Zatzskin, one of Isadore Lampe’s trainees from Michigan. He said that it was very important that you be “trained” in radiation oncology because with diagnostic radiology, you will eventually have to learn the nuances of differential diagnosis for yourself. My draft notice didn’t arrive until after Christmas, and my service was not to start until the following Christmas; that meant that I would be unemployable for half a year before and after military service. That is how I ended up at Charity Hospital in New Orleans.

Question: Was that part of the military service or before you had to go to military service?

Dr. Sagerman: This was actually before my military service. I was able to convince the Air Force that if I was allowed to train reasonably completely, I would be of much more value to them than simply being an intern or a post-internship and they agreed; so we had a deferment. But in 1955 and 1956, actually, everyone who had been in the Second World War and then was “re-upped” for the Korean conflict was retiring from military service, so all 300 radiology residents who had deferments were taken into service.

Question: And then, if I remember correctly, you went from New Orleans to the other extreme temperature-wise in Alaska.

Dr. Sagerman: Yes, when I got my notice we had something called “concurrent travel.” Alaska was not a state at that time but a territory and classified as an overseas base. Malyne was 7 months pregnant, so technically we couldn’t be assigned overseas. I went to Washington to complain and after waiting in the colonel's office for several hours, he said, "Dr. Sagerman, you are number 300 on my list of 300. The first 299 have complained. They've all been reassigned. I need you. You're going to Alaska. If you don't like it, please go see the president" [laugh].

Question: Then you went to Alaska to … where in Alaska?

Dr. Sagerman: I was in Fairbanks, Alaska, stationed at the 5040th U.S. Air Force Hospital at Ladd Air Force Base, which was the major hospital aside from the one in Anchorage at Elmendorf Air Force Base. We were responsible for the Army troops, the SAC bases and the DEW Line, and I was the most northerly radiologist in North America.

Question: Tell me a bit about that. You know, young people today have no concept of what you mean when you say “the DEW line.”

Dr. Sagerman: DEW stands for “distant early warning site.” This was at the time of very intense Cold War activities. At Ladd we had the “fighter wing” and at Eilson, 26 miles down the road, we had the Strategic Air Command bombers ready to go out and either defend us or to counterattack. We went through all sorts of training for various eventualities in mind. The most important thing I can remember from that is that we had a wonderful time there. We had our first child there who considers himself an “Alaskan.” And we learned that, despite all of the evacuation studies, there was only one dirt road out of Fairbanks. You would go through hundreds of miles, and there would be no civilization whatsoever unlike now where there are 60,000 people going down this one evacuation route. So I told Malyne, "You stay at home. If I'm all right, I will come and find you." We never did have to evacuate.

Question: Now, how long were you there and what kind of medical practice were you doing there?

Dr. Sagerman: I was doing diagnostic radiology. In my year at Charity I did predominantly diagnostic radiology, which was my interest at that time, but I did have an opportunity to work for several months with Manuel Garcia, a wonderful radiation oncologist with particular knowledge of cervical cancer. As part of our rotations, we would be on call 24 hours a day on the radiation therapy service. We would have 30-40 beds on both sides of Charity Hospital, which was a segregated hospital at that time.

Question: I didn’t know Dr. Garcia. I know him by name, you know, literature and certainly papers on the cervix, which were quoted. Gynecological cancers were very common and, in view of the health care system in Louisiana, Charity Hospital had a tremendous load.

Dr. Sagerman: Absolutely. It was filled all the time.

Question: Garcia had developed, as you alluded to, a tremendous reputation in the management of patients with gynecologic cancers.

Dr. Sagerman: Dr. Garcia was not in very good health at that time, so he was no longer traveling, lecturing and going to meetings.

Question: Right, because I remember him very distinctly early on with all of his presentations. What happened after you finished your tour of duty in Fairbanks?

Dr. Sagerman: At that point I had been doing diagnostic radiology essentially for three full years, and I missed the “practice of medicine’; I missed the patient contact. So I thought that Dr. Zatzskin was right; I really should have an interest in radiation therapy and at that time there were very few training programs. I was not a prime candidate for any of them for several reasons so I had made a contract with Simeon Cantril to join him at the Swedish Tumor Institute in Seattle. I got out of the service in June of 1957, and he unfortunately had a heart attack at a meeting in San Juan, I believe, in March or April of that year so my preceptorship arrangement was moot. At that point, our second child was on the way, and it was socially and economically more advantageous for us to return to New York for me to complete my training in radiology. This was accomplished at Montefiore Hospital in the Bronx with Harold Jacobson and Jerry Shapiro and others in diagnosis and for 10 months in therapy with Charles Botstein.

Question: Tell us a little bit about Dr. Botstein. I know that he has been mentor to a number of people like yourself and many others. Tell us a bit about your feelings about him as a physician and as a radiation oncologist.

Dr. Sagerman: Charlie Botstein was a wonderful person. He was very humanistic, one of the most brilliant physicians I have ever had the opportunity to work with. He is blessed with a wife who was even better than he, with obviously bright progeny who have gone to do various things in the world; he is a true renaissance man. Charles Botstein taught you the clinical practice of the radiation therapy, and he kept after you to learn. While he had use for the technical advances, he wasn't enthralled by them in the sense that they would really change the world or what the nature of cancer would be.

Question: You wouldn't believe that today by the program at this meeting.

Dr. Sagerman: No, I wouldn't, and that's one of the problems. But we did have the first Cesium-137 unit in New York City, and we did have the first Brown-Boveri Betatron, I believe, in the country, so I had an opportunity to work with those units. There was a wonderful physicist named Jack Spira, who was the best clinical teacher of physics for radiology residents. Both he and Dr. Botstein are no longer with us.

Question: Did he also have gynecological applicators?

Dr. Sagerman: Gynecological applicators, yes. I think the other important thing was that at Montefiore Hospital, I came under the influence of a physicist, Edward Segal. This is the Segal of Seidlin and Segal of the initial uses of I-131 for thyroid disease. He actually changed the course of my life. He suggested that I was bright enough not to join an already established Fifth Avenue radiation therapy practice in New York City and that I might want to see if my intellectual abilities and work habits were sufficient to succeed in an academic career, which I had not seriously considered.

Question: So, was that the stimulus that caused you to accept the position at Columbia?

