By David Larson, MD, PhD, FASTRO, and Ted Phillips, 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 conversation with Scotte Doggett, MD, FASTRO, David Larson, MD, PhD, FASTRO and Ted Phillips, MD, FASTRO, took place on January 30, 2004.
Question: Scotte, to start things off, could you tell us something about where you were born and something about your early education?
Dr. Doggett: I was born in San Diego on October 21, 1931. I went to grammar school in San Diego. At 6 months old, my mom entered a photograph of me in the San Diego Union Beautiful Baby contest. It won and was published—she was already attempting to get me into show business! At age 9, I began learning trumpet after a door to door salesman sold her a trumpet and music lessons. I worked very hard and soon was playing first chair in Bonham Brothers Marching band, which went to the Rose Parade annually.
Question: What did your dad do?
Dr. Doggett: He was a real estate salesman who came to San Diego from Florida in 1930, having lost his business there as a result of the depression. My mother was an RN who intended that I would be a doctor and a musician.
Question: What about your dad? What did he want?
Dr. Doggett: My father encouraged my mother to supervise my upbringing. I should emphasize that my mother's responsibility for raising children was particularly great as my sister, three years my senior, suffered significant symptoms of cerebral palsy. I did not know the details other than the real estate business was tough in San Diego, prompting dad's move to San Francisco where he established a favorable working relationship and two years later we joined him in San Francisco where I attended Lowell High School. Pursuing my music, I thought I was playing the trumpet well but wished to take trumpet lessons from somebody other than a trombone player, which had been the case to this point. I auditioned with Vic Kress, first chair, San Francisco Symphony. I failed my audition even though I was playing first chair in the Lowell band. The number two chair trumpet player eventually became Mr. Kress's replacement in the San Francisco Symphony, so I really was playing quite well by high school standards.
Dr. Larson: Now, this was in San Francisco at Lowell High School, which has always been one of the really top public high schools in the country.
Dr. Doggett: Yes, you are right; it has always been an unusual situation. It is a public school funded by the City, but you can take a test to qualify for enrollment regardless of where you live in the City. As long as a student can qualify academically, they can attend, though it is very competitive.
Dr. Larson: And it's got a long list of famous graduates, such as Supreme Court justices, governors, entertainers and other accomplished people.
Dr. Doggett: It is rather remarkable. The school began in 1856; the majority of students at Cal Berkeley in the first year came from Lowell. It is a distinguished high school, no question about it. However, I would like to finish the "trumpet thing." Mr. Kress indicated I had two options, either quit or start all over again. Being somewhat discouraged at this prospect, my “career as a banjo player" looked more promising. About this time my mom was saying "Why don't you audition for the Horace Heidt show?" Clearly, the doctor/showbiz thing was in her mind and she made it more complicated by urging me to play banjo, which I thought was foolish as I had just begun to play and knew only one song! This didn’t bother her. There were 200 people auditioning and Mr. Heidt’s front man thought the trumpet/banjo combination was "cute – let's stick with it." Their arranger, a very clever fellow, put together a very difficult trumpet solo (triple tonguing, rips, high notes, chord takeoffs, etc.) and then said "on the banjo, what you’re going to do is play it toward the end, smile a lot and jump up and down a lot, and then at the end jump up and twirl your banjo." He realized that he had a real problem with this nonbanjo-banjo player. When I finally auditioned for Mr. Heidt, his reaction was "Great! This is great!"
Question: Were you nervous in front of him, though?
Dr. Doggett: No, no—I'm never nervous. I performed at the San Francisco Civic Auditorium, 10,000 in the audience, performing live. I won the competition and subsequently went on the road with Mr. Heidt performing in his show. The next summer I played the El Capitan Theatre in Hollywood, staying at his Santa Monica home with his sons, Jack and Jerry, for two months. By that time I was playing the banjo a good bit better and Mr. Heidt indicated he would like me to stay with the show, tour the country and then on to Europe.
Question: And you're 17?
Dr. Doggett: Yes and by this time I have been accepted to Stanford. I have a very vivid recollection of what happened. I came home and was standing at the front door with my suitcase, banjo, and trumpet. I opened the door and mom says, "What are you doing here?" I said, "I'm home. I finished the Hollywood thing and I'm getting ready to go to Stanford." The door closes. So there I stood, not knowing what was going on. I should confess, I still don't know, but I think what happened there was an understanding between my mom and dad that they would not communicate with me at all about the Stanford versus the music thing. It was to be my decision, but I suspect mom did not trust that my father hadn’t influenced me.
Question: You think she didn't want you to go to Stanford?
Dr. Doggett: Right. She wanted me to stay with Mr. Heidt.
Question: But during that last year of high school, you were playing music, you were in high school and you were applying to Stanford and both parents knew all of this and during that period they weren't pushing you particularly in one way or the other, but they each had their own hopes in different directions?
