Michael Steinberg, MD, FASTRO
By Colleen Lawton, MD, FASTRO and Paul Wallner, DO, FASTRO
The following interview of Michael Steinberg, MD, FASTRO, was conducted on February 6, 2020, by Colleen Lawton, MD, FASTRO and Paul Wallner, DO, FASTRO.
Colleen Lawton: So, Mike, I think Paul, or somebody sent you this outline.
Michael Steinberg: Yes.
Colleen Lawton: I don't know the answers to this, so I guess, Paul probably does. But I don't know where you were born or where you grew up. So do you want to tell us that part of your life, the early years?
Michael Steinberg: Yeah. This is pretty simple. I was born in L.A. and never left. I grew up here. I grew up in the West San Fernando Valley, in Woodland Hills, went to high school there as well.
Colleen Lawton: Did you go to public high school or private high school, Mike?
Michael Steinberg: Public.
Colleen Lawton: Public, cool. Are schools good in L.A.? I don't know anything about them.
Michael Steinberg: Then they were. I think they were decent. And this was kind of in the far reaches, the suburbs of the time. They were good. It was kind of a middle-class environment. I went to Occidental College.
Colleen Lawton: This is where? I don't know where it is.
Michael Steinberg: It's in L.A. It's in the Eagle Rock suburb of L.A. The reason I went there, rather than Berkeley where I was also accepted, was –– I did some research –– I didn't get into Stanford which was my first choice. And Oxy was a place where Stanford accepted transfers from, but I went to Oxy and never left. I settled in at Oxy and did well there. You know, you get good grades, good enough to get into medical school and you stay.
Paul Wallner: Did your parents pack lunches for you?
Michael Steinberg: No.
Colleen Lawton: Did you commute or did you live on campus?
Michael Steinberg: No. It wasn't a commuter campus. It's a small liberal arts school. My father died when I was a freshman. He had rheumatic heart disease as a kid and went to - what's his name - not DeBakey - but the other guy that was down in Houston at the time. At the time the operation for a valve replacement had a 50 percent mortality. He had the operation and unfortunately died [cross-talking] --
Paul Wallner: Denton Cooley?
Michael Steinberg: Denton Cooley. Yes. That happened in my freshman year. It was part of the reason I didn't leave Oxy, actually. But I didn't go home much because by this time my parents had separated, and they both went to smaller apartment living. It wasn't going home anymore. It wasn't Ozzie and Harriet in those days.
Paul Wallner: You have one sibling, don't you, Mike?
Michael Steinberg: I do. I have an older brother.
Colleen Lawton: What did he do?
Michael Steinberg: He's retired now, but he was in the movie business, mostly TV at the end of his career. So, he did things like Diagnosis: Murder, and Jake and the Fatman. The Perry Mason mysteries were his. He had a good career.
Colleen Lawton: How was he part of that? What did he do? Was he an actor, or a writer, director? What did he do?
Michael Steinberg: He went to Princeton and was an English major, a really good writer that he won Story Magazine Award in 1968. And he got an MFA at UCLA. He wanted to be a screenwriter, but he ended up being a producer. He did write some stuff, but eventually he produced for television.
Paul Wallner: Did you ever try to pitch him a radiation oncology sitcom?
Michael Steinberg: No. But I had more of a background in acting than he did. I was an extra in the movies. First of all, I was a mail boy in a movie studio from the time I was 13 until I was 18 in the summers. And I would train the next mail boy because the mail boys would either be promoted or drafted in that era. Some of them became famous producers actually. The guy that ended up producing a number of the James Bonds was a guy I trained to be a mail boy. He was like about 19, 20 years old, and I was like 14 years old, showing him where to go, how to use the Xerox machine, and stuff like that.
Then I was able to join the Screen Extras Guild, and eventually got established in a movie. Established means you interacted with a principle actor. So, I was given a Screen Actors Guild card as well. I did that off and on all the way through college and medical school, when I had the time.
Colleen Lawton: Was that a way to make extra cash, Mike?
Michael Steinberg: Yeah. You could make money, relatively speaking, with only a few days of work. You could work like ten days in a summer and make as much money as you could make if you worked the entire summer as a camp counselor or something like that.
Paul Wallner: Did you ever consider it as a career rather than medicine?
Michael Steinberg: No. You know, there is the question about where does medicine come from? How did you decide to become a doctor. And this is a story I tell. My older brother was in some ways more of a mentor than my father was, who was more of a workaholic type.
Colleen Lawton: What did your dad do, Mike?
Michael Steinberg: He was a CPA by training, but he was a CFO of a movie company, a small, independent movie company called Mirisch Corporation, which was real hot in those days. They did a lot of famous movies in the '60s like In The Heat of The Night, The Apartment, and Some Like It Hot. It was a significant company. That's what he did.
So, I get this thing in the mail, my summer between high school and college, where they're asking me to declare a major in college. Not that you have to stick with it, but they just want to know what you might be interested in. And so I asked my brother, what should I say? He said, well, do you have any interest in becoming a doctor? I said, yeah, that's something I'd like to do. He said, then put yourself as premed. You'll know quick enough if you're going to make it or not.
Colleen Lawton: That would be true.
Michael Steinberg: There were 400 kids in the class. A hundred people were taking the Intro of Bio course, the first premed class. They were all premed. By the time we applied to med school as seniors there were only 25 of us left. So in some way, it became a self-fulfilling prophecy. Had I failed in my freshman or sophomore year, I would have done something else probably. But I continued to do well. In fact, I did better in college than I did in high school in terms of grades and so on.
Colleen Lawton: Yeah. So, you go to medical school. Radiation oncology, obviously, that's the question. How did that come about?
Michael Steinberg: That also is an interesting story. I started with an interest in orthopedics. I was a surgical intern at L.A. County. Internship was when you applied for residency in those days. I decided to apply to various ortho programs. But I had been at USC for medical school, now at County. For me, at any rate, the “county” experience was getting wearing. I started to think maybe I wanted to go into radiology. My father's best friend was the chief of radiology at Cedars at the time. He had been an academic at the University of Pennsylvania. So, I knew him and talked to him about how I was feeling. He encouraged me to apply to radiology programs.
So I applied to the radiology programs in and around Los Angeles to see what was available. I came to UCLA for a radiology interview. At the time the rad onc department was still part of radiology. And I met this guy named Ned Langdon. He was the past Chief of Radiation Oncology and was, at the time the Dean of Students of the Medical School. You may have met Ned, Paul. Did you ever meet him?
Paul Wallner: Yes.
Michael Steinberg: He was kind of a Marcus Welby kind of doctor. He didn't know the literature or things like that. That wasn't his thing. His thing was the patient relationship. He was a real relationship person. So as part of the interview process, I interviewed with him. The interview took place walking around the hospital, and he took me up to the 10th floor where there were carpets and they served lobster to people for dinner, and things like that. It was a kind of like a concierge floor. The floor doesn't exist anymore. I found myself -- by the time we got back to his office, at his desk filling out an application for the radiation oncology residency. Then he called three days later, no match in those days, and he said, you're in, and I took the position. So he basically --
Colleen Lawton: Mike, was he a diagnostic radiologist that was also a radiation oncologist, or was he solely radiation oncology?
Michael Steinberg: He practiced solely radiation oncology. You know the way those guys trained, they all trained in general radiology and then focused in diagnostic or therapeutic radiology.
Colleen Lawton: Sure.
Michael Steinberg: Ned also had a nuclear medicine background as well. He was dean of students of the medical school at the time. He was just a very charismatic person, and I was very impressionable. So by the end of this interview, I accept that and I withdraw my applications from the radiology residencies, and ended up at UCLA as a resident.
Colleen Lawton: Mike, I just want to go back and ask. Did your mom work outside the home?
Michael Steinberg: Yes. She was a teacher, a schoolteacher at the junior high school level. Yeah.
Colleen Lawton: Like a generalist, or did she teach specifically something?
Michael Steinberg: Remember, it's junior high, so they don't really have AP. So she taught an honors kind of English class, but then she taught the remedial reading to students that couldn't read.
Colleen Lawton: Sure. They were struggling. Yeah.
Michael Steinberg: So she got like three or four of those classes, and and 1 or 2 honors classes. She was a journalism major in college so she did the newspaper at the various junior high schools she worked at.
Paul Wallner: Mike, was your program three or four years at the time?
Michael Steinberg: It was three.
Paul Wallner: Three. Was Bob Parker there then, or did he come after?
Michael Steinberg: Bob was there. Bob came maybe a year or two before I came. It just took a while to split the department off from radiology to go through all the academic/university issues to become a separate department. But by the time I arrived, it was had just separated from radiology.