Dr. Sagerman: He said there are these various places where you might go to train and at that point, my idea was to spend one or two years in laboratory training, which I had not really had before, to see what radiobiological research could do for radiotherapy. I elected to go to Stanford University to work with Henry Kaplan and his team. Ed Segal was instrumental in securing that position for me.

Question: And you were there for how long?

Dr. Sagerman: I then worked with Henry and Malcolm Bagshaw and the laboratory team doing all of the things that I really wanted to do for three years. I learned the real clinical practice of radiation therapy. I learned how to run a department because the first year I was there, Henry was on sabbatical, so I worked with Malcolm as my chief. The second year Malcolm was on Sabbatical, so Henry Kaplan was my chief. I was the chief operating officer, perhaps, and chief cook and bottle washer [laugh]. The only potential down side of that experience was that I do not think that they ever accepted another radiology resident graduate into the program. At that point we had established a residency training program.

Question: Jerry Hanks?

Dr. Sagerman: Jerry Hanks was there and then a whole bunch of people came.

Question: That was after you, though. Wasn't it?

Dr. Sagerman: No, Jerry Hanks was there while I was still there and went off into the Navy for two years and then came back. John Ingold was there in training radiation therapy. One of the important things to realize at that point in time is that John was a superb radiation therapist but didn't have the confidence that there would be a continuing practice of radiation therapy; he went back to Michigan to complete his surgical training and has that unique background of being both a surgeon and radiation therapist, so that radiation therapy in Michigan burgeoned.

Question: Was he at the University of Michigan?

Dr. Sagerman: He was for a while, but then he went to William Beaumont. He was, I believe, the chief of surgery there.

Question: I see. So after that, I think you were at Stanford from . . .

Dr. Sagerman: From 1961 to 1964.

Question: That's the period during which the National Cancer Institute developed the programs for support of clinical or research training in radiation oncology. Stanford and Yale were some of the first institutions to be funded.

Dr. Sagerman: Mort Kligerman was up at Yale, and we also then had straight radiation therapy residents. That was the beginning of the first formal residency program, aside from preceptorships or other arrangements such as that of Juan del Regato at the Penrose Hospital.

Question: So, what encouraged you to leave or what made you decide to leave Stanford?

Dr. Sagerman: I left because I was a New York City boy. I had gone out to do some work. I had done that work and the siren call came, “Would you like to come to join us at Columbia Presbyterian? We would consider you for the chair at an appropriate time.”

Question: Who is the person who actually encouraged you to go there?

Dr. Sagerman: That was Bill Seaman.

Question: Bill Seaman? Who was chairman of the department?

Dr. Sagerman: Who was chairman of the department of radiology.

Question: And radiation oncology was a division of the department of radiology.

Dr. Sagerman: Was a division of the department of radiology and Bill Seaman had some radiation therapy experience from his time in St; Louis. I believed him and returned to New York.

Question: So you were at Columbia?

Dr. Sagerman: I spent four years at Columbia.

Question: Was Chu Chang there?

Dr. Sagerman: Chu Chang was there but Harold Jacox was the director of the division for the four years that I was there. Chu Chang succeeded to that position when Jacox retired.

Question: But Chu, I think, during the time that you were there, actually, was at the Neurologic Institute doing brain tumor work primarily.

Dr. Sagerman: He was doing predominantly central nervous system work, but at that time, Columbia had just made their new radiation therapy department in the basement of the Babies Hospital so that we now had all of the equipment there. We had the accelerators, Allis Chalmers Betatron, cobalt units, hyperbaric chamber, so radiotherapy was no longer being done at the Neurological Institute.

Question: At Columbia you began your interest in eye tumors, I presume, and also in retinoblastoma and in rhabdomyosarcoma. How did that come about?

Dr. Sagerman: Well, I have to back up one step. It's important to know that when you are the junior member on the faculty, whatever it is no one else wants to do is what you end up doing. And those days, treating children was not a very fashionable thing because we didn't have very good results in general and you didn't want to damage the children, so you treated the children with a certain degree of fear of complications.

Question: But do you think that grew out of the historical perspective relative to George Pack and the treatment of patients with retinoblastoma with techniques caused the severe late effects that occurred as a consequence of that treatment program. And second tumors, of course.

Dr. Sagerman: Absolutely. When I came to Columbia, Patricia Tretter was doing this work, and she said, "Bob, you're now a junior; you're going to do it." So having the Harkness Institute of Ophthalmology available (with Algernon Reese, Bob Ellsworth and that whole coterie of people), I got to working hand in glove with them. The retinoblastoma children were easy in the sense that we now had equipment; we didn't have to use an old fashioned kilovoltage technique with a contralateral oblique nasal field and so forth. We now had cobalt treatments and the Betatron, so we had very good techniques for the time. We also had a tumor registry just for these children, so I could go back to the early 1920s and early 1930s and had an opportunity to review all of the retinoblastoma children. And we could demonstrate that according to the staging system, stage for stage, we did very well and you didn't really have to lose your eye. The senior on that paper was Bob Cassidy, who was one of the radiology residents at Columbia who went on to a successful career in radiotherapy. In those years at Columbia, no one had gone into radiation therapy for more than 15 years since Al Byrne had left in 1952 or 1953; he was a very knowledgeable radiotherapist and superb diagnostic radiologist who turned out to be instrumental in attracting me to undertake the development of a department at the SUNY Upstate Medical University in 1968.

Question: In terms of that, just to explore that relative to the retinoblastomas, I know that Nora Tapley had been doing a lot of that work in the beginning with triethylene melamine as a chemotherapeutic agent, with treatment on the Betatron, which, as you know, was an incredible kind of weight-lifting machine with which to work. But did this beginning actually evolve into the recognition that you could treat retinoblastoma without having to remove the eye?

Dr. Sagerman: Yes, absolutely. One thing that we were able to demonstrate was that triethylene melamine made no practical difference in the success of irradiation.

Question: And today as well.

Dr. Sagerman: Well …

Question: I mean the concept of “drug du jour” chemotherapy.

Dr. Sagerman: Perhaps the more interesting story is what happened in terms of rhabdomyosarcoma. That went back to my Stanford days because, being the junior faculty member, I was also treating the children, and we had a number of children with a primary or more often metastatic rhabdomyosarcoma—not many in the eye as such but in various parts of the body. We would treat them, usually palliatively, but a few lesions we treated to a full therapeutic dose, which we could get away with say 50 or 60 Gy. We demonstrated that we had local control for a year or two years until the children went on to their demise.