Dr. Doggett: Well, you're actually being rather insightful. My dad had hopes, but I never knew what they were. I always knew what my mom wanted. Anyway, I'm standing out there for a number of minutes when my mother announces that she has Mr. Heidt on the telephone in Texas. "I think we've come to a decision and Dusty, (I was Dusty, that's what they called me, Dusty,) Dusty's going to be coming with you." I said, "No, No, I am going to Stanford."
Question: You had already made up your mind?
Dr. Doggett: Yes. In fairness, the real influence was my sister, Ruth, who was attending Stanford. She took me to a football game, and I was determined to be at Stanford. In retrospect, now after 50 years, I think I made a mistake, but...
Question: You think you should have stayed with the music?
Dr. Doggett: No. I should have stayed with Mr. Heidt, toured the country, gone to Europe and then gone to Stanford.
Question: So a year or two of doing that and seeing how that went and learning more about the world and so forth.
Dr. Doggett: Of course, but I should tell you I was satisfied that I was not an accomplished entertainer because while I was at the El Capitan Theater, we had lots of parties and I saw many people in Hollywood without work, very talented musicians, actors, vocalists, whatever. We would get together and they’d perform, and I thought, "My God, these guys are good! So much better than I am. If these are the people that I'd be competing with professionally, wow, I'm nowhere." I was very comfortable that the music was a fun thing but not what I wanted to make a living.
Question: So how during that phone call . . . you’ve got your mom and Horace and you're saying, 'Wait a second.' How did that play out?
Dr. Doggett: Oh, it was truly sad because that's when my mom really had to cave in. She had to tell Mr. Heidt I didn’t want to go with the show. I don't know what they said but that was the end of the conversation and she was clearly disappointed.
Question: Let me ask you something about your musicianship because others have said that you became, at some point, one of the best banjo players in the US.
Dr. Doggett: That may be a bit of an exaggeration; however, I was very good.
Question: Is that despite medical school and everything else?
Dr. Doggett: This was during my undergraduate years at Stanford. However, I continued to play, though not professionally, until around 12 years ago.
Question: To study what at Stanford, by the way?
Dr. Doggett: Biology (Premed). I had never taken banjo lessons, but I played well and my talent as a trumpeter went away because I wasn't practicing. I kept playing up and down El Camino Real in essentially all the bars, especially L’Omelette's. We (Bill Bowles, my fraternity brother, piano player, also premed) and I spent too much time at L’Ommy's. My grades in the undergraduate school were not as good as they should have been.
Question: Because of the banjo?
Dr. Doggett: Screwing off, in general.
Question: In general?
Dr. Doggett: Banjo, yell leading, ladies, fraternity activities, etc.
Question: Were you playing in the Stanford band also?
Dr. Doggett: No. I played trumpet the first year in the Stanford band and didn't enjoy that very much, so I decided to play just the banjo. Of interest, Dr. Wallace Sterling, president of the university, was a good rag piano player. He liked to play old stuff and so he and I would get together and have a good bit of fun. We played at my wedding reception. The night before the “big game” (Stanford versus Cal), the Board of Chancellors and Board of Trustees and deans from both schools would dine and be entertained at the Bohemian Club, San Francisco. An entertainer was chosen from each university – this time a superb violinist from Cal was to "play against a banjo player" selected by Dr. Sterling. The spirit of the evening very much favored the banjo player; however, there was bad news in store for him. I was a Stanford Yell Leader and my team subsequently lost the big game as well as a game against Ohio State played at the Rose Bowl. To make matters worse, I had applied to Stanford Medical School as a junior, despite my lousy grades, and had been turned down.
I was applying after three years, so I figured there would be another chance after the fourth year. But my disappointment was such that I went to see Dr. Chandler, dean of the medical school. I told him that I was terribly disappointed at having failed to get into medical school. He interrupted me at this point asking: "Aren't you the Bohemian Club banjo player?"
"Well, why don't we do this, why don't I make you the 28th alternate for admission to the medical school?" Sure enough, at least 27 applicants who had been accepted elected not to attend Stanford. So, I got into medical school basically based on my banjo playing (the fact that my piano player was dating the dean's daughter may have been a factor; he had been admitted to the medical school the year before.)
Question: At that time, the first two years or basic science was spent on the campus in Palo Alto and the clinical experience was achieved in San Francisco?
Dr. Doggett: Yes. There were a few things that were very uncomfortable for me; for example, my future wife's father, Dr. Rogers, Dr. Lefty Rogers, an Olympic Gold medalist, was on the Board of Chancellors of Stanford University, and he and I were never very close. Do you remember him?
Dr. Phillips: I knew him very well, yes.
Dr. Doggett: He was not at all anxious for Louise to marry me and had another preference for her. Nonetheless, I got into medical school and did very well. I was Alpha Omega Alpha and president of the senior class. When it came time to apply for internship, I was speaking with Dr. David Rytand, chairman of the department of medicine, asking what do you think I should do? He said, "What do you want to do?"