Paul Wallner: I think that was part of the deal when he left the University of Washington, and that was probably '73, '74, something like that.
Michael Steinberg: '77 is what I remember.
Paul Wallner: '77?
Michael Steinberg: Yeah.
Paul Wallner: Do you recall who any of your colleagues were, any of the peers, any of the faculty?
Michael Steinberg: Yeah. The faculty, there was Ned, there was Bob Parker. There was a guy named Tom Weisenburger that went to Santa Barbara Cancer Foundation, and Guy Juillard were the faculty. Another guy named Alan Tesler who went up to join the Swedish group. Tom was an associate professor. I would consider him one of my mentors. And he went to the Santa Barbara Cancer Foundation which is kind of a plum of a private practice in California.
The one resident that I was with that you guys all know was Jeff Demanes. He was my chief resident. I almost quit because of him. I still tell that story, even today. In those days the chief resident ran the clinic and assigned the cases. If there was a direct referral to a faculty, the faculty would of course see it. But otherwise, if they were coming to the general service, the chief resident would assign cases to the residents and to the faculty. In any case, the chief would always assign the residents. Jeff basically hogged all the good cases. We didn't have to keep logs then, but I had this spiral notebook where I took down all of my notes on my cases. So in this form I had a list of all my cases. In the first six months, I had seen nothing but bone and brain mets.
Colleen Lawton: Yeah.
Michael Steinberg: And so I went to Ned Langdon to tell him I was going to quit because I was depressed. I showed him the book where I hadn't seen any curative cases. Jeff ended up getting in trouble and eventually demoted. And a guy that you may not know, Fred David, became chief resident early as result of all this. I was not the only one to complain. Fred later went on to practice in Santa Rosa, in the wine country area, and he became president of his county medical association and ended up on state’s board of medicine. I haven't heard from Fred in a few years.
Then the other person that I was a resident with who came to UCLA for medical school and stayed for an entire career was Mike Selch. Mike stay for about 5 years while I was Chair and then retired just before our electronic health record was installed. Mike did CNS and was well-published.
Colleen Lawton: So, Mike, when does Eve come into the picture, during this time, after?
Michael Steinberg: Just before. I'm an intern when I meet Eve.
Colleen Lawton: How did that happen?
Michael Steinberg: Blind date, set up on a blind date through a good friend of mine who I have known since I was in kindergarten. He had become engaged to is a girl he had met at UCLA was friends with high Eve since high school. Since she and I were going to be in the wedding –– usher and bridesmaid –– they thought, maybe we would meet before their wedding. So Eve and I went out on a date. That was in September of internship year. They got married in May of that year and Eve and I married in June.
Colleen Lawton: Oh my gosh. What was Eve doing at the time when you met her?
Michael Steinberg: She's getting an MBA at the time at UCLA.
Paul Wallner: Was that before or after her PhD?
Michael Steinberg: After.
Colleen Lawton: Okay. So you finished residency, then what happens?
Michael Steinberg: I had difficulty getting a job and it was a time when there were supposed to be a lot of jobs. But, I had some difficulty getting a job. I finally landed a job at the end of my chief year in Las Vegas. I joined this combined radiology group. My practice trajectory was very rapid. The radiation oncologist who recruited me was busy, but when I joined, we became very busy. Elsewhere in town there was only a cobalt machine. This practice had been recently set up by a radiology group. They had a LINAC and a cobalt machine, and a simulator. It was fairly well equipped for the time. And then, I had skills in interstitial implants that I learned during my residency. I spent six months with Nisar Syed learning complex brachytherapy. I was basically promoting myself as an implanter and became very busy doing implants as well as external beam. My implant activity continued to be a significant part of my practice for the first 25 years of my career.
So, in the 15 months I was in Vegas I probably did 200 implants of all sorts including things at the time we kind of novel such as big head and neck implant, and rectal implants, and so on. There was a colorectal surgeon that had been president of the colorectal society who “retired” to Vegas. He hated the APR operation. I met him and told him what we could do with radiation therapy. I think I did about 25 patients while I was in Las Vegas on his patients. He had a huge referral base and we treated small primary rectal cancers.
Another doctor was recruited into the group, and I became the odd man out. I was the one with the big practice, and they were the ones that went to lunch together, and soon I realized it was time to get out of Dodge. I started looking for jobs back in L.A. and landed a job with another radiology group. It tuned out it wasn't a very good practice situation. But after I year I get a call from Lee Avalone who was a radiation oncologist who practiced in Santa Monica. He was looking for someone to join him. Actually, Mike Selch was the one who took the job and at the last minute decided he didn't want to leave UCLA. I said I might be interested. Well, six weeks later, I went to work with him a hospital-based practice in Santa Monica.
Subsequently, when the hospital – with a very provincial administrator - wouldn't allow us to hire a nurse, Lee and I decided to leave and set up our own freestanding department. We had a very busy practice and our front office person would answer phones, room the patients and act as chaperone for exams. And this administrator would not allow us to have a nurse.
Coleen Lawton: Yeah. Think about that.
Michael Steinberg: Yeah. We left the meeting with the administrator and decided we had to leave the hospital and set up a freestanding center – which we did. Somehow, we didn't get kicked out of the hospital in the meantime, and we were able to build and establish our center in Santa Monica. Subsequently, about four or five years later, we started adding practices. I think in our peak we had nine sites. Lee retired young a few years after that.
Colleen Lawton: Mike, were all sites in Southern California?
Michael Steinberg: Yes. They were all in the L.A. area. Mostly hospital sites. I saw patients and managed the practice for years.
Paul Wallner: How did you become involved in service to radiation oncology?
Michael Steinberg: It was in the early '90s that I first became involved in radiation oncology service. Earlier I was appointed to an insurance committee for the county medical association where they would adjudicate claims for the proprietary insurance companies. I would go down once a month and eat dinner with other doctors on the committee and people from the insurance companies and discuss insurance claims they did not understand. We'd explain the complexities of bills and determine if the bills were appropriate. All specialties were in the room. This experience sharpened my interest in healthcare economics. I had to get good at it because I was asked to be the local expert in radiation oncology billing. When I started, I really didn't even know exactly what I was volunteering for. It was at that time managed care was taking off in California.
However, the ramp up of my activity in the health policy and healthcare economics began when I was asked to speak at a UCLA faculty retreat about managed care contracting. I spoke about what I knew from my own experience in practice. They thought I did such a good job they invited me back to talk at the retreat the following year. I basically had told them everything I knew the year before so I had to go looking for a new topic.
At about that time, Oregon was doing health planning for its Medicaid program. They were creating a priority list of conditions and this was how they were going to pay for their Medicaid. They created this complex process with one of the big eight, at the time, accounting firms. They were going to create priority list, do a budget, and then they're going to draw a line. Below the line they weren't going to pay for care, and above the line they were. So at the top of this list were things like vaccinations for kids, and at the bottom of the list was questionable back surgery and things like that. Also, low on the list, interestingly enough, was AIDS related treatments. There was still a stigma related to AIDS at the time so AIDS related treatment ended up very low on the list.
Do you know, I read about it in Time Magazine and thought maybe I would talk about this as an interesting health policy topic. I got detailed information from the state of Oregon. Looked at it closely and found out that radiation therapy was left out as a covered service. It wasn't mentioned. So, I called radiation oncology folks I knew in Oregon to find out what was up. They were not aware of this finding that radiation therapy was left off the priority list but their response was very low key. They thanked me for telling them about it and did not think it was a a problem. We'll be included they said.
So, I took what I had learned about the Oregon Plan for Medicaid, which was interesting in and of itself, and presented it to the UCLA faculty retreat. Bob Parker and Rod Withers heard the talk and were very concerned about radiation oncology be left out of the Oregon Plan. They called the ACR and told them about my talk. Subsequently, I get a call from Nick Croce who was an executive with the ACR.
Paul Wallner: Yeah, he was the associate executive director. He ran the Philadelphia office for a time, and then John Curry took him to Reston to be associate executive director.
Colleen Lawton: I remember that.
Michael Steinberg: Right. As part of his job he was the executive director of ASTRO. Did you know him?
Colleen Lawton: Yeah.
Paul Wallner: That was when ACR ran ASTRO, and he was, I think, allocated about 10 or 20 percent time from the ACR to run ASTRO.
Colleen Lawton: Yeah, and that's how I knew him.