Question: With systemic disease.

Dr. Sagerman: With systemic disease.

Question: But with local control.

Dr. Sagerman: But with local control. When I came to Columbia, with the Harkness Eye Institute, I looked at the orbital rhabdomyosarcomas and a whole group with metastatic orbital rhabdomyosarcoma and was able to demonstrate in about 30 patients that it was a dose-dependent phenomenon. The philosophy that was published then was if you gave 20 gray and everything disappeared, maybe you would give 50 percent more but you wouldn't want to do anything more than that because of the fear of damage and losing the eye. I challenged my colleagues and the pediatric oncologists that the question was why should we treat this cancer differently than any other cancer, aside from seminomas or lymphomas. Everything else required a full dose, say 60 Gy. Why don't we do that? “But you'll lose the eye” was the response. I will be happy to lose the eye if I have a living child. You lose the eye right now, and you're survival rate is 20 percent and the best figures you have ever published are somewhere around 45 percent, which I have never found.

Question: You know, I'm trying to evolve the impact of this information because it's really critical that you were able to demonstrate that you could control the primary tumor by an adequate, appropriate degree of radiation dosage. And yet, the patients died from systemic disease. Was this the foundation?

Dr. Sagerman: No.

Question: No?

Dr. Sagerman: Not for the eye.

Question: I mean in general.

Dr. Sagerman: In general, yes.

Question: Was that the genesis of the decision that one needed to look at chemotherapy and combine treatment with radiation?

Dr. Sagerman: In a certain sense, yes, but I think that applies to all other sites but not to the eye. What we demonstrated in the eye was that radiation therapy alone—with or without drug du jour chemotherapy, which made no difference—achieved a 90 percent local control rate and a roughly 70 or 75 percent survival rate, and the people who went on to die, that smaller group, died from dissemination of the disease process, never with local recurrence. So we were able to demonstrate that irradiation alone was an effective therapy and need not be done with anything else in this one site, which for anatomical and biological reasons, we were able to make the diagnosis early on. And that's a difficult adjective to define, but before they had disseminated or you don't have lymph node metastases. This was in the 1960s, before CT and MRI.

Question: I guess actually the point I'm driving at is that the contribution of the work you did clearly demonstrated and confirmed that the rhabdomyosarcomas in the eye behaved differently from other locations and that radiation was an effective treatment program for those patients. But rhabdomyosarcoma in other locations, because of the high risk of dissemination, really dictated that one had to do combined, integrated, multimodal programs of management.

Dr. Sagerman: Exactly. Radiation was fine for the primary site, but it was not fine for the disease overall and that was the need for the development of all of the chemotherapy programs.

Question: The other thing that to me I think is important is your contributions while you were at Columbia; the assessment of the patients and the risk of second tumors. I remember clearly the publication indicating that it was a dose-related phenomenon and was clearly an important point relative to determining that it was a different histology from the beginning tumor and that you could safely irradiate in the doses that we conventionally use without majorly, significantly increasing the potential for second tumors.

Dr. Sagerman: And that remains true today.

Question: Yes, and it led to the criteria for radiation-induced malignancies, which actually, you established the information for, in my opinion.

Dr. Sagerman: Well, I think he published his ideas before and we followed. This was certainly excellent confirmatory evidence. I must admit that the one thing we were really ignorant about at that point was of the significance of bilateral or hereditary retinoblastoma. Because now everyone knows that with this genetic abnormality, you will develop second primary tumors.

Question: High risk for second tumors.

Dr. Sagerman: Right. And if you're not genetically at risk, you won't and that remains true today. When we wrote that paper, we didn't know that did not include a whole bunch of other bizarre kinds of tumors that occurred and couldn't understand how this could be radiation induced, so those patients were never included.

Question: Let me ask you what about the development of “cooperative studies.” Tell us a little bit about that.

Dr. Sagerman: Well, I can't tell you very much about those. I participated in them, but I was never a major player in that sense. As these things were developing, I was now directing the division in Syracuse, building a department, and there were so few of us and so much work to do that I stayed at home doing my own research and treating a full load of patients, starting a residency program and so forth. Even more interesting is, back in the Stanford days, we radiation oncologists were the medical oncologists. I remember Saul Rosenberg, and I came at the same time, within a few months of each other, and Saul had no internists who were doing medical oncology. It wasn't looked upon with great favor, so all of the radiation therapy residents and faculty were his residents and his faculty. We worked hand in hand and that's how all of the lymphoma work that Henry Kaplan and Stanford is famous for developing.

Question: It seems to me that the critical contributions that you made when you were at Columbia and in that short, general time frame, were really rather dramatic. First off, you demonstrated that you could treat retinoblastoma, without having to remove the eye, successfully with radiation therapy. You demonstrated the differences between rhabdomyosarcoma in the orbit and how local radiotherapy could be very effective not only in terms of improved survival but by demonstrating that rhabdomyosarcoma in other locations really dictated that you had to give combined programs of management. And certainly, I think, most importantly was that you identified that there was a dose-related response situation relative to second tumors. Those are three very critical observations, in my opinion, that you made with your colleagues when you were at Columbia.

Dr. Sagerman: To those I would add a fourth. Because these were children, and if you succeeded in your initial goal of curing them of their cancer, you followed them for the rest of their lives.

Question: Absolutely, absolutely and for adults you can say the same. And now we know that than ever before. So what really, with these kinds of contributions, which are major and significant, possessed you to leave Columbia to go to Syracuse?

Dr. Sagerman: There were two factors: one was that after two years at Columbia, I had turned the heads of a number of residents, six or seven of who were radiology residents who ended up doing radiation therapy—notable residents. I think Bob may be the only one who became a university professor chair. It was clear that we would not become a separate department, at least in the foreseeable future for me. Henry had taught me that he was training me to become a professor and chair, which the U.S was looking for to build a department. One of these institutions was in Syracuse, N.Y., and one in Tucson, Ariz., which have roughly the same population size. What I wanted to do was to make a department in the Canadian or English or European style, where for a population of a half a million or three-quarters of a million people, you would have one radiation oncology center. And that's what we started and that's what we had interest in originally, so that was a lingering challenge for me. At that time, the opportunity came and there were two cities built in Syracuse and that lasted for about 15 or 17 years before we then had to give up the ghost and other private offices opened.

