Editor’s note: This is a longer version than what appears in the December issue.
Mark Green: You’ve lived, trained and worked a variety of places. What attracted you to the dean’s job at the University of Kentucky College of Medicine?
Dr. Robert DiPaola: I finished medical school at the University of Utah, and went to Duke University Medical Center for my internal medicine residency and internship. My background is in oncology, and I did a fellowship in hematology-oncology at the University of Pennsylvania Hospital in Philadelphia. Following that, I went to New Jersey; I was at the Rutgers University system about 24 years. I participated in growing an NCI-designated comprehensive cancer center, and I was its director. I also served as a vice chancellor of cancer programs that ran throughout Rutgers University.
In spending my career looking at one important aspect of healthcare, specifically prevention and treatment of cancer, I always felt very passionate about looking at the community and figuring out ways to help with its well-being. In the Northeast we really had a focus on that: What were the needs of the community? Where were healthcare disparities that we could help improve leveraging the strengths we have in a large, academic organization? Those strengths usually came in the form of research and discoveries that could be applied to the patients, as well as education and excellent, exceptional clinical care.
When I saw this position, what’s here is a remarkable, incredibly exceptional academic medical center with all those components: research, and education, and exceptional clinical care, and growth of its capabilities to serve the community and the commonwealth of Kentucky. With those strengths there is the opportunity to really serve a community in need. In Kentucky, we’re ranked number one in cancer mortality, we’re ranked within the top 10 or 15 in diabetes, stroke, cardiovascular disease, et cetera. There’s addiction and many other needs. A lot of it relates to the need for access to care and bringing the best care to various communities. Between those two pieces, understanding the importance of an academic medical center’s strengths – research, education and clinical care at its highest levels – and the fact that the community here is in great need, I felt I could be really passionate about leveraging our strengths here to solve those challenges for the community in Kentucky.
MG: What aspects of your previous career most played into preparing you up to take on the role of dean at UK?
RD: When you look at taking an area of healthcare to its highest level, one of the models is the nation’s NCI-designated comprehensive cancer center model. The National Cancer Institute within the National Institutes of Health, or NIH, designates and supports cancer centers around the country when they achieve extraordinary excellence in bringing together, in an active transdisciplinary way, the strengths of research to clinical care. Some of the biggest are MD Anderson (Cancer Center in Houston) and Memorial Sloan Kettering (Cancer Center in New York City), but it’s all the same model of bringing together strengths and expertise and research to do the best in terms of clinical care. That model and being a leader in that realm of trying to grow and recruit for great research strength will make it grow for a purpose: to have impact in the clinic. The experience of being a cancer center leader is very important.
As a cancer center director, I served on committees and participated in site visits to designate cancer centers. For the last couple of years, I have served as chair of the parent committee for NCI to review other cancer centers. I’ve been going around the country chairing site visits to designate the cancer centers, including the largest ones. I’ve seen what’s best in class around the country that we could bring here as models.
I have a background in cancer research; my particular area was in prostate cancer. I’ve done everything from laboratory research to large clinical trials, including national clinical trials that have led to changes in the standard of care. I’ve served as chair of the Eastern Cooperative Oncology Group, one of the national committees that generate large clinical trials that lead to changes in care. One of their trials published in the New England Journal of Medicine a couple of years ago changed the standard of care for treatment in advanced prostate cancers. I see the ability to take science and change the standard of care; that has impact not on a single patient in the clinic but has impact nationally, has impact globally.
Putting those experiences together led me to think about opportunities to leverage strengths and impact patient care. Here, we launched the Multidisciplinary Value Program to get at the concept of how to help an academic medical center with great strengths leverage them to help with great needs in clinical care and do this rapidly. If there’s a discovery in a laboratory, it could take 10 years before it gets into the clinic. We’ve worked out a way with the MVP to do this much more rapidly. With specific criteria, we form teams where the strongest scientists team up with the strongest clinicians, and if they can solve a problem – get the science to the clinic in the form of a clinical trial today – they can apply and we support them with funding to get their idea launched. This past year we got 30-plus applications in two rounds, and we awarded nine teams. Each now is taking an area of discovery from the UK College of Medicine and getting it to patients today.