"I want to be an internist."
He then said, “I would advise that you be on the Harvard Service at the Boston City Hospital working with Charlie Davidson.”
So that's what I did and went to the Boston City Hospital and it was a great year.
Question: What was so great?
Dr. Doggett: I received some exceptional training in internal medicine. At the Boston City Hospital, Harvard had it set up so that the Medical Service ran the emergency room. Most everybody that came there was alcoholic with cirrhosis. Many had esophageal varices. A significant number of them had tuberculosis. All in all, this was a group of sick people requiring a great deal of care. And a little more music was part of my life, as training with me was a fellow intern named Rich Lee, who happened to be a fine piano player. We played well together and started going over to Cambridge to be with the somewhat rowdy Harvard undergraduate students.
Question: Was he a doctor?
Dr. Doggett: He was an intern with me, but there was a problem. He was a Mormon, a good Mormon—no beer. We were able to work that out. He even elected to date a Catholic girl. Things got a little wild. Eventually, he went back to being a good Mormon and became the Dean of the University of Utah School of Medicine. After completing my internship, I was called into the Air Force.
My personal life was a factor at this point in that Louise and I planned to marry after my internship, despite Lefty. After a spell at Gunter Air Force Base, where I learned to be a gentleman and officer, I was sent to Travis Air Force Base. This turned out to be significant in my professional life as we came to like the Sacramento Valley where I eventually would practice. We spent two years at TAFB where our daughter, Wendy, was born.
Question: Was the Travis experience rewarding?
Dr. Doggett: There was an interesting aspect in that. Although I knew I had epilepsy, it had not been a problem until Travis. Once again, I would cover the emergency room under stressful circumstances. The young men would go out onto Highway 80 and suffer terrible accidents. Of course, I had no surgical training and surgeons were not readily available. After a tough night in the emergency room, I frequently would experience seizures.
Question: How old were you when you knew you had epilepsy?
Dr. Doggett: I‘m not entirely sure, but I think I was around 23 or 24. It invariably related to long periods without sleep. At the end of my internship, this was of concern for me professionally. As I did not tolerate the late hours favorably, being an internist may prove to be a bad idea. This led me to consider radiology as a favorable compromise. Unfortunately, I was making the decision late but had the good fortune to know Dr. Harry Garland. Do you remember Dr. Garland?
Dr. Phillips: Oh, yes.
Dr. Doggett: In my judgment, he was an outstanding physician and individual who did a great service for me. I was in touch with him and he did essentially what Dr. Rytand had done three years previously. He made two telephone calls, one to the Massachusetts General Hospital and the other to Dr. John Evans, chairman at the New York Hospital-Cornell Medical Center Department of Radiology. Solely on the basis of Dr. Garland's calls, I was accepted to both programs but chose to go to Cornell as Dr. Evans contacted me first.
Question: How long were you in the military?
Dr. Doggett: Two years.
Question: So you were at Travis Air Force Base for two years and then you went to New York.
Dr. Doggett: Yes, I went to the New York-Cornell Medical Center to do a combined residency (diagnostic and therapeutic radiology as well as nuclear medicine). I had a few months rotation in each and decided that I did not enjoy diagnostic radiology. As before, it was my choice to be a clinician making radiation oncology the natural choice. I should emphasize the great good fortune that I have had throughout my training. In this instance, Dr. Evans was very sensitive to my desires and arranged for me to spend my next two years "across the street" at the Memorial Sloan-Kettering Cancer Center where Dr. James Nickson was chair. Dr. Ralph Phillips was to have been chairman; however, he contracted tuberculosis. After recovery, he returned as the director of pediatric radiation oncology. Dr. Phillips influenced my career to a great extent, but I also gained considerable experience in gynecologic oncology while training under Dr. Ulrich Henscke, also at SKMCC.
Question: Quimby was there then, right?
Dr. Doggett: No. Dr. Edith Quimby had gained the reputation as being an extremely difficult Board examiner in physics. One way to avoid being examined by Dr. Quimby was to train wherever she taught, which at this time, I believe, was Columbia. I mentioned before that Dr. Phillips contracted tuberculosis just before leaving England or just after arriving in New York. A sad coincidence was that soon after arriving in New York, my daughter, Wendy, became critically ill with a diagnosis of a posterior fossa tumor for which she was scheduled for surgery. A chest x-ray showed an infiltrate with subsequent lumbar puncture showing tuberculosis. No one at the New York Hospital was confident as how best to treat Wendy. Dr. Edith Lincoln, to whom I will always be grateful, became responsible for her care, traveling to see her from Bellevue Hospital each day. Though she survived the disease, she had considerable brain damage such that our lives centered around her for the rest of her life. After finishing the two years at SKMCC, I was most surprised when Dr. Phillips arranged an appointment for me to spend time with him in his office. He said, "Your experience here has not been optimal, and you are talented. I think you should train under a young radiation therapist by the name of Henry Kaplan at Stanford." I did not know of Dr. Kaplan but held Dr. Phillips' judgment in very high regard.