Question: So you went to State University in Syracuse in 1968 and were in charge of the division of radiation oncology in the department or radiology. And who was chair of radiology then?

Dr. Sagerman: John McAffee was chair of radiology.

Question: Whose basic background was in nuclear medicine, if I remember correctly.

Dr. Sagerman: Yes. So he and a fellow you also may know, Lou Blumley, who became the dean and the president, the two of them attracted me to Syracuse. During my initial visit with my wife, we went up through a snowstorm on the New York State Thruway and a truck driver said, "Oh you can't possibly get through, they've closed the Thruway." I tried to call John. There was no answer on the phone. One of the great characteristics for a good radiation therapist is being sort of anal. If I couldn't get to him and say that I couldn't make it, but I was going to make it, so we made it [laugh]. Malyne holed up in the hotel. At the end of my two-day visit I went back and said I would not be interested and John said, "Well, we paid your way. Would you tell us what it is that we need to do to make this place attractive to someone?" So I sent a three-page single-spaced letter and as the next two years went by, he finally called and said, "Well, we have 50 of your 53 criteria met. Would you now consider coming?" And this was now after four years at Columbia when I thought it was time to take the plunge.

Question: Tell me about the facilities and resources that you had when you arrived in Syracuse. I know that you had 53 different requirements that you would like them to meet and they had 50, but in reality, what was it really like when you got there?

Dr. Sagerman: We had a small department. We had no simulation. We had two cobalt units, one of which was a Picker C9 with a trap door in the floor. We had two examining rooms. We had no waiting room worth the name, and we had really very little in the way of help. So I went there and we then recruited a second radiation therapist and then a third and then finally a fourth and we worked with four faculty members. We started the residency program in 1970.

Question: What year did you actually go to Syracuse?

Dr. Sagerman: In 1968.

Question: 1968, so three years to get things organized.

Dr. Sagerman: Well, it's even worse than that. To treat Hodgkin’s disease as I was used to treating it, you have to get a certain distance, which you could only do with the Picker C9 and/or by putting people on the floor. And the Picker C9 had an isocenter of plus or minus 1 centimeter in all three dimensions, and so we took steel rods and put it into the head of the machine so the isocenter had a diameter of one centimeter and for the mantle field and inverted ‘Y’ field patients we used the other machine at its greatest height. We built a little caster like you use when you're a mechanic going under a car, and we rolled people under that and then we took a little coffee table and we put our blocks on that and we were then able to treat as I was used to. After a few years we could demonstrate that we, in fact, were doing it quite successfully. But one of the problems with the cobalt units was that they were forever getting stuck in an on position. So it fell to me more often than to anyone else to run into the room and get the patient out of the room and then manually turn off the cobalt unit. So I would do this and finally in about 1973 I said, "I've had enough," and I went to the administration of the hospital and I said, "I am your nominal radiation safety officer. I have declared this department closed as a radiological hazard." It took them a week to call me back and say, "Well, you have always asked for those accelerators, but we've never had the money. When would you like one and which one would you like?" So it then took us another year-and-a-half because we had to do major kinds of reconstruction.

Question: This was about the time of the advent of linear accelerators.

Dr. Sagerman: I was used to working with linear accelerators from the early 1960s.

Question: In general, through the country.

Dr. Sagerman: That's right. So we did that, and we had a Varian 4 that we used for head and neck cancer for all the years. We gave that up only reluctantly because we then had six Mv, which was all you could get, really. But the construction for that room was interesting because we were directly under the main entrance to the hospital. It was a room that had a certain dimension in the ceiling with a certain amount of concrete there, but that was all. In order to put in an appropriate shielding for a primary beam, we would have had to make five steps up and down to get into the university.

Question: The main lobby in the university.

Dr. Sagerman: Exactly, right into the main lobby. So, Jerry King, who was with me at that time, and I put our heads together and got the architects who were knowledgeable in architecture, but not in this, and we designed strengthening side walls, making a cutout at the top, layering support beams on there and then layering in a step-wedge fashion 2-inch-thick plates of steel 24 feet long by I forget how many feet wide and so on so that we didn't have to disturb the entrance to the hospital at all And we had the equivalent because we could use this instead of concrete. You needed 7 or 8 feet of concrete.

Question: I'm interested in the way you solved the problem of the shielding.

Dr. Sagerman: We were very innovative [laugh].

Question: So when you started your training program, that was in radiation oncology and that was about the time that the American Board of Radiology began to deal with separation of training programs or the separation of certification in radiation oncology as opposed to general radiology as opposed to diagnostic radiology and the residents began to determine criteria by which one would judge the quality of the training program. So you started the training program in …

Dr. Sagerman: 1970 with our very first resident, Richard Evans, who is still in practice in California.

Question: And were there others in the training program whom have gone on to academic careers?

Dr. Sagerman: Our graduates came from a different background and our resources were very different. One of my criteria for going to Syracuse was to have a laboratory. We had designed space in what was know as Pioneer Homes, which was a low-income housing project—I believe the very first one in the United States back from about the 1930s and was being used by the state of New York. I didn't realize that they didn't own the space as such, and in the summer of 1968 there were major disturbances—racial disturbances—all over the country and one of the things that we could not do was to build our laboratory. So my 2,000-square-feet of space for research evaporated. And it didn't come to fruition with us funding it out of our private practices for 15 years. So we could not attract the same kind of resident to this out-of-the-way minor city in the United States with cold weather patterns, without the resources of the Stanford or Yale or MD Anderson or any other place like that. Nor did I have the reputation to attract people just on the basis of my own name. So we attracted people that we thought would be excellent physicians with the goal of hands-on teaching them. If you were uninterested in participating—if I could not have my resident with me—then you were not my patient. Serving the mayor and the mayor's wife and VIPs didn't come until years later. And in those days, we were a very minor part in the institution. I can well remember the day that internists, hematologists, oncologists would come down with a prescription pad written and say, "This is what you will do," to which my reply was, "You are asking for a consultation. You are free to accept it or not. If you don't accept it, that's fine with me, but when I can tell you how to make your surgical incision or what chemotherapeutic agents to give and when to give them and in what dosage, then you can tell me how to practice radiation therapy."

Question: So your residents really worked with you like a preceptorship.