Michael Steinberg: He calls me up and I tell him the story. He said, "Can you do a white paper for us on the topic." And, directly written to a typewriter, I typed a 20-page white paper on how the process worked, and where the interventions needed to be for radiation oncology, and sent it to him. I didn't hear from him or a while, and then I get a call. It may have been six months or almost a year later. I get a call from Jerry Brickner, who got my name from Nick, and asked if I wanted to get involved with health policy at the ACR on behalf of ASTRO. That's when I think I first met you, Paul. Who else was involved then? Bogardus was around, but I don't recall who else was around -- [cross-talking]
Paul Wallner: Chris Rose. Chris was involved a little later, I think.
Michael Steinberg: Chris, a little later on. I think he was a little later after this actually.
Paul Wallner: Yeah.
Michael Steinberg: Jerry asked me to become involved in this small volunteer group overseeing ASTRO health policy issues. As Paul knows, Colleen, it was a very centralized process, that ACR didn't have a committee structure for this function. It was three or four people kind of doing the policy and economic stuff. They did the same thing for the radiologists, too. And we did that way for a number of years.
Then, ASTRO split off from the ACR. Actually, it was the ACR's idea at least from my understanding of it. ACR was getting out of the subspecialty society business. In any event, at that time, I was asked to run the Joint Economics Committee for ASTRO and the ACR – the JEC. I said I'll do it, but I didn’t want to do it alone. I was in private practice. My partner was understanding but not that understanding. And so it was initially Jerry and I who were the co-chairs of this Joint Economics Committee. Then Jerry became president of the ACR, right?
Paul Wallner: Yes.
Michael Steinberg: Then Paul becomes the other co-chair with me. You and I did that for a couple of years.
Paul Wallner: Right.
Michael Steinberg: Then after that, I think it was Lou Potters?
Paul Wallner: Right.
Michael Steinberg: We kept running the committee with co-chair leadership. This was all before the reorganization of the ASTRO board. This goes from about 1999 until about 2002. In 2003 the reorg of the ASTRO board occurs. You were already on the Board, Colleen, elected as an academic leader or something like that.
Colleen Lawton: Yes.
Michael Steinberg: I was asked to run for, I think they called it health economics council chair or something like that, at the time. That was the initial name of the council.
Colleen Lawton: Yeah.
Michael Steinberg: The way the reorganization came down, I ended up as Chair of the Council for four years. I was never vice chair of the Council.
Colleen Lawton: Right.
Michael Steinberg: And I think the junior position was reallocated, if you remember this, to Peter Blitzer who was already sitting on the Board in a legacy community practice position.
Paul Wallner: Mike, do you want to talk a little bit about your transition from private practice to academic practice? That's obviously an unusual pathway, and it's more often the other way.
Michael Steinberg: Yes. I actually wanted to stay in academics when I finished residency, but there was no job position for me at the time at UCLA, and I didn't really look elsewhere. To be honest with you, they strung me along a little bit dangling a job through my Chief year that never came through. Then I got a late start in job hunting and I wasn't really looking at other programs.
What happened was Rod stepped down. And there was a search that turned into one of those endless academic search committee processes. It went on for a few years. As people came through UCLA for interviews, because I ran a group with a big practice footprint in LA and I was known from my ASTRO Board and health policy activity, I would get calls from some of candidates. I'd go to dinner with them and inform them about the LA radiation oncology scene and opportunities for collaboration. So through this, my name became known to the search committee.
The bottom line, when somebody asks me, how did you become Chair? I would say, kidding on the square, I'm the result of a failed search. But, what actually happened was the committee basically had gone through a number of people. Some had some pretty large asks. They would want $30 million or $40 million packages. Our dean at the time, Gerry Levey, was not in the habit of doing those kinds of packages. Although the department had fallen on hard times, with an interim chair for a number of years and a number of people left. No junior faculty had been promoted to Associate Professor for more than ten years, and there had not been an investigator-initiated trial in the department for a decade. It really had fallen on hard times and the faculty even fell below the critical level of four required for the residency.
I get a call from the Dean. (I later learned that it was Bill McBride that gave my name to the dean.) The Dean says he wants to go to lunch with me. I ended up going to lunch with him and Dave Callender who was the CEO of the hospital at the time. He's now the president of the University of Texas, Galveston. So, we go to lunch at the Regency Club, a high-end private club. We had a nice lunch. I gave them the lay of the land for radiation oncology in Los Angeles and nationally. They asked me some academic questions that retrospectively I didn't even know were academic questions. I think, I truly think, that I am being interviewed to become a new search committee member to help them in their search.
I get a call a few days later from Gerry. He says, "You know, David and I met and talked after we went to lunch with you, and we liked you better than anybody that we interviewed. Do you want to be chair?" This is the truth, I said, and this was my response, "Did you call the wrong number?" And he laughed. He says, "I didn't call the wrong number." We talked for a while. I asked him for time to "think about it." I thought about it for a week, and called back. I said, " I am honored. What's the process?" I went through an interview process where I interviewed with 17 people over about three days and then got offered the job. It took almost a year to finalize the contract, and it wasn't for the reason that the Dean thought. The reason was after some due diligence I found that the documentation and billing function for the department was way below par. If we were audited, it would have been a mess.
So, as a condition of my employment, I requested that someone specifically be hired from outside to UCLA to oversee billing and compliance for the department. What I didn't understand was to make this hire meant obtaining a something called a “sole source” contract. And that was something that was hard to do in the university. It took a year to get that done. In the meantime, the dean thought I was playing hard to get, which I wasn't. I was just trying to land this compliance thing. One of the associate vice chancellors from the medical school shepherded this through the bureaucracy and kept the Dean calm during the interim. That's how I got here.
The thing I should mention – Paul shouldn’t listen now – in this process, I had to create PowerPoints about vision/mission and so forth. At the time I really didn't know the nuances of the tripartite mission of an academic department. I didn’t even know what that was. I'd do these half-assed PowerPoints and Paul would rip them apart. He basically took me by hand and taught me the details of academic department organization and process. So those initial PowerPoints targeted at faculty and the Dean’s Office, the structure of those PowerPoints, and I would even say, a lot of the content, was actually created by Paul.
Colleen Lawton: That’s really fascinating.
Michael Steinberg: Yes.
Colleen Lawton: I've got two burning questions. The first is, how does the family – I mean you obviously raised a successful family amongst all of this – how did Eve do with the moves? Where did the kids come into play? How did all that happen?
Michael Steinberg: Early on in our careers, when the kids were young, Eve worked longer hours than me and traveled a great deal as well. In fact, when the kids were little in the early '90s, she went platinum on five airlines one year. She had a lot of responsibilities that were out of town. We had help in the house like nannies and housekeeper and we had a schedule to be with the kids on the weekends. One of us would always be home in the evening to help with homework and be there for the kids.
Colleen Lawton: How did you, for example, so you graduate residency, you go to Las Vegas, how was that for Eve with her career, and maybe being pregnant along the way? I'm fascinated to know how at the time when it's not easy to be a working mom, did you make all that work?
Michael Steinberg: She made it all work. I didn’t make it work. We would pay for help, for nannies and so on. When we went to Vegas, we didn't have kids yet. She was up for a new adventure and was going to figure something out. At that time she was going to give up what she was doing at the time and find a new career, but didn't stay long enough for that to happen. When we came back to L.A., she got back on career trajectory in business consulting. She was a consultant with Arthur Andersen, and another company called Amherst Associates. When she came back to LA and continued to be a consultant with Amherst, and then a year later ended up in a Fortune 500 healthcare company where she rose fairly quickly.
To give you a sense of her drive and commitment, the night our second child Drew was born, I went home after the delivery at 2:00am in the morning and come back at 7:00 am. I walk into the room and her five direct reports are sitting by the bed taking notes. Eve is breastfeeding the baby or trying to breastfeed the baby, while giving directions to her direct reports.
Colleen Lawton: Good God.
Michael Steinberg: Eve had the ability to do that. The weekends were for the kids. Our friends became people who had kids in our kids school. We didn’t socialize outside that bubble very much. That's how it pretty much worked. I tended to come home earlier than Eve. So if there was homework, that tended to fall to me. The weekends for the kids would be led by Eve.
Colleen Lawton: Fascinating. You had nannies, in-home care, or in-home help?
Michael Steinberg: Yes. In fact, our help had help. So our nannie would have a housekeeper, somebody to clean the house, and then the nanny would be responsible only for the children. Our kids were good kids. They were not handfuls. They rarely went down the wrong pathway. We were blessed in that way.
Paul Wallner: Did either Beth or Drew ever consider medicine?
Michael Steinberg: Never, neither of them. I wasn't one of those docs who came home and complained that medicine is going to hell and all that. They were both good students, and actually very good science and math students, both of them. But they never really had the interest. My oldest, Beth, who you both know, was interested in what her mother did for a living. Beth is in private equity now. She was always drawn to that. Early on, she always wanted to go to New York, and that's where she ends up going to college. So she goes to college in New York, never came home. She still lives there.
