But What Can I Do?


Leonard Zwelling

         Whether local or international, the news is grim.

         Members of the MD Anderson community have been repeatedly
greeted with more and more bad news mostly surrounding the behavior of its
leadership and now with the hard to grasp fact that MD Anderson is no longer
the number one place for cancer care, albeit by a whisker. That patient safety
should be the differentiator is even more unsettling given the immense effort
made in this area by the clinical care team. Frankly, I did not dissect the
details of the USNWR rankings, nor do I care to for MD Anderson is still
obviously a first-rate place for care. Far more troublesome is the sideshow
that this annual charade has become for it distracts one and all from the
important existential questions facing MD Anderson, medicine in general and
academic medicine in particular.

         What is the best strategy for a free-standing academic
cancer center to employ in order to compete in a marketplace where
cost-containment is king, quality is a nebulous quantity that may or may not be
rewarded by payers, and patient volumes and payer mix can mean financial life
or death?

         The private practice of medicine is disappearing giving way
to a corporate model where doctors are less and less important players in
making the key decisions affecting actual patient care.

         And academia is on the run as the NIH budget vanishes into
the sunset and drug companies call the research tunes.

         Besides going to law school, what can a member of the MD
Anderson faculty do to improve the lot of the institution, medicine, academics
and by osmosis, at least, her own well-being?

         There are two schools of thought of which I am aware.

         School One is known as the Lippman School, named after the
originator of its tenets, Marc Lippman, breast cancer researcher
extraordinaire, Chief of Medicine at several academic institutions and a friend
of long-standing (1975).

         Here are Marc’s Rules:

1. Outdo yourself and bite your tongue.

2. In bad times, there is no substitute for good work.

3. Don’t take it personally, it’s only business.

4. You have to eat a little sh—t, to get what you want.

I think that most of the MD Anderson faculty is using
the Lippman School of survivalism to get through their days.

School Two is the Zwelling approach and uniformly
results in turmoil, heartache and often job loss. It has one tenet only:

If you see something, say something.

Throughout my life, I have been the little boy along
the parade route pointing at the unclad king on the float and saying he was
naked. This is not good for one’s longevity in most complex systems where quiet
is preferred over justice.

I write this having finished an excellent article in
the NY Times Magazine Sunday, July 20 by Michael Sokolove about the former
president of Penn State, Graham Spanier who lost his job and perhaps will lose
his freedom over his behavior, or lack thereof, during the Joe Paterno-Jerry
Sandusky affair. Should he have known what was going on and should he have
intervened and does his absence of intervention constitute a crime? To be
determined, but it does emphasize the importance of the “not okayness” of
simply doing nothing and not getting involved. Biting your tongue can bite you

Many faculty members to whom I have spoken over the
past 3 years simply are unwilling to go any further in opposing the actions of
the leadership and in particular the embarrassing comportment of the President
of MD Anderson. Just leave me alone to do my research and see my patients and
collect my salary. I will follow the Lippman Rules and I will survive.

And I believe that they will.

It’s MD Anderson that might die, but given my track
record, I am not sure my tenet is the one to follow with regard to viable

In the larger world now, throughout the Middle East
and into Eastern Europe, major struggles are occurring with innocent people as
well as armed combatants dying every day. At each location, two (or at least
two) opposing groups believe that they are fighting an existential battle in
which they have no choice. They may be correct. The history and geography as
well as the politics of these areas create no easy solutions and neither side
in any of these conflicts is of the Lippman School.

I have no easy answers here either, whether it is
about conflicts in which I have a dog (Israel) or ones in which I do not (the
Ukraine). I do know that only individuals can solve the problems and it won’t
be the ones that will not get involved.

By comparison, the turmoil at Anderson is a nothing.
No shots fired yet. But the problem of intransigence is the same and at least
at Anderson it is largely on one side only. Perhaps that should give us all
hope. But the faculty cannot follow Lippman’s Rule #4 forever.

Or can it?

Leonard Zwelling