Dr. Sagerman: Very much so.

Question: Hands-on day-to-day patient management with you and the two of you working together.

Dr. Sagerman: Right. Closely. And our philosophy was “graded responsibility.” The more you demonstrated your abilities, the more freedom you had. We were always looking over your shoulder. We would never tell you what to do. We would make you decide what to do so that you could think. And if you didn't choose something that we were happy with, we would ask you why you did that and would you consider something else and we would then come an agreement. Obviously when they were younger, they always agreed with me, but eventually they would not agree with me and as long as they were not doing harm to the patient, we would allow that. And my teaching at the end was that when they were finished here, they should go somewhere else to see how other people practice because they now know a way to do things successfully. Now they have to see that the world doesn't always do them this way and now they have to evaluate why other people do it differently and decide for themselves what is going to be the best way.

Question: You alluded a moment ago in your discussion to the incredible change that has occurred in having a central focus for referral to where there was the developing private practice situation, if you will, in the community which was really in direct competition to the university. Tell me a little bit about what actually happened in Syracuse that leads to the present situation that exists there.

Dr. Sagerman: Well, that was the beginning of it. One private office opened.

Question: Were they people that you trained, by the way?

Dr. Sagerman: There was one person in that office who trained with me for part of the training but not completely but who could not have a position with us because we had no positions and who had enough financial resources to open an office.

Question: So that was the first office.

Dr. Sagerman: Technically, it wasn't. Clinton Hale who was an old chairman and professor of radiology at the university had by then left the university and had a private office. There were two brothers, Clinton did therapy and DeForest did diagnostic radiology; they had a cobalt unit. We had a very amicable arrangement. They did not want to do Hodgkin’s disease. They didn't want to do anything complex. They didn't want to do any brachytherapy, and so they basically had a lower-level predominantly metastatic disease radiotherapy practice.

Question: So they really had an affiliated kind of association with the university, even though maybe not formal, but in practice.

Dr. Sagerman: Yes, and it worked very well. And when Clinton was sick, we covered his office for him and tried to convince the university that we should now take over and just buy out this office and maintain our independence as the only major focus in town.

Question: But in their wisdom they elected not to do that?

Dr. Sagerman: And they elected not to do that. They thought that was crass materialistic or something. Of course, they have since changed their mind.

Question: But you talk about the first, I wouldn't necessarily say viable, but certainly competitive, practice was a private practice with an accelerator.

Dr. Sagerman: Private practice with an accelerator and a cobalt unit. Even today, no hospital officially has any radiotherapy in the city of Syracuse.

Question: Except your place.

Dr. Sagerman: Except ours. But at two of the hospitals, there is a radiotherapy department, if you will, on the grounds of the hospital.

Question: But private practice.

Dr. Sagerman: But private practice.

Question: Is that what really led you, then, to develop the Hill Center?

Dr. Sagerman: Eventually we did. We were never in favor of doing that, certainly in the early years. We couldn't go anyplace else. We were doing 1500 new patients a year just with the four of us, trying to do research and running the residency program. I, in those days, would consult with the people I helped: Harold Heinz who designed the first integrated office in Utica, Andy Adams was down in Binghamton. We had a working arrangement with them so that he could get an accelerator and so forth. These were all unofficial outside the world of the university.

Question: These were really personal kinds of relationships.

Dr. Sagerman: Exactly. They were there in practice and wanted to get better. I would come down and help them design and how we do so on and so forth. We did that for many years.

Question: So, the university practice in Syracuse now really includes a “private free-standing facility,” which is, in fact, an integral part of the department.

Dr. Sagerman: At this point.

Question: And the university facility.

Dr. Sagerman: Right. We didn't open another facility. The first one was what we called the Hill Office, which is all of three blocks away. That was opened because 35 percent of our referral practice came from the medical oncology group of private practices who said, "We are now consolidating our offices in this building and we would like to have radiation therapy in this building," and financially I was no longer the director.

Question: When did you step down as chairman of the division?

Dr. Sagerman: In 1994.

Question: And then Dr. Chung became …

Dr. Sagerman: Then a separate department was established, and Dr. Chung was appointed as chair.

Question: Right. But you still work actively in the department, and you work not only at the university, but also at the Hill Center.

Dr. Sagerman: I work at the Hill Office, and subsequent to that, we've opened an office in Oswego, which is about 35 miles north and we now have another office in Binghamton.

Question: So the realities are that you have developed an outreach program as a practical purpose of survival.

Dr. Sagerman: Yes and no. That's certainly true to a certain degree, but I hadn't thought about outreach programs in all of the years before we had any other offices. We had an outreach program in what we called the North Country, in Alexandria Bay, in Clayton, in Potsdam. We would go up once a month—one of the faculty with a resident—we would do our own dictating; we would do our own typing; we would frank the reports to mail out.

Question: But that was really for consultation and follow up?

Dr. Sagerman: Not for treatment—consultation and follow-up. We had enough people coming from up there that we thought if we could do this once a month, it would be much more advantageous for them, and we could also, in fact, make them aware of what we could do.

Question: And they then would come to Syracuse for treatment.

Dr. Sagerman: And they would eventually come anyway rather than stopping for kilovoltage therapy in Watertown.

Question: Sure, that's a very important service. You know, you bring the doctor to the patient …

Dr. Sagerman: We did for about 15 years and we finally stopped when one winter, in three consecutive months, we went off the road and the institution would not allow me to provide insurance for the people who were doing this outreach program.

Question: Let's go back and talk about what you consider to be the important contribution that you have made at Syracuse. We talked a moment ago about the four really major kinds of contributions you made at Columbia. In your judgment, what do you think are the major things you've been able to accomplish while you were chair and now professor in the department at Syracuse?

Dr. Sagerman: We have clearly established that we have a first-class department; we provide clinical care, we publish as one would expect from the academic world, we have results that are the equal of those from all other reputable institutions, we were able to establish and maintain a residency training program with people who go out and practice. About 20 percent of our graduates would initially start in what I call an academic practice in the sense that they were part of the university or major hospital with a teaching program. But within three to five years, the majority of that group would end up leaving the academic setting because the financial rewards were different—were greater outside. And it's the same story now. Remember, these people that we recruited were not true academicians to start with. They didn't like writing papers; they didn't know how to write papers at the beginning.