The younger one is five years younger. Her trajectory, she was interested in different things. She's not money driven. She's interested in public service and found herself doing things with that kind of focus and got her graduate degree in public policy. She was a religion and society major in college at Haverford. And her second parents, who she notes to this day were much better parents than Eve and I, were Paul and Susan.
Paul Wallner: I understand right. We were more permissive.
Colleen Lawton: Just like that.
Michael Steinberg: So, she worked for the mayor in L.A., and she now works for the fire chief in L.A. She runs performance excellence for the fire department. And actually she does risk management as well for the fire department. They trained her to do that. That's what she does. She goes to work with a bunch of firemen.
Colleen Lawton: Switching gears a little bit, Mike. So, I think Paul knows better, but I think I have a good handle on like the contributions that you've made. If you have one or two that you would say is at the top of your list of the things that you've done.
Michael Steinberg: For ASTRO or in the specialty?
Colleen Lawton: As you look back on your career, I don't think it necessarily has to be for ASTRO. I would say even more broadly the field.
Michael Steinberg: Yes. At least on the ASTRO side, I guess my legacy is the health policy platform that we put in place. We basically totally changed from the way the ACR did it, where it was very centralized, to create a four subcommittee structure reporting to the major committee and the council. It became 70 to 80 members casting a wide net that could create consensus among the various constituencies of our specialty. We took healthcare economics from what was kind of negatively called “billing”, and you were at those board meetings where our presidents or president-elect would be reading the newspapers, as I presented my reports, to become known as the health policy arm of the organization. At the time it was a big fight. To even change the name of the council to health policy from economics, for whatever reason was a very big deal.
Colleen Lawton: Yeah.
Michael Steinberg: So we were able to put that platform in place. And what we did – and this is a general contribution as well – we had an attitude that we weren't going to be buffeted by CMS and the insurance companies. What we were going to do was we were going to bring new processes of care and new technologies to patients as rapidly as was reasonable. Paul knows we were pretty aggressive about that, and we were very successful in bringing IMRT in place, and in retrospect, probably overvalued at the time. But that overvaluing allowed for the recapitalization of the specialty because when it happened, everybody all of a sudden had the money to buy new linear accelerators and so on.
Colleen Lawton: Yeah.
Michael Steinberg: I would say one of my significant contributions as ASTRO Chair was leading our organization to participate in Choosing Wisely. Chris Cassell was executive director of the American Board of Internal Medicine Foundation and was the lead for the Choosing Wisely campaign. She approached me when she was at UCLA as a visiting professor. That triggered a number of conversations both with the ABIMF and ASTRO which lead to our specialty’s participation in Choosing Wisely. I think another contribution would be my leadership in establishing ASTRO’s commitment to equity and disparity in healthcare. During my first run on the Board (2003-2007), I was a PI of a NIH disparity grant (U-56). There were four or five of those grants around the country awarded to radiation oncology PIs. Over a number of Board meetings, along with a particular ASTRO staff person, I proposed a permanent committee to deal with EDI - equity, diversity, inclusion. For whatever reason, there was resistance to such a move by the Board at that time. But finally, a committee was put in place when you and I were on the Board the first time around, Colleen.
Colleen Lawton: Yeah.
Michael Steinberg: If you recall, there was some pressure not to do it, for some reason. I don't know why. But, anyway, we were able to get that established, and I am happy to say it has a lot of traction now. Another leadership contribution was RO-ILS, the Patient Safety Organization. It was not my idea but came up in 2010 when the specialty was buffeted by the NY Times articles about safety. It kind of got lost in the shuffle of rolling out the ASTRO response to the Times articles. I kind of picked up the idea of a national peer reviewed protected platform for the specialty when I was president-elect and continued to doggedly push it. Eventually, staff was able to figure out how to do a PSO. It was launched either under my watch or your watch as Chair, I think.
Colleen Lawton: It was evolving during that time.
Michael Steinberg: Yes. On the academic side of things, when I got to UCLA, I looked at some numbers. We'd seen about a thousand patients, and we're treating about 600 of them. It was a pretty small department. Patients were leaving and going elsewhere for treatment. We were basically doing a lot of second opinion. It was also at a time of nine weeks of IMRT for the treatment of prostate cancer. So, if somebody lived only 20 miles away, that could be a two-hour drive in L.A. That was a reality I had to deal with when I first arrived at UCLA.
And at that time Bill McBride's lab demonstrated this notion that large SBRT-like fractions were associated with beneficial immunologic effect. At about the same time, something similar came out of Zvi Fuks’ lab at Sloan Kettering as well. So, I decided to go big with this in prostate cancer and recruited Chris King from Stanford. With substantial leadership from Pat Kupelian we began a robust SBRT prostate program. By 2013, we were able to report 1,100 cases. And last year, 2,000 cases with many with over 9 years of follow up. So, now we have a couple of randomized trials published from Sweden and the UK as well.
So I think it is fair to say that under my leadership, ultra-hypofractionation in the prostate was encouraged at UCLA. Ideas related to this have stimulated a number of our junior faculty to pursue these concepts and they are careers out of it. Percy Lee was one of those faculty. He just went to MD Anderson to run thoracic oncology there. Amar Kishan is another who has distinguished himself by elucidating our understanding of the high-risk prostate cancer and the need for high biological dose to treat those patients.
The Ultra hypo-fractionation focus of our department dovetailed into addressing the value proposition from policy point of view. We wrote an article about value in 2013 published in JCO. The article elaborates the whole notion of value in our specialty. So, I would like to think that I have made some modicum of a contribution as part of the group that pushed the edge when it came ultra-hypofractionation and value in our specialty.
Colleen Lawton: Yeah.
Paul Wallner: Mike, we're getting close to the end of the hour. For the last five or ten minutes, do you want to give us some sense of what you see as the future both technologically, scientifically, training, payment policy, you know, put on your scepter and orb, and see where things are going in your eyes?
Michael Steinberg: Sure. The present, where things are going, and if this sounds more articulate than I usually am, it is only because I'm preparing a talk about the future of the specialty for the UCLA Dean's Council.
I think one can think of our future as falling into four related or overlapping domains.
One is personalizing radiation therapy around a biology axis. Using tumor specific and patient specific germline informed notions in treatment is in our immediate future. Omic information like genomics, metabolomics, and transcriptomics will inform us how and when to intensify or de-intensify treatment as well as to better understand side effects of our treatments. So I think that's one domain.
I think another area of precision or personalizing radiation therapy relates to the physics axis. Yes, I think that there will be progress in that area. I thought we were at the end of that a decade ago, but I don't think so now. An example of leveraging technological advance has been forwarded by one of our faculty in the form of 4 Pi. The notion of real time adaptive therapy, something you can do with in real-time with an MRI movie running concurrently as you are treating has begun to show promise. I think that that could be a game changer in the way we treat a number of tumors such a pancreas and maybe even prostate. It may likely be more of a game changer than protons. Although real-time adaptive protons I suppose is a possibility, too.
I think the other area that will be particularly beneficial to us as a specialty is what I call kind of bridging the local control chasm. Basically, there is a renewed focus now, I think, on local control, particularly as it relates to oligometastasis or oligoprogression, and I think we'll see a dramatic change in and who we treat going forward. I mean I was shocked by the findings of the Gomez lung oligomet trial. I thought treating of oligomets would benefit patients, but I didn't think it would work in a disease like lung cancer. But it does. We are on the verge or a whole new set of treatment paradigms in our approach to oligometastatic disease.
Then the final domain relates to optimizing value. You know, optimizing quality of life for the patient while minimizing costs, and along the way creating efficiencies. I think that describes future directions for our specialty at this point in time.
Paul Wallner: Do you want to weigh in on the current controversy as to the weighting of clinical knowledge versus physics knowledge versus biology knowledge perplexing the Board of Radiology right now?
Michael Steinberg: First of all, I am not sure what is behind this. Possibly fear about the job market. But, there are jobs. Our residents are getting good jobs. I don't think there is a glut. The thing I do know is every time we try to predict workforce needs particularly around radiation oncologist needs, we've been bad at it. Our predictions miss the mark every time. It's the same discussion we had in the late '90s, and then what happened? IMRT happened. The discussion existed even in the '80s as I recall as well.
So, the conversation is occurring again now. Contrary to what some of the anonymous blogs are saying, I don't think there is a glut of radiation oncologists at this point in time. I think there are good opportunities for these brilliant residents that we are training. Colleen, you may not have heard. As probably my last leadership hurrah, I will be on the radiation oncology RRC.