Question: How long were you there?
Dr. Doggett: Two years.
Question: So two years in Travis and then three years in New York.
Dr. Doggett: Yes, one year at Cornell in diagnostic and therapeutic radiology and nuclear medicine and two years in radiation therapy at SKMCC. Dr. Phillips was disappointed with the quality of my training experience there, but we all appreciate how strong the clinical and laboratory investigation and training have become at SKMCC.
Question: Was there board certification or anything at that time?
Dr. Doggett: Yes, I became Board certified in 1963.
Question: You got certified in general radiology and so technically you were trained, but practically not to the extent that you'd like to be.
Dr. Doggett: Yes.
Question: Did you take your Boards in general radiology or in radiation oncology?
Dr. Doggett: Combined Boards (diagnostic and therapeutic radiology and nuclear medicine). It is interesting; I have spent time preparing for this interview and found out that in addition to Stanford, I had applied to UCSF, University of Washington and Swedish Hospital. Dr. Kaplan said he would like for me to come and so on the basis of Dr. Phillips' recommendation, I knew that's what I would want to do under any circumstance. Jerry Hanks and I are proud that we trained under Dr. Kaplan together; however, Jerry arrived at Stanford one year or more before me.
Question: So you got to Stanford in 1962. Where had Jerry Hanks been?
Dr. Doggett: Jerry went to Washington State University and Washington University School of Medicine in St. Louis. He interned in medicine at Yale. I should say that you are touching on some sensitive stuff. Jerry will claim, accurately, that he was the first resident at Stanford in radiation oncology, and I'd say, "No you weren't, I was". Well I wasn't a resident; I was a fellow as I had completed my residency. And adding to the spirit of competition, not only was Jerry at Stanford a year prior to me, he had the honor that comes with being the first radiation oncology resident to train under a National Cancer Institute grant, more prestigious than my Advanced Clinical Fellowship funded by the American Cancer Society, though I would not admit it. This competition was the start of a wonderful professional and personal relationship, which persists till this day!
Question: When you went to Stanford, were you the only fellow who came that year?
Dr. Doggett: Yes.
Question: And who came as a resident at that time beside Jerry?
Dr. Doggett: No one. Jerry was the first, to be joined by myself, a fellow, the following year.
Question: How did the fellowship progress?
Dr. Doggett: Very well. The training experience with Drs. Kaplan and Bagshaw was extraordinary. As I had been led to believe and as I look back, it was remarkable how these two men could combine the science of radiation therapy with a keen clinical insight. Jerry and I came to appreciate this very much and attempted to pass it on to residents who we would eventually train. After completion of my fellowship, I was invited to join the faculty.
There was a situation developing in which Dr. Kaplan felt compelled to respond to, i.e., the well-funded NCI prospectus, Regional Medical Program, which was basically intended to extend optimal cancer patient care (surgical, radio-therapeutic, medical oncologic) from major cancer centers to peripheral communities. Of course, this would require preparing lectures and spending a great deal of time away from the department. Dr. Kaplan asked me to become involved with a surgical and medical oncologist, both of whom I knew well and respected. Though I was honored, Jerry said, "Don't do it! Don't do it! It's not a good thing. It will screw you up relative to your training and tenure!" In retrospect, I think he was right because I spent a great deal of time traveling around and getting a feel for what was going on throughout the area and what the needs were in cancer delivery systems and offering some assistance. But that wasn't really helping me a whole lot in becoming a fine radiation oncologist and an associate professor, though it may have provided me insight relative to the type of radiation therapy that I would be practicing most of my professional life. At the end of five years at Stanford, it became clear that I had to make the decision as to what I should do professionally. Radiological Associates of Sacramento (RAS) had offered me a job. They had a 1 million volt GE and two major cobalt units. I asked them to commit to installing a linear accelerator. After two months, I visited the department. It was an absolute mess as the 4 MV linear accelerator was being installed.
Question: So part of the reason they got the linear accelerator was because they knew you knew something about it, more than they did and that was, for them, a plus?
Dr. Doggett: Certainly. It would be the only linear accelerator in the Valley and I was coming from Stanford, the "birthplace" of linear accelerators (no one knew of Hammersmith). I failed to mention something that was of interest. When I was in medical school, during a summer, I went to the Hammersmith Hospital in London to do a medical rotation and had an unusual experience. I did not appreciate that in the building next door to the hospital, they were developing the first medical linear accelerator to be used in the world; Stanford was second.
Question: Did that influence you later in any way?
Dr. Doggett: No. I didn't have any idea what was going on in the building next door! I didn't even walk over to look. I just found out about this a few years later. What a shame.
Question: Who would you say played the major roles in your overall training?