Nevertheless, we now have a laboratory with a radiation biologist. Our residents now all spend time in the laboratory, so we have a perfectly respectable good clinical training program. None of the residents in Syracuse have gone out to be departmental chairs. One of the important things that we did was simply a fluke. The person teaching about radiation hazards in the pharmacology course in the second year was going on sabbatical, so I was asked if I would like to teach about radiation hazards—the deleterious effects of radiation. Ike Weiner was the professor at the time and I said, "I'd be very happy to do this, but I will not do it for one hour. I want eight hours in your course." They also had a seminar course, "and I want to have a seminar course with a limited number of students." He said, "Fine." So we did, and by fairly obvious subterfuge I would not only cover the materials that I was expected to cover, but I would show these eager medical students who were anxious to see a patient, having done two years of basic science, pictures of before and after irradiation illustrating tumor regression without the “complications” they had been taught to expect. Then I would invite them to come down to see a patient with me and they'd say, "Boy, we never felt anything like that before such as lymphadenopathy. The medical students’ expressions were, "Boy, you guys got real pathology here."

In the seminars we didn't try to make anyone into a radiation oncologist. They would look up various topics, including socially important topics, like do you build a nuclear power plant 40 miles away from the city of Syracuse, which was going on at that time. The essence of that was that all of a sudden, from an institution that did not turn out medical students who went into radiation therapy, with the notable exception of Sam Hellman who came by it totally outside of his medical school training, we now have medical school students who were interested in radiation therapy, some of whom trained with us. The best of the medical students that I thought had true academic potential, I would send out to be trained at more major institutions.

Question: You mean in radiation oncology.

Dr. Sagerman: In radiation oncology.

Question: Tarbell now is vice-president in charge of medical affairs or women's affairs? I can't remember.

Dr. Sagerman: I think it's women's affairs at Harvard.

Question: The thing that you're alluding to in terms of radiation hazards, etc., is a very central key in this meeting with Dr. Janjan; making the point that people like yourself should step forward to be the leaders in developing programs to deal with the potential terrorist activity with dirty bombs and all the other things that you read about in the newspaper every day. Teaching that kind of material and having that kind of expertise indicates that the physicians in radiation oncology are uniquely qualified to be the leaders in that particular area.

Dr. Sagerman: Absolutely. And we have done this. We are the medical people for the Nine Mile Point Nuclear Power Plant in Oswego, so we are the disaster backup. And equally, I think Dr. Janjan has a theme of “you really must be a practitioner of medicine” — that you cannot simply be a technologist and you cannot pay attention only to IMRT or 3-D conformal treatment planning— that you have to be able to take care of your patients. That's something that we did back in old Stanford days and over the years for very practical reasons. I think in general, as a specialty, we have given up taking care of patients to a major degree because, in the early years, there were always too few of us. So, when I went to Syracuse there were two caveats: one is your practice of radiotherapy and you return the patient to the referring physician. I always did that anyway because that's how we built a practice. And the other was: with only four of us, there wasn't time to take care of the patient's heart attack, diabetes and so on. The minor things we could do. One of the things that many hospitals did not have then (and I suspect don't have now) is their own radiation therapy beds. In the early days we would borrow beds from the appropriate service, but over the years, with the constraints and changes in the practice of medicine, that practice gradually eroded.

Question: Yes, I think you're right about that. The other area that seems to be very important in your contributions is the continuance of your interest in managing patients with eye disease. Not only in eye disease like macular degeneration but also to your major interest in other tumors, primary tumors of the eye including not only rhabdomyosarcomas but other rare tumors of the eye like choroidal melanomas, etc. So maybe tell us a bit about how you got involved with macular degeneration, first off, and then how you got involved with the choroidal melanomas, which really is an additional part of the story that you began at Columbia with retinoblastomas.

Dr. Sagerman: Well, we have relatively few choroidal melanomas and that was simply an extension of what we had already been able to demonstrate back in New York City and also the work that was eventually published in the mid-1980s out of the university in Essen, Germany, at their eye institute. That has simply continued, and with the wonderful advances in terms of proton beams, for example, today you can use very fancy techniques. You could spare the major portion of the eye. We happened to have a unique group of retinalvitreous surgeons who were used to working with me in terms of other ophthalmological problems. They saw lots of people with macular degeneration. Trials were going on elsewhere, I said, "You guys have enough material here. We can run our own trial even if we are not allowed to join them for whatever reason." We never did end up joining them as such, and I don't know why that was, but we were able to do our own; there registered about 100 macular degeneration every single year for three consecutive years. We published those results, which I thought were quite satisfactory. It was clearly not the answer to the problem in and of itself, but I think it delayed the time to progression of the loss of vision.

Question: Why do you think, though, the ophthalmology community has emerged to be so against the exploration of radiation for macular degeneration of the wet type?

Dr. Sagerman: I think it's a matter of a lingering very strong fear that radiation damages the eye with no further thought of the process. Very few ophthalmologists have any real understanding of the use of radiation for what it can do, what it has already been able to do, demonstrably over decades in terms of treating things in or about the eye without damaging the eye significantly in clinical terms.

Question: Let me reiterate what I believe to be the kinds of major contributions that you have made at Syracuse. Number one, you built a program that's highly qualified, appropriately properly staffed, training residents in radiation oncology for general radiology oncology practice, I gather, not necessarily for academic practice. Secondly, you introduced the whole issue of radiation hazards and demonstrated how important it is to have the radiation oncologist involved in disaster planning. You've clearly indicated that there is a role for radiation therapy technology in age-related macular degeneration of the wet type, and you've extended the work that has been done in terms of management of patients with choroidal melanomas. Four very important and significant contributions; I think when added to the forefront of Columbia really become quite impressive in character. The other thing that I think is important at Syracuse is the fact that you have published the premier textbook for tumors of the eye, now in the second edition.

Dr. Sagerman: That's a wonderful story. I got my copy—the first copy—last week but didn’t bring it thinking it would be for sale by Springer, but it was not on display; a missed opportunity.