Colleen Lawton: Oh my god.
Michael Steinberg: Yes. So, I'm here for at least another six years because it's a six-year term for that.
Paul Wallner: I had heard.
Michael Steinberg: I feel strongly that if we maintain or raise the quality bar for our programs and demand a certain level of quality of our programs, and don't look the other way when programs aren't meeting the criteria that we already have set, that we can address some of these problems related to workforce and training. And, yes, I think a good radiation oncologist needs to understand didactic physics, and yes, you do need to understand didactic cancer biology and even some radiobiology. And I think most of those deleterious comments that - you and Lisa had to endure were inappropriate, anti-intellectual even anti-professional.
Colleen Lawton: Yeah, I see your point.
Paul Wallner: So, if Lev or Micah or Liam were interested in radiation oncology, would you encourage them or discourage them?
Michael Steinberg: They're all under three-years-old, Paul.
Paul Wallner: Yeah. But that could change.
Michael Steinberg: I'm not dodging the question, but right now I think all three of them want to be firemen.
Paul Wallner: They have good genes, so I expect great things from them.
Colleen Lawton: Well, I want to thank you personally for your time. Mike, I find this fascinating, so I really have enjoyed this. I hope that it's good for you, and I personally need to thank you for everything you've done. I'm learning things that I didn't even know that you had done, so way to go.
Michael Steinberg: Thanks for taking the time to listen to me pontificate.
Paul Wallner: Great. Thanks very much, Mike. We really appreciate it.
Michael Steinberg: Thanks guys.
The following interview of Michael Steinberg, MD, FASTRO, was conducted on February 6, 2020, by Colleen Lawton, MD, FASTRO and Paul Wallner, DO, FASTRO.
Colleen Lawton: So, Mike, I think Paul, or somebody sent you this outline.
Michael Steinberg: Yes.
Colleen Lawton: I don't know the answers to this, so I guess, Paul probably does. But I don't know where you were born or where you grew up. So do you want to tell us that part of your life, the early years?
Michael Steinberg: Yeah. This is pretty simple. I was born in L.A. and never left. I grew up here. I grew up in the West San Fernando Valley, in Woodland Hills, went to high school there as well.
Colleen Lawton: Did you go to public high school or private high school, Mike?
Michael Steinberg: Public.
Colleen Lawton: Public, cool. Are schools good in L.A.? I don't know anything about them.
Michael Steinberg: Then they were. I think they were decent. And this was kind of in the far reaches, the suburbs of the time. They were good. It was kind of a middle-class environment. I went to Occidental College.
Colleen Lawton: This is where? I don't know where it is.
Michael Steinberg: It's in L.A. It's in the Eagle Rock suburb of L.A. The reason I went there, rather than Berkeley where I was also accepted, was –– I did some research –– I didn't get into Stanford which was my first choice. And Oxy was a place where Stanford accepted transfers from, but I went to Oxy and never left. I settled in at Oxy and did well there. You know, you get good grades, good enough to get into medical school and you stay.
Paul Wallner: Did your parents pack lunches for you?
Michael Steinberg: No.
Colleen Lawton: Did you commute or did you live on campus?
Michael Steinberg: No. It wasn't a commuter campus. It's a small liberal arts school. My father died when I was a freshman. He had rheumatic heart disease as a kid and went to - what's his name - not DeBakey - but the other guy that was down in Houston at the time. At the time the operation for a valve replacement had a 50 percent mortality. He had the operation and unfortunately died [cross-talking] --
Paul Wallner: Denton Cooley?
Michael Steinberg: Denton Cooley. Yes. That happened in my freshman year. It was part of the reason I didn't leave Oxy, actually. But I didn't go home much because by this time my parents had separated, and they both went to smaller apartment living. It wasn't going home anymore. It wasn't Ozzie and Harriet in those days.
Paul Wallner: You have one sibling, don't you, Mike?
Michael Steinberg: I do. I have an older brother.
Colleen Lawton: What did he do?
Michael Steinberg: He's retired now, but he was in the movie business, mostly TV at the end of his career. So, he did things like Diagnosis: Murder, and Jake and the Fatman. The Perry Mason mysteries were his. He had a good career.
Colleen Lawton: How was he part of that? What did he do? Was he an actor, or a writer, director? What did he do?
Michael Steinberg: He went to Princeton and was an English major, a really good writer that he won Story Magazine Award in 1968. And he got an MFA at UCLA. He wanted to be a screenwriter, but he ended up being a producer. He did write some stuff, but eventually he produced for television.
Paul Wallner: Did you ever try to pitch him a radiation oncology sitcom?
Michael Steinberg: No. But I had more of a background in acting than he did. I was an extra in the movies. First of all, I was a mail boy in a movie studio from the time I was 13 until I was 18 in the summers. And I would train the next mail boy because the mail boys would either be promoted or drafted in that era. Some of them became famous producers actually. The guy that ended up producing a number of the James Bonds was a guy I trained to be a mail boy. He was like about 19, 20 years old, and I was like 14 years old, showing him where to go, how to use the Xerox machine, and stuff like that.
Then I was able to join the Screen Extras Guild, and eventually got established in a movie. Established means you interacted with a principle actor. So, I was given a Screen Actors Guild card as well. I did that off and on all the way through college and medical school, when I had the time.
Colleen Lawton: Was that a way to make extra cash, Mike?
Michael Steinberg: Yeah. You could make money, relatively speaking, with only a few days of work. You could work like ten days in a summer and make as much money as you could make if you worked the entire summer as a camp counselor or something like that.
Paul Wallner: Did you ever consider it as a career rather than medicine?
Michael Steinberg: No. You know, there is the question about where does medicine come from? How did you decide to become a doctor. And this is a story I tell. My older brother was in some ways more of a mentor than my father was, who was more of a workaholic type.
Colleen Lawton: What did your dad do, Mike?
Michael Steinberg: He was a CPA by training, but he was a CFO of a movie company, a small, independent movie company called Mirisch Corporation, which was real hot in those days. They did a lot of famous movies in the '60s like In The Heat of The Night, The Apartment, and Some Like It Hot. It was a significant company. That's what he did.
So, I get this thing in the mail, my summer between high school and college, where they're asking me to declare a major in college. Not that you have to stick with it, but they just want to know what you might be interested in. And so I asked my brother, what should I say? He said, well, do you have any interest in becoming a doctor? I said, yeah, that's something I'd like to do. He said, then put yourself as premed. You'll know quick enough if you're going to make it or not.
Colleen Lawton: That would be true.
Michael Steinberg: There were 400 kids in the class. A hundred people were taking the Intro of Bio course, the first premed class. They were all premed. By the time we applied to med school as seniors there were only 25 of us left. So in some way, it became a self-fulfilling prophecy. Had I failed in my freshman or sophomore year, I would have done something else probably. But I continued to do well. In fact, I did better in college than I did in high school in terms of grades and so on.
Colleen Lawton: Yeah. So, you go to medical school. Radiation oncology, obviously, that's the question. How did that come about?
Michael Steinberg: That also is an interesting story. I started with an interest in orthopedics. I was a surgical intern at L.A. County. Internship was when you applied for residency in those days. I decided to apply to various ortho programs. But I had been at USC for medical school, now at County. For me, at any rate, the “county” experience was getting wearing. I started to think maybe I wanted to go into radiology. My father's best friend was the chief of radiology at Cedars at the time. He had been an academic at the University of Pennsylvania. So, I knew him and talked to him about how I was feeling. He encouraged me to apply to radiology programs.
So I applied to the radiology programs in and around Los Angeles to see what was available. I came to UCLA for a radiology interview. At the time the rad onc department was still part of radiology. And I met this guy named Ned Langdon. He was the past Chief of Radiation Oncology and was, at the time the Dean of Students of the Medical School. You may have met Ned, Paul. Did you ever meet him?
Paul Wallner: Yes.
Michael Steinberg: He was kind of a Marcus Welby kind of doctor. He didn't know the literature or things like that. That wasn't his thing. His thing was the patient relationship. He was a real relationship person. So as part of the interview process, I interviewed with him. The interview took place walking around the hospital, and he took me up to the 10th floor where there were carpets and they served lobster to people for dinner, and things like that. It was a kind of like a concierge floor. The floor doesn't exist anymore. I found myself -- by the time we got back to his office, at his desk filling out an application for the radiation oncology residency. Then he called three days later, no match in those days, and he said, you're in, and I took the position. So he basically --
Colleen Lawton: Mike, was he a diagnostic radiologist that was also a radiation oncologist, or was he solely radiation oncology?