Dr. Doggett: I failed to mention my mentors at Harvard, who were giants in medicine. They were Drs. William Castle, Max Finland and Charles Davidson. I have already made reference to Drs. David Rytand (Stanford), Victor Richards (Stanford), Harry Garland (San Francisco), John Evans (Cornell), Ralph Phillips (SKMCC), Henry Kaplan and Malcolm Bagshaw (Stanford).
Question: You were in charge of the residency training program at Stanford, I think. Which radiation oncologists do you feel benefited from your training?
Dr. Doggett: I was an instructor and assistant professor at Stanford radiation oncology from 1964-1969 during which time I participated in training Sarah Donaldson, John Earle, Tony Engelbrecht, Karen Fu, Bob Stewart, Eli Glatstein, Saul Silverman and others whose names I can't recall unfortunately.
Question: When you were at Stanford, I think you worked on the esophagus study, didn't you? And the head and neck sensitizer study?
Dr. Doggett: I didn't think you were going to bring that up.
Question: You don't want to talk about it?
Dr. Doggett: Do I have an option? What Ted's pointing out is that the two institutions, Stanford and UCSF, were working together, comparing clinical investigative efforts, etc. I remember on one occasion, I went to UCSF and presented our experience with high-dose preoperative radiation therapy of patients with thoracic esophageal cancer who had been surgically staged, biopsies of infradiaphragmatic and mediastinal lymph nodes would determine target volume, only liver metastases would exclude patients. This was a flawed study. The dramatic finding was the 50 percent incidence of subclinical subdiaphragmatic metastatic tumor. To me, this was a significant clinical investigative finding, but the therapeutic results were unfavorable. One of 42 patients survived five years.
Dr. Philips: That was the surgeons' fault. They were all dying of post-op pulmonary complications as I remember.
Dr. Doggett: Oh, you're being very kind, Ted. We were having local failures and, no, it was a very bad study for two reasons. One, it failed but the second thing, it was published without emphasis on the fact that esophageal carcinoma patients we thought to be T1, T 2 and T3 N0 lesions were in fact pathologically proven subdiaphragmatic node positive or stage IV 50 percent of the time. I have never seen this data in the literature. At this point in time, based on significant radiobiological data, Drs. Kaplan and Bagshaw made a decision to investigate radiation sensitizers. So Dr. Bagshaw and I became very much involved in radiation sensitization of advanced head and neck cancer. We had received a major NCI grant that allowed us to have 14 beds and to cover surgical costs for placing arterial catheters to infuse methotrexate and 5-bromo-2'-deoxyuridine (BUdR). I particularly enjoyed being on the infusion unit, being responsible for the methotrexate intra-arterial infusion which was used to increase BUdR incorporation. There was no question that there was significant increase in both tumor and normal tissue radiation sensitivity. Tumor tissue biopsy revealed 5 percent BUdR incorporation, the same as seen in animal models. Unfortunately, no definite increase in tumor radiation sensitivitywas demonstrated. There was a dramatic increase in normal tissue radiation sensitivity.
Question: How was the Sacramento program involved?
Dr. Doggett: The linear accelerator was being installed and the technical staff proved to be excellent there.
Queston: Which hospital was this?
Dr. Doggett: Sutter General Hospital was an old facility with limited radiotherapy capability. After the first year, the practice began to grow significantly, such that I was not able to cover the service by myself adequately and Dr. Ripple, who was director on my arrival, had elected to discontinue radiation therapy in favor of Nuclear Medicine. It was at this time that I was in touch with Jerry Hanks who had left Stanford to chair the department of radiation oncology at the University of North Carolina. I told him that the department is becoming strong, with a large number of patients, and that I needed his help. "Would you join me?" And he did. The practice continued to expand with persisting inadequate space. There was a chiropractor's office next door, not in use. We extended our lease and did a remodel to provide space for patient evaluation and treatment simulation. The history of this spot was of interest in that it had been a house of prostitution with an illegal bar (time of prohibition). When the place was raided, there apparently was a lever that could be pulled so that the booze would go down into the basement. Dr. Ripple was in the habit of going down into the basement and locating these very old bottles (great interest in the bottle, not the contents thereof). Anyway, I thought it was going to be great as we were about to build this facility in an old whorehouse. My friends at Stanford and UCSF would have loved this. But this did not come to pass. The Sutter directors had decided that the old Sutter Hospital was indeed too old and needed to be replaced. The decision was to move everything out to Sutter Memorial Hospital (a primarily OB/GYN and pediatric facility) and build a new radiation therapy department, and so they did. Radiologic Associates purchased an 18 MeV and two 6 MV linear accelerators. There were two simulators, six to eight doctors’ offices, conference rooms, physics/dosimetry section, etc. As I recall there was approximately square 12,000 ft. It was quite a step up from the previous location; however, there were problems. The neighbors just did not like the big hole and heavy construction. After long conversations, which eventually extended to the Sacramento City Council, the decision to move Sutter General to Sutter Memorial was scrapped, leaving radiation therapy by itself attached to an OB/GYN/pediatric hospital. Sutter elected to build a new hospital with an expanded radiation therapy section within a five-story cancer center eventually. Predictably, the practice continued to grow. We acquired the Mercy Hospital radiation therapy practice including two physicians and an upgrade of equipment. During my tenure in this practice, it grew from one (myself) to 15-16 radiation oncologists. Not only was there a growth in the staff of our practice, it also extended to six facilities in the greater Sacramento area and beyond. I should say right up front, one of the things that attracted me to Radiologic Associates was the favorable relationship the group had with Sutter hospitals.