One example is the science on stroke research in a laboratory here under Dr. Gregory J. Bix (M.D., Ph.D). Dr. Bix has grant funding; he’s a superstar in the laboratory. What he thinks about day and night is, how do you improve care for stroke, which is a real clinical care problem in Kentucky as well as elsewhere? He found recovery can happen faster where there’s a big stroke in a large vessel if at the same time you put a catheter in and remove the stroke – the clot – to re-perfuse the brain (restore circulation) you instill compounds to get the vessels to open up a little more. You’ve got to do that rapidly. He found if you infuse simple magnesium and verapamil, which is a cardiovascular drug (for high blood pressure, severe angina and arrhythmia), at the same time you remove this large clot, you’re able to get better brain recovery.
He partnered with a neurosurgeon, Dr. Justin Fraser, who does the clinical procedure to put a catheter in to remove the clot. We awarded them an MVP team. The two of them created a clinical trial. Patients coming in today now have an option of not only getting the treatment that might the best standard of care, bringing in a catheter to remove the clot, but at the same time infusing these agents. It gives a patient an option for something that wouldn’t have been available before. They did this all within a year.
And it’s now eight times that, eight additional MVP teams. Another team came up with a cancer drug for colorectal cancer. There’s another team in addiction medicine. There’s one team looking at a better, more effective way to treat patients who have addiction and who get admitted to the hospital because of a complication, reduce the chance that they’ll go back and get addicted again.
This is taking the strengths of a great academic institution and bringing it to impact the needs of Kentucky rapidly. It’s that transdisciplinary approach – the approach model that a great cancer center might have, that a great stroke center might have, that a great aging center might have. Those are strengths we have here. What excites me most is being able to leverage what we have that’s unique in a center like this.
MG: If an MVP team’s idea is fulfilled and works, does it propagate out to everybody else?
RD: Absolutely. You might look at an MVP team as having an opportunity to conduct a clinical trial, publish the results, and now it becomes even more broad than just an opportunity for patients in Kentucky. They apply for federal grants, go to podium sessions nationally to broadcast what they’re doing here and the results. That’s how you lead to new standards of care and national impact for us.
Of the nine MVP teams, six have put in for federal grant funding; four have been awarded funding. We supply some money, which is small in comparison to what gets amplified (by grants). We’ve created an infrastructure to take what we do here as academic business and put it together with the need on the clinical end.
Something like this was launched in the past that they called IMPACT teams; that stood for Institutional Multidisciplinary Paradigm to Accelerate Collaboration and Translation. We decided we would do it better; and it also has a bit of an athletic theme since everybody “gets” MVP. Same concept, though: bringing people together.
MG: How do UK College of Medicine facilities compare to peer institutions?
RD: We do very well in terms of facilities in key areas. Our new medical center hospital facility is incredible; not much beats that. We also do very well on the research; the new ($265 million) Research Building 2 slated to open midyear 2018 will be state-of-the-art. It’ll allow for additional recruitment of more superstars like Dr. Bix, more strength to do more of what I just described. We’re always looking to upgrade and build in terms of next steps for the education end, but our facilities compare incredibly well. The university leadership and our president have had the vision and foresight to see those needs as we grow on the research end, and on the clinical end, and the foresight to see the needs of building a large health system to serve the public.
MG: Does the design of RB2 implement collaboration with the clinical side?
RD: It does. If we leverage what we do well in an academic medical center, we’re going to leverage that research piece with the clinical piece, so that new building is going to be very important. It’s meant to be very transdisciplinary or interdisciplinary, to bring people together. (Among its many features, collaborative research space includes: six floors of wet laboratory space with 96 benches clustered into 6-bench neighborhoods; four floors with 234 offices for researches within the connector building linking RB2 to the Biological Biomedical Research Building that is called the Appalachian Translational Trail; full modern vivarium for animal work in the basement; shared use core imaging, behavioral and metabolic facilities with cutting-edge equipment.)
MG: What is the breakdown between in-state and out-of-state students among the 547 enrolled in the College of Medicine?
RD: In the freshman class there’s about 20 percent out-of-state versus 80 percent in-state. Overall, about 75 percent are in-state students. But the other concept that is important is we have these College of Medicine expansion site campuses. One of the goals here is serving Kentucky; we don’t have enough healthcare workers and physicians. The two expansion campus sites we’re developing are in Bowling Green and in Northern Kentucky. We already have some students in Morehead; there is discussion of hopefully expanding that as well. But the first full expansion campus that will come online is in Bowling Green. We’re enrolling students now, and the first class will be next year. That would add, on top of the number you see here, approximately 30 new students coming in each year. So an additional 120 for the whole expansion sites class once we get through four years.