Michael Steinberg: He practiced solely radiation oncology. You know the way those guys trained, they all trained in general radiology and then focused in diagnostic or therapeutic radiology.
Colleen Lawton: Sure.
Michael Steinberg: Ned also had a nuclear medicine background as well. He was dean of students of the medical school at the time. He was just a very charismatic person, and I was very impressionable. So by the end of this interview, I accept that and I withdraw my applications from the radiology residencies, and ended up at UCLA as a resident.
Colleen Lawton: Mike, I just want to go back and ask. Did your mom work outside the home?
Michael Steinberg: Yes. She was a teacher, a schoolteacher at the junior high school level. Yeah.
Colleen Lawton: Like a generalist, or did she teach specifically something?
Michael Steinberg: Remember, it's junior high, so they don't really have AP. So she taught an honors kind of English class, but then she taught the remedial reading to students that couldn't read.
Colleen Lawton: Sure. They were struggling. Yeah.
Michael Steinberg: So she got like three or four of those classes, and and 1 or 2 honors classes. She was a journalism major in college so she did the newspaper at the various junior high schools she worked at.
Paul Wallner: Mike, was your program three or four years at the time?
Michael Steinberg: It was three.
Paul Wallner: Three. Was Bob Parker there then, or did he come after?
Michael Steinberg: Bob was there. Bob came maybe a year or two before I came. It just took a while to split the department off from radiology to go through all the academic/university issues to become a separate department. But by the time I arrived, it was had just separated from radiology.
Paul Wallner: I think that was part of the deal when he left the University of Washington, and that was probably '73, '74, something like that.
Michael Steinberg: '77 is what I remember.
Paul Wallner: '77?
Michael Steinberg: Yeah.
Paul Wallner: Do you recall who any of your colleagues were, any of the peers, any of the faculty?
Michael Steinberg: Yeah. The faculty, there was Ned, there was Bob Parker. There was a guy named Tom Weisenburger that went to Santa Barbara Cancer Foundation, and Guy Juillard were the faculty. Another guy named Alan Tesler who went up to join the Swedish group. Tom was an associate professor. I would consider him one of my mentors. And he went to the Santa Barbara Cancer Foundation which is kind of a plum of a private practice in California.
The one resident that I was with that you guys all know was Jeff Demanes. He was my chief resident. I almost quit because of him. I still tell that story, even today. In those days the chief resident ran the clinic and assigned the cases. If there was a direct referral to a faculty, the faculty would of course see it. But otherwise, if they were coming to the general service, the chief resident would assign cases to the residents and to the faculty. In any case, the chief would always assign the residents. Jeff basically hogged all the good cases. We didn't have to keep logs then, but I had this spiral notebook where I took down all of my notes on my cases. So in this form I had a list of all my cases. In the first six months, I had seen nothing but bone and brain mets.
Colleen Lawton: Yeah.
Michael Steinberg: And so I went to Ned Langdon to tell him I was going to quit because I was depressed. I showed him the book where I hadn't seen any curative cases. Jeff ended up getting in trouble and eventually demoted. And a guy that you may not know, Fred David, became chief resident early as result of all this. I was not the only one to complain. Fred later went on to practice in Santa Rosa, in the wine country area, and he became president of his county medical association and ended up on state’s board of medicine. I haven't heard from Fred in a few years.
Then the other person that I was a resident with who came to UCLA for medical school and stayed for an entire career was Mike Selch. Mike stay for about 5 years while I was Chair and then retired just before our electronic health record was installed. Mike did CNS and was well-published.
Colleen Lawton: So, Mike, when does Eve come into the picture, during this time, after?
Michael Steinberg: Just before. I'm an intern when I meet Eve.
Colleen Lawton: How did that happen?
Michael Steinberg: Blind date, set up on a blind date through a good friend of mine who I have known since I was in kindergarten. He had become engaged to is a girl he had met at UCLA was friends with high Eve since high school. Since she and I were going to be in the wedding –– usher and bridesmaid –– they thought, maybe we would meet before their wedding. So Eve and I went out on a date. That was in September of internship year. They got married in May of that year and Eve and I married in June.
Colleen Lawton: Oh my gosh. What was Eve doing at the time when you met her?
Michael Steinberg: She's getting an MBA at the time at UCLA.
Paul Wallner: Was that before or after her PhD?
Michael Steinberg: After.
Colleen Lawton: Okay. So you finished residency, then what happens?
Michael Steinberg: I had difficulty getting a job and it was a time when there were supposed to be a lot of jobs. But, I had some difficulty getting a job. I finally landed a job at the end of my chief year in Las Vegas. I joined this combined radiology group. My practice trajectory was very rapid. The radiation oncologist who recruited me was busy, but when I joined, we became very busy. Elsewhere in town there was only a cobalt machine. This practice had been recently set up by a radiology group. They had a LINAC and a cobalt machine, and a simulator. It was fairly well equipped for the time. And then, I had skills in interstitial implants that I learned during my residency. I spent six months with Nisar Syed learning complex brachytherapy. I was basically promoting myself as an implanter and became very busy doing implants as well as external beam. My implant activity continued to be a significant part of my practice for the first 25 years of my career.
So, in the 15 months I was in Vegas I probably did 200 implants of all sorts including things at the time we kind of novel such as big head and neck implant, and rectal implants, and so on. There was a colorectal surgeon that had been president of the colorectal society who “retired” to Vegas. He hated the APR operation. I met him and told him what we could do with radiation therapy. I think I did about 25 patients while I was in Las Vegas on his patients. He had a huge referral base and we treated small primary rectal cancers.
Another doctor was recruited into the group, and I became the odd man out. I was the one with the big practice, and they were the ones that went to lunch together, and soon I realized it was time to get out of Dodge. I started looking for jobs back in L.A. and landed a job with another radiology group. It tuned out it wasn't a very good practice situation. But after I year I get a call from Lee Avalone who was a radiation oncologist who practiced in Santa Monica. He was looking for someone to join him. Actually, Mike Selch was the one who took the job and at the last minute decided he didn't want to leave UCLA. I said I might be interested. Well, six weeks later, I went to work with him a hospital-based practice in Santa Monica.
Subsequently, when the hospital – with a very provincial administrator - wouldn't allow us to hire a nurse, Lee and I decided to leave and set up our own freestanding department. We had a very busy practice and our front office person would answer phones, room the patients and act as chaperone for exams. And this administrator would not allow us to have a nurse.
Coleen Lawton: Yeah. Think about that.
Michael Steinberg: Yeah. We left the meeting with the administrator and decided we had to leave the hospital and set up a freestanding center – which we did. Somehow, we didn't get kicked out of the hospital in the meantime, and we were able to build and establish our center in Santa Monica. Subsequently, about four or five years later, we started adding practices. I think in our peak we had nine sites. Lee retired young a few years after that.
Colleen Lawton: Mike, were all sites in Southern California?
Michael Steinberg: Yes. They were all in the L.A. area. Mostly hospital sites. I saw patients and managed the practice for years.
Paul Wallner: How did you become involved in service to radiation oncology?
Michael Steinberg: It was in the early '90s that I first became involved in radiation oncology service. Earlier I was appointed to an insurance committee for the county medical association where they would adjudicate claims for the proprietary insurance companies. I would go down once a month and eat dinner with other doctors on the committee and people from the insurance companies and discuss insurance claims they did not understand. We'd explain the complexities of bills and determine if the bills were appropriate. All specialties were in the room. This experience sharpened my interest in healthcare economics. I had to get good at it because I was asked to be the local expert in radiation oncology billing. When I started, I really didn't even know exactly what I was volunteering for. It was at that time managed care was taking off in California.
However, the ramp up of my activity in the health policy and healthcare economics began when I was asked to speak at a UCLA faculty retreat about managed care contracting. I spoke about what I knew from my own experience in practice. They thought I did such a good job they invited me back to talk at the retreat the following year. I basically had told them everything I knew the year before so I had to go looking for a new topic.
At about that time, Oregon was doing health planning for its Medicaid program. They were creating a priority list of conditions and this was how they were going to pay for their Medicaid. They created this complex process with one of the big eight, at the time, accounting firms. They were going to create priority list, do a budget, and then they're going to draw a line. Below the line they weren't going to pay for care, and above the line they were. So at the top of this list were things like vaccinations for kids, and at the bottom of the list was questionable back surgery and things like that. Also, low on the list, interestingly enough, was AIDS related treatments. There was still a stigma related to AIDS at the time so AIDS related treatment ended up very low on the list.