Question: Well, I think that's probably true but certainly my copy arrived last week- and I did have the opportunity to look at it and it really is excellent—there's no question about that. Better than the first edition. But also, too, I think you worked actively in publishing the basic documents, looking at all the various treatment programs in age-related macular degeneration. You and Winfried Alberdi from Hamburg and Professor Ruchardt from Hamburg who looked at surgical techniques and radiation techniques and other techniques in terms of management of the wet type of macular degeneration. So really, I count nine really very significant and very important contributions that you have made thus far. But what I'd like to move on now to is talk a little bit about your interests nationally because I know for years you were the only person who had any interest in and worked with the technologists in terms of improving the examination system, the quality of the training programs, the registry etc. So tell me a little bit about that and how that got started.

Dr. Sagerman: That got started because I inherited a school for radiation therapy technology. Our chief tech at that time, as he was called, was an English person. He eventually left and was succeeded by Joan O'Brien, who was superb, and I was then the medical adviser and became the medical director of that program. We set up a program, which continues today and is probably the largest in New York state. From that I went to work with the registry. I wrote test questions, didn't actually give the exam myself or score it, and went around the country site-visiting programs in terms of their approval for a training program. Then I became part of the group that oversaw all of this aside from the registry. That was a time of terrible financial stress and things changed, but we put that right again so that this was now a viable group which continues and is in overall charge of doing, not the examinations, which the registry ends up doing, but of approving training programs in technology. In those years, ASTRO was very forwardly thinking; when I was the chair it was probably called the technology committee. We were the first ones who ended up giving money to institutions for the benefit of students as scholarships, and I believe we set a limit of $50,000 a year, over $100,000 a year—I forget now, it's too many years ago. That was a time of a critical shortage and after eight or 10 years, the shortage disappeared so there was no need to give money anymore and then 10 years later, all of a sudden there's a shortage again and Bob Cassidy, I believe, has re-instituted that program.

Question: Isn't Bob the one who took your position with the ...

Dr. Sagerman: No, he's working with them, but there were certainly other people in between. I don't have off the top of my head the years I served and when I was the chair, but it was probably close to two decades ago.

Question: Let me ask you, what is the status of the school of training in Syracuse? Is there a college community program, a diagnostic and a therapy program?

Dr. Sagerman: There is a separate diagnostic program. The therapy program now offers a two-year associate of arts degree, which they have to do as part of the university. We don't have a simple hospital degree/certificate program. We also offer a baccalaureate degree, but we have changed the baccalaureate program in the sense that we used to have to do all of the non-radiation therapy parts of the program—English, mathematics, social studies—as part of our own limited university. We now take students who studied in conjunction with Onondaga Community College or Syracuse University or any university and who have a couple of years of training. We flesh out their non-radiotherapy education. They will do the two years of clinical practice with us and then earn a baccalaureate degree. So we offer both of those programs. Joan and I published a paper—it's got to be at least 15 years ago now—where we surveyed whether or not it would be advantageous to have a baccalaureate degree as compared with a certificate or an associate's degree.

Question: And?

Dr. Sagerman: We decided that it was not worthwhile for the entry-level technologist. Now, if you wanted to do more than that, if you wanted to learn how to repair accelerators, to run a department, to run a proton beam, to do other things beyond the entry level, that certainly would require additional education. I thought that's where the more advanced degree should go.

Question: I know that you have encouraged the individuals in your technology program to take courses in a university to put themselves in a position to be better trained to do higher qualified jobs. Can we move on next to the impact, in my opinion, that you had in the technology situation, which has been immeasurable to upgrade the quality of the significant programs and to upgrade the quality of the baccalaureate programs for training. What about your involvement with ASTRO?

Dr. Sagerman: I have served on any number of committees, often as chair, working from my home. Taking care of my own institution was paramount, so I did not play a political game. And trust that I have been a valued member and made my contribution.

Question: You've been on the program and panels and refresher courses.

Dr. Sagerman: And I've also, in terms of training for radiation therapy residents, written questions and examined for the boards for many years. My impact there was in terms of what was necessary in order to have a seriously approved program, the fleshing out of programs of quality and disabling or the closing of programs that did not do a good job.

Question: You're now talking about the Residency Review Committee because you were on that committee and you served as chair, if I'm not mistaken.

Dr. Sagerman: That's correct.

Question: And you were an appointee to that committee from the ...

Dr. Sagerman: Actually from the AMA I think.

Question: So you've clearly had—I know because we were on the committee together—significant input in evolving the criteria by which programs were judged as to whether they should or should not be allowed to continue training residents in radiation oncology. But going back to ASTRO, I know that you've played a significant part in giving refresher courses for the Society and being on the program with scientific presentations and on panel discussions and chairing sessions and so on.

Dr. Sagerman: I prepared clinical “case of the day” poster sessions for any number of years. Wonderful posters ...

Question: I'm refreshing your memory. And go on because I think the contributions that you've made in ASTRO have been really significant because you're one of the premier educators in this country in oncology and in radiation oncology. But going on to the Radiological Society of North America, the RSNA, I know you've been critically involved there on many different efforts doing all of those same things for the RSNA.

Dr. Sagerman: … education committee, poster sessions, scientific presentations ...

Question: And now you are its associate editor of Radiographics, which has the responsibility for choosing the very best posters for radiation oncology to be published in the journal.

Dr. Sagerman: With the separation of the journals and where we publish our materials now, while we were publishing in radiology, it's interesting that one of my original papers was one of the hundred most cited papers in radiology. Don't ask me why it should have been, but it was.

Question: And the subject?

Dr. Sagerman: Obviously eye tumors [Laugh]. That's one no one knew about.

Question: And you also were vice-president of the Radiological Society.

Dr. Sagerman: Oh, that's correct, and I gave an “Erskine lecture.”

Question: You have the Erskine lectureship at the RSNA, which is the premier oncology lectureship in that society, and if I remember correctly, it was about rhabdomyosarcoma. Also, if I remember correctly, the audience was something like 4,000 people, which is very nerve-wracking to have to face so many people. Although I must say that standing behind the podium, you're not aware that they're …

Dr. Sagerman: You're not aware of them at all and I must say in my own defense, the only relative I have in Chicago is my brother [laugh].

Question: Well, I know that your wife was there.

Dr. Sagerman: Well, that's beside the point.

Question: Oh, it's not beside the point. It's a very important point actually. Tell me about your activities in the American Radium Society.

Dr. Sagerman: Oh, goodness! You’re cooking up things up … I should have brought my CV.

Question: Well, we have it here. Right here.

Dr. Sagerman: We also did scientific presentations, chair sessions and selected people. I was in charge of the Janeway lectureship for several years. What else did I do for the Radium Society?