Question: What was your relationship with UC Davis (UCD)?
Dr. Doggett: Jim Goodnight, surgical oncologist, UCD, whom you both know well, and I thought it would be appropriate if UC Davis was to work with Sutter and develop a UC Davis/Sutter Cancer Center. Jim was able to get the university to back the idea, and I thought I had Sutter on board as well. We went so far as to invite Dr. Vince DeVita, director, National Cancer Institute, to a medical society meeting to announce the cooperative adventure. At the last moment, the Sutter surgeons said "No, we will not take part."
Dr. Doggett: I think they were afraid of the university, and I think I was the guy that goofed. At least that's what the surgeons tell me. They say they were not in on the planning. Looking back at the meetings that took place, they had the opportunity to be involved, but they just did not take part. I went out to meet Dr. DeVita at the airport and told him that we have a problem. He said he knows what it is, I've been here before, your efforts to bring the community hospital and the university together have failed as occurs in more than half of the cases. Don't be worried, it's a nice trip and I'll enjoy myself, and do appreciate I came with two speeches. In fact, he carried it off quite smoothly, but it was a great disappointment for Jim and me. The other university/radiation oncology center interaction was with the proposed proton facility.
Question: First, did you have interactions with Dr. Rick Raventos?
Dr. Doggett: Yes. Rick was the chairman of the division of radiation therapy at UCD, though the university did not at that time have a radiation facility. Patients were seen by one of my colleagues, Dr. David Deer, at the UC Davis Medical Center as Rick was not much involved in patient management. David would basically do all of the clinical stuff and so it was a ROC doctor at the university providing consultations for patients who would then be treated at Sutter. We also had a relationship with the Air Force such that we were responsible for training residents at the Air Force University in radiation therapy as the radiation therapy phase of the general residency program. Rick provided us the academic credibility to do this. In fact, we trained two straight radiation therapists over a three-year interval. The program went away when Rick started his full-time clinical affiliation at the university. After this, we were primarily involved in training radiation therapy technologists.
Question: Give us a word or two about that training for all of the technologists.
Dr. Doggett: One of the things that I've always been very concerned about is the importance of the radiation therapist in our provision of care. And so I got our corporation to commit to paying extra staff to support a technologist training program. Our senior therapist, Connie Johnson, became the director of the school.
Question: In what year? When did the school start? And how many people did you train, roughly?
Dr. Doggett: I'm guessing 1978. We were training eight to 10 technologists a year in our two-year program. This was discontinued in about 1993. The American Registry of Radiologic Technologists began to discuss requiring a bachelor’s degree for therapists to become certified. We could not commit to a four-year program, which would have to have been affiliated with Sacramento State University, so we discontinued technologist training early 1993. The school was a good program of which I was proud. Many of the therapists went to UCSF and to Stanford where one became chief therapist and another the administrative director at Swedish.
Question: You were going to say something about the proton thing.
Dr. Doggett: Well, Ted Phillips made efforts to get a proton program in San Francisco. As I recall, you didn't get the dean's financial support prompting you to come to Davis.
Dr. Philips: That was the proton facility. When the dean said no we decided we would try to establish proton support in Sacramento. And I think we approached the ROC to see if they would join in.
Dr. Doggett: I don't recall there having been a close communication between UCSF and the ROC in the evolution of this program, though I recall there was concern among my colleagues about how this thing was going to develop. But the way everything works in this kind of business, it was political and the politics was in Boston with Kennedy and so forth. And nobody got funding for the proton unit/facility other than Herman Suit at the Massachusetts General Hospital. It was at this time that I elected to retire, leaving the group in 1993. At this time, you both will recall, UCSF had been sending faculty up to Sacramento to run the Davis radiation therapy facility as they had not been able to recruit a full-time person after Rick's retirement. I believe Ted was designated chair and he and his faculty were traveling from San Francisco to Sacramento.
Dr. Larson: for a few years, temporarily. It was wonderful.