Do you know, I read about it in Time Magazine and thought maybe I would talk about this as an interesting health policy topic. I got detailed information from the state of Oregon. Looked at it closely and found out that radiation therapy was left out as a covered service. It wasn't mentioned. So, I called radiation oncology folks I knew in Oregon to find out what was up. They were not aware of this finding that radiation therapy was left off the priority list but their response was very low key. They thanked me for telling them about it and did not think it was a a problem. We'll be included they said.
So, I took what I had learned about the Oregon Plan for Medicaid, which was interesting in and of itself, and presented it to the UCLA faculty retreat. Bob Parker and Rod Withers heard the talk and were very concerned about radiation oncology be left out of the Oregon Plan. They called the ACR and told them about my talk. Subsequently, I get a call from Nick Croce who was an executive with the ACR.
Paul Wallner: Yeah, he was the associate executive director. He ran the Philadelphia office for a time, and then John Curry took him to Reston to be associate executive director.
Colleen Lawton: I remember that.
Michael Steinberg: Right. As part of his job he was the executive director of ASTRO. Did you know him?
Colleen Lawton: Yeah.
Paul Wallner: That was when ACR ran ASTRO, and he was, I think, allocated about 10 or 20 percent time from the ACR to run ASTRO.
Colleen Lawton: Yeah, and that's how I knew him.
Michael Steinberg: He calls me up and I tell him the story. He said, "Can you do a white paper for us on the topic." And, directly written to a typewriter, I typed a 20-page white paper on how the process worked, and where the interventions needed to be for radiation oncology, and sent it to him. I didn't hear from him or a while, and then I get a call. It may have been six months or almost a year later. I get a call from Jerry Brickner, who got my name from Nick, and asked if I wanted to get involved with health policy at the ACR on behalf of ASTRO. That's when I think I first met you, Paul. Who else was involved then? Bogardus was around, but I don't recall who else was around -- [cross-talking]
Paul Wallner: Chris Rose. Chris was involved a little later, I think.
Michael Steinberg: Chris, a little later on. I think he was a little later after this actually.
Paul Wallner: Yeah.
Michael Steinberg: Jerry asked me to become involved in this small volunteer group overseeing ASTRO health policy issues. As Paul knows, Colleen, it was a very centralized process, that ACR didn't have a committee structure for this function. It was three or four people kind of doing the policy and economic stuff. They did the same thing for the radiologists, too. And we did that way for a number of years.
Then, ASTRO split off from the ACR. Actually, it was the ACR's idea at least from my understanding of it. ACR was getting out of the subspecialty society business. In any event, at that time, I was asked to run the Joint Economics Committee for ASTRO and the ACR – the JEC. I said I'll do it, but I didn’t want to do it alone. I was in private practice. My partner was understanding but not that understanding. And so it was initially Jerry and I who were the co-chairs of this Joint Economics Committee. Then Jerry became president of the ACR, right?
Paul Wallner: Yes.
Michael Steinberg: Then Paul becomes the other co-chair with me. You and I did that for a couple of years.
Paul Wallner: Right.
Michael Steinberg: Then after that, I think it was Lou Potters?
Paul Wallner: Right.
Michael Steinberg: We kept running the committee with co-chair leadership. This was all before the reorganization of the ASTRO board. This goes from about 1999 until about 2002. In 2003 the reorg of the ASTRO board occurs. You were already on the Board, Colleen, elected as an academic leader or something like that.
Colleen Lawton: Yes.
Michael Steinberg: I was asked to run for, I think they called it health economics council chair or something like that, at the time. That was the initial name of the council.
Colleen Lawton: Yeah.
Michael Steinberg: The way the reorganization came down, I ended up as Chair of the Council for four years. I was never vice chair of the Council.
Colleen Lawton: Right.
Michael Steinberg: And I think the junior position was reallocated, if you remember this, to Peter Blitzer who was already sitting on the Board in a legacy community practice position.
Paul Wallner: Mike, do you want to talk a little bit about your transition from private practice to academic practice? That's obviously an unusual pathway, and it's more often the other way.
Michael Steinberg: Yes. I actually wanted to stay in academics when I finished residency, but there was no job position for me at the time at UCLA, and I didn't really look elsewhere. To be honest with you, they strung me along a little bit dangling a job through my Chief year that never came through. Then I got a late start in job hunting and I wasn't really looking at other programs.
What happened was Rod stepped down. And there was a search that turned into one of those endless academic search committee processes. It went on for a few years. As people came through UCLA for interviews, because I ran a group with a big practice footprint in LA and I was known from my ASTRO Board and health policy activity, I would get calls from some of candidates. I'd go to dinner with them and inform them about the LA radiation oncology scene and opportunities for collaboration. So through this, my name became known to the search committee.
The bottom line, when somebody asks me, how did you become Chair? I would say, kidding on the square, I'm the result of a failed search. But, what actually happened was the committee basically had gone through a number of people. Some had some pretty large asks. They would want $30 million or $40 million packages. Our dean at the time, Gerry Levey, was not in the habit of doing those kinds of packages. Although the department had fallen on hard times, with an interim chair for a number of years and a number of people left. No junior faculty had been promoted to Associate Professor for more than ten years, and there had not been an investigator-initiated trial in the department for a decade. It really had fallen on hard times and the faculty even fell below the critical level of four required for the residency.
I get a call from the Dean. (I later learned that it was Bill McBride that gave my name to the dean.) The Dean says he wants to go to lunch with me. I ended up going to lunch with him and Dave Callender who was the CEO of the hospital at the time. He's now the president of the University of Texas, Galveston. So, we go to lunch at the Regency Club, a high-end private club. We had a nice lunch. I gave them the lay of the land for radiation oncology in Los Angeles and nationally. They asked me some academic questions that retrospectively I didn't even know were academic questions. I think, I truly think, that I am being interviewed to become a new search committee member to help them in their search.
I get a call a few days later from Gerry. He says, "You know, David and I met and talked after we went to lunch with you, and we liked you better than anybody that we interviewed. Do you want to be chair?" This is the truth, I said, and this was my response, "Did you call the wrong number?" And he laughed. He says, "I didn't call the wrong number." We talked for a while. I asked him for time to "think about it." I thought about it for a week, and called back. I said, " I am honored. What's the process?" I went through an interview process where I interviewed with 17 people over about three days and then got offered the job. It took almost a year to finalize the contract, and it wasn't for the reason that the Dean thought. The reason was after some due diligence I found that the documentation and billing function for the department was way below par. If we were audited, it would have been a mess.
So, as a condition of my employment, I requested that someone specifically be hired from outside to UCLA to oversee billing and compliance for the department. What I didn't understand was to make this hire meant obtaining a something called a “sole source” contract. And that was something that was hard to do in the university. It took a year to get that done. In the meantime, the dean thought I was playing hard to get, which I wasn't. I was just trying to land this compliance thing. One of the associate vice chancellors from the medical school shepherded this through the bureaucracy and kept the Dean calm during the interim. That's how I got here.
The thing I should mention – Paul shouldn’t listen now – in this process, I had to create PowerPoints about vision/mission and so forth. At the time I really didn't know the nuances of the tripartite mission of an academic department. I didn’t even know what that was. I'd do these half-assed PowerPoints and Paul would rip them apart. He basically took me by hand and taught me the details of academic department organization and process. So those initial PowerPoints targeted at faculty and the Dean’s Office, the structure of those PowerPoints, and I would even say, a lot of the content, was actually created by Paul.
Colleen Lawton: That’s really fascinating.
Michael Steinberg: Yes.
Colleen Lawton: I've got two burning questions. The first is, how does the family – I mean you obviously raised a successful family amongst all of this – how did Eve do with the moves? Where did the kids come into play? How did all that happen?
Michael Steinberg: Early on in our careers, when the kids were young, Eve worked longer hours than me and traveled a great deal as well. In fact, when the kids were little in the early '90s, she went platinum on five airlines one year. She had a lot of responsibilities that were out of town. We had help in the house like nannies and housekeeper and we had a schedule to be with the kids on the weekends. One of us would always be home in the evening to help with homework and be there for the kids.
Colleen Lawton: How did you, for example, so you graduate residency, you go to Las Vegas, how was that for Eve with her career, and maybe being pregnant along the way? I'm fascinated to know how at the time when it's not easy to be a working mom, did you make all that work?
Michael Steinberg: She made it all work. I didn’t make it work. We would pay for help, for nannies and so on. When we went to Vegas, we didn't have kids yet. She was up for a new adventure and was going to figure something out. At that time she was going to give up what she was doing at the time and find a new career, but didn't stay long enough for that to happen. When we came back to L.A., she got back on career trajectory in business consulting. She was a consultant with Arthur Andersen, and another company called Amherst Associates. When she came back to LA and continued to be a consultant with Amherst, and then a year later ended up in a Fortune 500 healthcare company where she rose fairly quickly.