In terms of the campus expansions, we start asking the questions, from the standpoint of in-state/out-of-state, who is likely to come back to Kentucky to serve in Kentucky. With our current campus, about 25 percent will stay and do their residency here. Most go out and do residency, but a good percentage come back. If you ask what overall percentage of those we train come back to Kentucky, it’s somewhere between 45 percent and 50 percent. So about half will end up coming back, helping Kentucky. When we thought about the campus expansions, we believe there will be a higher percentage coming back because more applicants seem to be from local regions in Kentucky. But it’s already a significant percentage.
MG: Is the shortage of doctors in the U.S. and Kentucky largely in the rural areas, while urban areas are adequately served?
RD: The biggest shortage is the need for more primary care physicians that serve rural regions. But we also have additional need, in hub areas like Lexington where many patients come for care such as organ transplant, for physicians to handle needs of high-specialty areas. But if you look at the statistics, the majority of need is in primary care in more rural regions, and for patients who need specialty care to have access to it from a distance. We want to try to serve the public as best we can in their communities.
MG: Is the college able to influence what type of specialties and practices students go into?
RD: We don’t force an excited student applicant to go in one direction or another. We provide an exposure in terms of where the future of medicine is going, an understanding of where the needs are. The students are smart. So they look at where the needs are. They come in very passionate to serve communities, and they seek out experiences that relate to that. Many of them do come back and serve in Kentucky. We have opportunities for residency throughout the state. The Rural Physician Leadership program in Morehead, which is for that third- and fourth-year student, is also another opportunity for students who are just very dedicated to serving those rural communities.
MG: Is there a link between the new satellite campuses and the previously existing Rural Physician Leadership Program that the College of Medicine has with Morehead State University and regional providers in that area?
RD: These satellite campuses are opportunities where we have very strong partners. To set up any campus in this state, especially at a distance from Lexington, we need both an academic partner and a clinical health system or medical center partner. It means understanding the state and where we could get partnerships like that, and then doing it in a sequential manner.
We’ve certainly had an effective partnership with The Medical Center at Bowling Green and then Western Kentucky University. We look at it as an opportunity to offer something that will help their academics overall, because now they’ll have a medical school campus. Their students, including those at Gatton Academy, which is incredible, will have opportunities to interact and to grow and maybe even do research projects. All of those things came into play: effective partners and a situation where we could grow a campus with excellence. It is the same thing with Northern Kentucky University and St. Elizabeth Healthcare.
In Morehead, we’ve had a great partnership already, with St. Claire Regional Medical Center in Morehead, in terms of the Rural Physician Leadership Program (10 UK medical students per year can do third- and fourth-year studies in Morehead with MSU, St. Claire and area hospitals and clinics). And there is discussion in terms of opportunities to also grow that in time.
MG: How much interaction is there between the College of Medicine and Kentucky’s hospitals and provider systems?
RD: There’s a lot in our great specialty areas. For instance, the Markey Cancer Center has a network of affiliates throughout the state to be sure we’re being as helpful as we can as an academic medical center. We have a research network throughout the state where they can conduct clinical trials. We have a stroke network throughout the state. We work with a collaborative of hospitals that get together in various partnership opportunities.
One initiative we just launched called Precision Medicine can do genomic gene sequencing on patients. The majority of it is with cancer patients; they can get their tumor analyzed doing gene sequencing, and then a molecular tumor board meets to reason out the best option of therapy for the exact genes that are abnormal in that particular individual. When people talked about lung cancer in the past, they usually talked about three or four different types. Gene sequencing might see 200 different combinations of gene changes very specific to a particular individual, and in many cases we now have targeted therapies specific to those gene changes. Our various affiliates for the Markey Cancer Center could have the opportunity to, even at a distance, get those genes analyzed and have that team meet for a patient in another part of the state.
I launched something like that in about 2012 (at Rutgers), and we published on that. Over the population at large where patients’ standard therapies weren’t any longer effective and you did gene sequencing, the percentage of patients you could come up with a new therapy for was fairly high, somewhere between 35 percent to 45 percent. These are for patients who didn’t have an option. And the percentage is increasing as we get better therapies.
There’s an additional percentage for whom it just helps guide therapy. An average cancer has usually more than one gene alteration. What we’re heading toward in terms of improvements is a Precision Medicine approach, which would include more of a cocktail, so to speak, of targeted agents that are hitting those multiple genes.
MG: How much instruction focus is there on the use of Big Data in medicine?
RD: It’s important. We have access to Big Data in a lot of different ways in the research world and the clinical world. Institutions are combining data under some sort of umbrella to keep it safe and so forth. The cancer center belongs to a group of institutions called ORIEN that share data on patients. You want to know not only if your institution treated 1,000 patients and got a certain result but what’s going on in other institutions.