Dr. Doggett: Jim Goodnight, at this point in time (1994), asked if I would be the acting director and clinical professor of the radiation therapy division, and I think at that point in time you both were of the mind that this was a good idea. Of interest, with the passage of time, it may be that you were more enthusiastic about this than my colleagues, although they did not speak to me to express concern. So, in 1994, I became – are you ready? – a professor of surgery. I know everybody sitting around here has big smiles as we all had been professors of surgery at UCD School of Medicine, as radiation therapy was a division in the department of surgery. So, to be on the staff, you were a surgeon in radiation therapy. That appointment lasted for two years, as by 1995 I had been able to achieve departmental status. My other responsibility was to find a permanent chair for the department, which I was able to do by recruiting Dr. John Earle, who I trained at Stanford and was at that time chairman of radiation oncology at the Mayo Clinic. I returned to my old group, RAS, practicing at the Auburn and Roseville facilities until December 1999, at which time my oldest daughter, Wendy, was killed in an accident. After taking two weeks off, I came back to see my first patient, who had cancer of the rectum that had been incompletely resected. I did a routine pelvic examination with the daughter and my nurse in attendance. Soon after, the daughter accused me of committing sexual harassment performing the exam on her mother and initiated efforts to take away my license. We went through all of the things you might predict, three consultants who agreed there was residual cancer and that it was appropriate to carry out pelvic examination, a normal and proper phase of the consultation. But the family continued to pursue this, and I was being told that my license was at risk. My defense went on for a number of months and while it eventually concluded in my favor, it convinced me that I should no longer continue in medicine. It took the heart out of me. I stopped practicing altogether at the end of 1999. Since that time I have pursued some personal interests and enjoyed my wife’s company, though she is a radiation therapist and, after being recruited away from my group by UCD, was very much involved in setting up the department at UC Davis. More recently, our good friend Dr. Phillips thought, "Wouldn't it be good if Catherine were to assist me caring for patients at the Crocker Laboratory treating orbital melanomas with protons?" Catherine replied appropriately that this would be exciting and joined the UCSF program developed by Drs. Joe Castro and Ted Phillips which she has participated in for, I don't know Ted, for a couple of years?
Dr. Philips: Three.
Dr. Doggett: Three years. She has told me that she will be retiring soon to become a full-time housewife! Actually, I think she realizes I need supervision and plans to take that as her next vocation.
Question: What professional affiliations and activities do you feel allowed you to have the most influence and satisfaction?
Dr. Doggett: I have a long list of responsibilities that I held with ASTRO, the American College of Radiology, the American College of Surgeons and the American Radium Society. Of interest, my experience with the Regional Medical Programs (RMP) while at Stanford led me to develop the Northern California Radiation Oncology Society (NCROS), which was copied in Southern California and subsequently the two were brought together as the California Radiation Oncology Society (CROS).
Question: Let me ask you a question, and this is the last question. You've got 40-some years of radiation oncology experience, treated probably thousands and thousands of patients, so say something about how technology has changed during that period and what that has meant in terms of your practice.
Dr. Doggett: I tried to address this question when I was requested to review a document (SCOPE) written by ASTRO sub-committees addressing the future course of radiation therapy over the next 10-20 years. It led me to contemplate what radiation oncologists have been doing versus what they should be doing. Surely the dramatic occurrence during this interval has been the design and modification of linear accelerators. When I came to Sacramento, we had a 1000 volt GE unit, two Cobalt units, and a 220 KV and a 120 KV ortho-voltage machines. We soon replaced the 1000 voltwith a 4 MV accelerator. Subsequently, we replaced those with a Clinac 18 and two 6 MV accelerators. We installed 6 MV units with simulating equipment in our other facilities. Relative to our practice, the major change in addition to upgraded treatment and treatment planning equipment was the sheer growth of the practice to serve the growth of Sacramento and reach more outlying communities. We were ahead of the times in this strategy.My reflections of what has taken place during my practice has led me to contemplate the significance of the fact that 85 percent of cancer patients receive radiation therapy in the community and leave me to question how are we in the community doing technologically. Well, I believe without doubt that we are not doing as well as you are in the university. I would say my own group is doing very well but as an aberration. It doesn't really answer the question as to how well radiation therapy is being done throughout the country. I have concerns that we are trying to do it possibly too well. For example, Jerry Hanks, my very close friend, was president of ASTRO while at the ROC. He left our group after 15 years to chair the radiation therapy departments at the University of Pennsylvania and subsequently at the Fox Chase Cancer Center. He was of the impression that 80 Gy would cure more patients with prostate cancer than 70 Gy. He and his colleagues at Fox Chase and RTOG designed a clinical investigation to answer this question. Though I do not know the results of the study, I would anticipate that the larger dose will be more effective. At this time, however, the cost/benefit ratio becomes important. The cost of giving this therapy is very great and I don't know that our medical delivery system can afford it. I have seen our specialty evolve to the point that it is becoming compromised in that it cannot be used in the community, where most patients are treated. I think my practice is one of the few in which we can use this fancy stuff as we can afford to have the physicists, dosimetrists, commitment to clinical investigation, image modulated radiation therapy (IMRT), image guided radiation therapy (IGRT), stereotactic radiation therapy, etc. It would seem the logical thing to do nationally in the long run would be to refer all of the curable patients to the university because the physicians there are exceptional, the technology is the best, and they are committed to training and research, but, bottom line, there is not enough "university capacity" to treat them all. So there will have to be some way that we can come to an understanding as to how patients should be sorted out, and I can't answer that question. It will become a big issue of medical economics.