Question: I know that you've been on the program with scientific presentations.

Dr. Sagerman: Many times.

Question: I know that you've chaired sessions and you've chaired panel discussions, and I know that you've chaired the Janeway committee, which selected the individual. The Janeway lectureship has a gold medal, but I don't know that you ever gave a Janeway lectureship.

Dr. Sagerman: No.

Question: That's sad. That should be. You've also been a very loyal and a major supporter of that society. Let's go back and talk a little bit about your experiences on the Residency Review Committee as the representative from the American Medical Association because I remember when you came on the committee, it was a very difficult time relative to establishing the criteria for assessment of training programs. Ultimately when you became the chairman, you really were able to ensure that these would go forth in terms of where we are today in the judgment of these things.

Dr. Sagerman: A brief moment in charge in the sun where you can sometimes implement what you think is right.

Question: Yes, a very important position in which to be. My secretary used to tell me, if you're going to be anything, be the chairman or be the president. It's a lot less work, but you get done what you really want to have done. But you were critically important, I think, in the Residency Review Committee in the evolution of events.

Dr. Sagerman: It couldn't have been done without the wonderful people who served with me.

Question: Well, that's always the case. What other national kinds of organizations have you been involved with?

Dr. Sagerman: Well, in terms of organizations: the AMA, the NY State Radiological Society, the AUR and many others.

Question: National Cancer Institute committees.

Dr. Sagerman: Oh, I forgot all about that.

Question: I'm trying to cue you.

Dr. Sagerman: You are! You're doing an excellent job.

Question: It's quite a long list.

Dr. Sagerman: Yes, I know.

Question: We're on Page 18.

Dr. Sagerman: I've served on innumerable committees. My problem with them and one reason why I don't remember them particularly is that they always changed the initials every couple of years so I never knew what I was to be called. I chaired some of those, and we used to make site visits for NCI-approved cancer treatment centers. We wrote a number of position papers on what should be done.

Question: Did you serve on the Committee for Radiation Oncology Studies?

Dr. Sagerman: Yes.

Question: That is actually charged with the responsibility of developing white papers that set the standards for radiation oncology departments and research plans in radiation oncology, research plans in management and research and so forth.

Dr. Sagerman: And I did similar things in terms of being on committees but not necessarily chairing them in terms of what we could then contribute.

Question: The Children's Cancer Study Group.

Dr. Sagerman: I was, in fact, there when the decision was made that they would merge, and that's several years ago now.

Question: You served as editor for several journals. And also, you are the associate editor for the American Journal of Clinical Oncology for Radiation Oncology.

Dr. Sagerman: I haven't been editor for the European Journals, but I have certainly refereed papers.

Question: Also, I think, for the technologists journals.

Dr. Sagerman: Yes, absolutely.

Question: I guess, actually, we're coming fairly close to the end, and I'm saving one prime thing I want to talk about at the very end. But is there anything else you would like to have recorded from an historical point of view in which you think you have made important and significant contributions that we've not already covered?

Dr. Sagerman: I think I would acknowledge the many people who have had a major impact upon me in terms of directing the career in which I eventuated and maintaining a moral and ethical level of practice. Trying to improve the quality of the work that we do for our patient population, and those people include people I did end up getting to work with.

Question: Kaplan.

Dr. Sagerman: I can remember wonderful arguments with Fletcher when I was young and he would point his finger and say, "Sagerman, you're going to kill people!" This was the beginning of the total nodal irradiation—Inverted Y for Hodgkin’s disease. There are other wonderful stories I have. But then, certainly Charlie Botstein and Ed Segal and Jack Spira and Henry Kaplan and Malcolm Bagshaw and Sy Levitt and Phil Rubin and certainly any number of colleagues at several institutions, and you, Luther. As well as Odile Schweisguth, Maurice Tubiana, Alain Laugier, Michel Schlienger, all from my “French connection.”

Question: Oh, yes. Yes. Let me just close by asking you to tell us a little bit about the family. I know that you have four sons and one of them is a diagnostic radiologist. Perhaps you may elaborate on that a little bit more and the impact and support that you've gotten from your wife.

Dr. Sagerman: Well, the son, the firstborn, the Alaskan, is now a diagnostic radiologist in Philadelphia. The others are a marketing consultant, an architect and a federal judge. We now have five grandchildren—three girls and two boys. But most importantly, let me state that I owe so much, in so many ways to Malyne, without whom I would not be the person I am.

Question: That is true. She is the central most important person in your life.

Dr. Sagerman: Absolutely, as indicated by the dedication in the book.

Question: How absolutely true. You know, in closing, is there anything else you want to leave in your legacy on videotape?

Dr. Sagerman: I think we have to keep our heads high, and I think we have to continue to practice excellent medicine and take good care of our patients; talk to them so that they can understand what we are doing and they feel comfortable with what is being done to them and for them. And, if it is at all possible, to reopen the scope of our medical practice, which I fear cannot really be done as long as we are working with such a heavy workload. And I don't know whether the other changes in medicine where you now have to be credentialed for everything will ever allow that to happen again.

Question: You may very well be right.

Dr. Sagerman: Although I certainly can take care of many medical problems, if you have a heart attack, I want a cardiologist to take care of you. If you're in diabetic coma, I want your endocrinologist or internist to do this. You know, I would be second-class in those situations, and I would be happy to get the patient to you having recognized what was going on. So I think we need that kind of background in our training.

Question: One of the points that has been made in some of these interviews is the fact that you and I and Gus grew up in an incredible period of time when people like Simon Kramer, Bill Powers, Ted Phillips and Sam Hellman, etc., were all vying with one another about changing the practice and disagreeing with one another and having intense discussions about what is and what's not the best, but yet coming forth with a final decision that was for the good of oncology and radiation oncology. And that in itself, I think, is an incredible experience that I know you had, I had, Gus has had, in terms of our careers. And it's something that is so valuable and so precious that we really are truly lucky to have had it.

Dr. Sagerman: It's that camaraderie, that collegiality that made everything so exciting. I wouldn't change it for anything.

Question: I want to thank you again for being with us this afternoon at this session and for Dr. Montana who was very critically important, actually, in helping us try to pull out of you all of the things that you've done!

Dr. Sagerman: I appreciate your help.

Question: Thanks, Bob, very much.