Internally, we have a data warehouse for our clinical data so we can look at it and learn clinically how to improve upon results; what parameters relate to a particular outcome or might be changed? Looking at and being able to have access to Big Data and analyze it is becoming incredibly important for research and education; our learners need to understand how to reach out and get lots of data.
We tell our freshman students that by the time they graduate the amount of evidence has probably almost doubled. To be able to access and manage evidence and data is going to be a critical piece of their skill set. As we train the future generation of our physicians, they need to get better and better at managing data, using it for patient care, and doing it within systems that evolve. A physician needs skills to communicate with a patient for their best care in the context of new technology. And it’s not just Big Data; it’s the new technology. Electronic medical records systems allow us to access data that we couldn’t before and help us with documentation, but in some cases they slow processes or make it less personal.
We spend a lot of time trying to help our students learn that, and the next generation of physicians will be more adept at being able to navigate that. There are now programs – IBM Watson is an example – that are able to help with decision-making with large components of data. We teach our students that evidence is changing so rapidly, but decisions still need to be made – even with some degree of uncertainty. You may not have all the evidence, but a physician still must decide how to make that decision.
MG: There is a competition among all fields for skilled workers. Does the UK College of Medicine recruit?
RD: Students have a choice, especially the best students, in many different schools. Some come here because we have certain programs they like; some come because they like Kentucky, and they might have done undergrad here. Even though there’s always competition, we get many more applications of incredibly qualified applicants than we can take, over 3,000 to 4,000 applications. We interview 400-plus and take about 140 for each year’s class. That’s one of the reasons we need to expand the class. The average GPA and the average MCAT scores are just incredible.
MG: What characteristics do you look for in assessing a potential medical school student for admission?
RD: Obviously you look at academics in terms of their GPA and especially in science and STEM-related classwork. We do look at MCAT scores, but we also look at the student in many other ways in terms of their ability, how they come across in an interview setting. We have an admissions committee; it is a large group that does that assessment independent of any one of us, including me. It looks for the qualities of the future physician who is going to need to think critically, be able to work with patients well, those kinds of type of characteristics. This is done under the umbrella of an independent admissions committee.
MG: Is there any key focus area in cancer research and cancer care at UK?
RD: There are some foci. If you’re going to be comprehensive you tend to make sure you can take care of pretty much anything, but every cancer center has key areas they spend a lot of time on and focus on more. One focus at UK is on cancer metabolism. We have an incredible metabolomics center here, a very strong group. Cancer metabolism is the nutrition of cancer – targeting cancer with various drugs and ways of cutting off the fuel supply. Cancer cells are kind of like a Ferrari, and a normal cell might be like a scooter. The scooter plugs along, but the Ferrari needs a lot more fuel. If you cut down the fuel in different ways or you alter the metabolism, you can kill those cells in an effective way.
We also have expertise in colon cancer. We have expertise in lung cancers. We have expertise in some very specific cancers. We also have expertise in prevention that relates to, for instance, drug abuse and Hepatitis C, which can lead to liver cancer. We have some clear niches. One thing we try to do, especially in rural communities, is create access. Markey Cancer Center has been getting colorectal cancer screening out into the community. And they’ve been very effective. Research shows an increasing percentage of colorectal screening and a decreased percentage of impact from colorectal cancer in Kentucky since this program was launched throughout the state.
MG: What treatment modes are you most enthused about currently?
RD: One is immune therapies. It is taking off in ways no one would have believed years ago. In terms of one targeted area of therapeutics, immune therapies are key. The other aspect is that we need to take a more multi-pronged approach in cancer. Any one individual’s cancer is usually because of multiple changes in the cancer. The most exciting thing going forward is not only new therapeutic areas like immune therapies but our ability to leverage diagnostic technologies in a way where we can now hit cancers with multiple targeted approaches, but multiple drugs that are hitting their particular genes. You might categorize that as precision medicine. We have that in a way we never had before.
MG: Do you have a closing statement?
RD: As an institution, the University of Kentucky really has done everything possible to address the growth in talent, infrastructure and bringing that together to have the greatest impact for the needs of Kentucky. It’s allowed all of us who come here to be able to carry out what we do well. That quote about “we are the University for Kentucky” is very important. We couldn’t do it in isolation in a large university structure without that vision of paying attention to the infrastructure, the talent and being able to serve.
Mark Green is executive editor of The Lane Report. He can be reached at [email protected]