Question: Let me follow up along that line, Scotte. What you did here in Sacramento was to create a university department in sort of sheep's clothing. It masqueraded as a community private practice but it really was at the university quality level, quantity, size and everything else. And isn't that the best way to practice radiation oncology in the community as a larger group with more expertise and more equipment?
Dr. Doggett: Yes, surely. Now having said that, how did my group get to where we are: first, we are a monopoly. The first thing that Jerry and I did was to acquire the other group so there would be no competition. Our corporation, comprised primarily of diagnostic radiologists, had a long-standing relationship with Sutter Hospital so that we weren't competing with the hospital. The therapy division was in the favorable position of negotiating basically a new rent relationship every two to three years while we convinced our diagnostic partners to buy the facilities and equipment and pay the staff what we thought to be appropriate. We were able to recruit good doctors who understood there was to be a commitment to doing clinical investigation, primarily with RTOG. Intra-operative radiation therapy (IORT) has not been described as a breakthrough; on the other hand, we did introduce it to the West Coast and RTOG. I thought it was exciting to bring the surgeon and the radiation oncologist together in clinical investigation. And as you know, we have worked very closely with the medical oncologists in protocols that relate to RTOG and so, in a way, we're not really doing what the universities are doing, e.g., "niche" laboratory and clinical research, we are doing what the universities and other major clinical investigative groups are doing: we are cooperating with them, helping to design protocols, accessing patients and gathering treatment results. This has brought about incentive for us to provide optimal care. But, I do not know how much of this is taking place throughout the country.
Question: Let me ask one more question, and that is you've observed ASTRO grow from a small club to a large organization where the Annual Meeting attracts 10,000 registrants and now we have major initiatives in education, research, socioeconomics and governmental affairs. Is this going in the right direction from your standpoint? Is it getting too large or is ASTRO serving its members well or not?
Dr. Doggett: Well, I made reference to Scope, an effort by ASTRO to design guidelines for where the leaders of our profession believe radiotherapy should go over the next ten years, and I was critical of the document. I don't know whether anybody read my critique, but I think overall there's no question but ASTRO is serving its membership well. The flip side is does the membership appreciate what ASTRO is doing? For example, a couple of years ago I attended an ASTRO meeting at which David Larson appealed to the membership to allow for a dues increase. I thought that was pathetic, knowing how much radiation oncologists are being paid, for you to have to say, "We need the money to support what we're doing, to support you in what you're doing," and they said NO! This led you to write an article in the ASTRO journal literally apologizing for failing to keep the membership appraised of the work its elected leaders are doing.
Now, I guess the other question is, “Well, wait a second….Where is the college? Where does the American College of Radiology fit into this?” I do have a concern about this in that as you look about the evolution of radiation oncology, it would seem to me that the key to so many things that we're doing relates to imaging. We are utilizing more sophisticated simulation techniques as we utilize IMRT and IGRT to deliver higher doses to smaller volumes, which seems reasonable though not proven to be cost effective. We have excluded the imagers from our specialty to a great extent. Though I am a board certified diagnostic radiologist, I lack the skill and experience of my diagnostic colleagues. We are not going to suggest for a moment that we're very good at it, but at least we can say we've had training. I think with all of the new techniques that are developing now, it's inappropriate to expect our residents to get enough training in radiography to be able to take full advantage of the technology that is evolving without greater cooperation with the diagnostic radiologists. Within my own group within which a large group of diagnostic radiologists (40) are practicing with a large group of radiation oncologists (16), this relationship is as it is elsewhere. We order studies from them just like everybody else does, request the films, eventually get a report but continue to try to interpret the films ourselves for planning purposes. At the end of my practicing, I would arrange for a diagnostic colleague to come over to simulation for difficult cases and say, "Here's the problem. Here are the radiographs. I want you to help me define this tumor volume."
And, I should say, they were very cooperative, very helpful when asked. I think the reason that we're not getting that help, cooperation and collegiality is not because of the diagnostic guys; it's because of us. We're not taking advantage of their skills and we should.
Question: If you look back on your career which started out with a decision between music and medicine, what about that decision in retrospect?
Dr. Doggett: Unquestionably, I made the right decision to go into medicine. Not because I was a lousy musician as pointed out to me by this dreadful but honest chair of the San Francisco Symphony, but because I loved my patients and what I was able to do for them as a result of my training and experience. But the disappointment is now, in my retirement, I'm trying to play the trumpet because neurologic problems will not allow me to play my banjo. I'm not playing it well and of course, regret that I didn't play more when I was younger. I can’t complain, though, as I had the best of both worlds.
Dr. Larson and Dr. Phillips: Thanks, Scotte. It's been a pleasure.