To give you a sense of her drive and commitment, the night our second child Drew was born, I went home after the delivery at 2:00am in the morning and come back at 7:00 am. I walk into the room and her five direct reports are sitting by the bed taking notes. Eve is breastfeeding the baby or trying to breastfeed the baby, while giving directions to her direct reports.
Colleen Lawton: Good God.
Michael Steinberg: Eve had the ability to do that. The weekends were for the kids. Our friends became people who had kids in our kids school. We didn’t socialize outside that bubble very much. That's how it pretty much worked. I tended to come home earlier than Eve. So if there was homework, that tended to fall to me. The weekends for the kids would be led by Eve.
Colleen Lawton: Fascinating. You had nannies, in-home care, or in-home help?
Michael Steinberg: Yes. In fact, our help had help. So our nannie would have a housekeeper, somebody to clean the house, and then the nanny would be responsible only for the children. Our kids were good kids. They were not handfuls. They rarely went down the wrong pathway. We were blessed in that way.
Paul Wallner: Did either Beth or Drew ever consider medicine?
Michael Steinberg: Never, neither of them. I wasn't one of those docs who came home and complained that medicine is going to hell and all that. They were both good students, and actually very good science and math students, both of them. But they never really had the interest. My oldest, Beth, who you both know, was interested in what her mother did for a living. Beth is in private equity now. She was always drawn to that. Early on, she always wanted to go to New York, and that's where she ends up going to college. So she goes to college in New York, never came home. She still lives there.
The younger one is five years younger. Her trajectory, she was interested in different things. She's not money driven. She's interested in public service and found herself doing things with that kind of focus and got her graduate degree in public policy. She was a religion and society major in college at Haverford. And her second parents, who she notes to this day were much better parents than Eve and I, were Paul and Susan.
Paul Wallner: I understand right. We were more permissive.
Colleen Lawton: Just like that.
Michael Steinberg: So, she worked for the mayor in L.A., and she now works for the fire chief in L.A. She runs performance excellence for the fire department. And actually she does risk management as well for the fire department. They trained her to do that. That's what she does. She goes to work with a bunch of firemen.
Colleen Lawton: Switching gears a little bit, Mike. So, I think Paul knows better, but I think I have a good handle on like the contributions that you've made. If you have one or two that you would say is at the top of your list of the things that you've done.
Michael Steinberg: For ASTRO or in the specialty?
Colleen Lawton: As you look back on your career, I don't think it necessarily has to be for ASTRO. I would say even more broadly the field.
Michael Steinberg: Yes. At least on the ASTRO side, I guess my legacy is the health policy platform that we put in place. We basically totally changed from the way the ACR did it, where it was very centralized, to create a four subcommittee structure reporting to the major committee and the council. It became 70 to 80 members casting a wide net that could create consensus among the various constituencies of our specialty. We took healthcare economics from what was kind of negatively called “billing”, and you were at those board meetings where our presidents or president-elect would be reading the newspapers, as I presented my reports, to become known as the health policy arm of the organization. At the time it was a big fight. To even change the name of the council to health policy from economics, for whatever reason was a very big deal.
Colleen Lawton: Yeah.
Michael Steinberg: So we were able to put that platform in place. And what we did – and this is a general contribution as well – we had an attitude that we weren't going to be buffeted by CMS and the insurance companies. What we were going to do was we were going to bring new processes of care and new technologies to patients as rapidly as was reasonable. Paul knows we were pretty aggressive about that, and we were very successful in bringing IMRT in place, and in retrospect, probably overvalued at the time. But that overvaluing allowed for the recapitalization of the specialty because when it happened, everybody all of a sudden had the money to buy new linear accelerators and so on.
Colleen Lawton: Yeah.
Michael Steinberg: I would say one of my significant contributions as ASTRO Chair was leading our organization to participate in Choosing Wisely. Chris Cassell was executive director of the American Board of Internal Medicine Foundation and was the lead for the Choosing Wisely campaign. She approached me when she was at UCLA as a visiting professor. That triggered a number of conversations both with the ABIMF and ASTRO which lead to our specialty’s participation in Choosing Wisely. I think another contribution would be my leadership in establishing ASTRO’s commitment to equity and disparity in healthcare. During my first run on the Board (2003-2007), I was a PI of a NIH disparity grant (U-56). There were four or five of those grants around the country awarded to radiation oncology PIs. Over a number of Board meetings, along with a particular ASTRO staff person, I proposed a permanent committee to deal with EDI - equity, diversity, inclusion. For whatever reason, there was resistance to such a move by the Board at that time. But finally, a committee was put in place when you and I were on the Board the first time around, Colleen.
Colleen Lawton: Yeah.
Michael Steinberg: If you recall, there was some pressure not to do it, for some reason. I don't know why. But, anyway, we were able to get that established, and I am happy to say it has a lot of traction now. Another leadership contribution was RO-ILS, the Patient Safety Organization. It was not my idea but came up in 2010 when the specialty was buffeted by the NY Times articles about safety. It kind of got lost in the shuffle of rolling out the ASTRO response to the Times articles. I kind of picked up the idea of a national peer reviewed protected platform for the specialty when I was president-elect and continued to doggedly push it. Eventually, staff was able to figure out how to do a PSO. It was launched either under my watch or your watch as Chair, I think.
Colleen Lawton: It was evolving during that time.
Michael Steinberg: Yes. On the academic side of things, when I got to UCLA, I looked at some numbers. We'd seen about a thousand patients, and we're treating about 600 of them. It was a pretty small department. Patients were leaving and going elsewhere for treatment. We were basically doing a lot of second opinion. It was also at a time of nine weeks of IMRT for the treatment of prostate cancer. So, if somebody lived only 20 miles away, that could be a two-hour drive in L.A. That was a reality I had to deal with when I first arrived at UCLA.
And at that time Bill McBride's lab demonstrated this notion that large SBRT-like fractions were associated with beneficial immunologic effect. At about the same time, something similar came out of Zvi Fuks’ lab at Sloan Kettering as well. So, I decided to go big with this in prostate cancer and recruited Chris King from Stanford. With substantial leadership from Pat Kupelian we began a robust SBRT prostate program. By 2013, we were able to report 1,100 cases. And last year, 2,000 cases with many with over 9 years of follow up. So, now we have a couple of randomized trials published from Sweden and the UK as well.
So I think it is fair to say that under my leadership, ultra-hypofractionation in the prostate was encouraged at UCLA. Ideas related to this have stimulated a number of our junior faculty to pursue these concepts and they are careers out of it. Percy Lee was one of those faculty. He just went to MD Anderson to run thoracic oncology there. Amar Kishan is another who has distinguished himself by elucidating our understanding of the high-risk prostate cancer and the need for high biological dose to treat those patients.
The Ultra hypo-fractionation focus of our department dovetailed into addressing the value proposition from policy point of view. We wrote an article about value in 2013 published in JCO. The article elaborates the whole notion of value in our specialty. So, I would like to think that I have made some modicum of a contribution as part of the group that pushed the edge when it came ultra-hypofractionation and value in our specialty.
Colleen Lawton: Yeah.
Paul Wallner: Mike, we're getting close to the end of the hour. For the last five or ten minutes, do you want to give us some sense of what you see as the future both technologically, scientifically, training, payment policy, you know, put on your scepter and orb, and see where things are going in your eyes?
Michael Steinberg: Sure. The present, where things are going, and if this sounds more articulate than I usually am, it is only because I'm preparing a talk about the future of the specialty for the UCLA Dean's Council.
I think one can think of our future as falling into four related or overlapping domains.
One is personalizing radiation therapy around a biology axis. Using tumor specific and patient specific germline informed notions in treatment is in our immediate future. Omic information like genomics, metabolomics, and transcriptomics will inform us how and when to intensify or de-intensify treatment as well as to better understand side effects of our treatments. So I think that's one domain.
I think another area of precision or personalizing radiation therapy relates to the physics axis. Yes, I think that there will be progress in that area. I thought we were at the end of that a decade ago, but I don't think so now. An example of leveraging technological advance has been forwarded by one of our faculty in the form of 4 Pi. The notion of real time adaptive therapy, something you can do with in real-time with an MRI movie running concurrently as you are treating has begun to show promise. I think that that could be a game changer in the way we treat a number of tumors such a pancreas and maybe even prostate. It may likely be more of a game changer than protons. Although real-time adaptive protons I suppose is a possibility, too.
I think the other area that will be particularly beneficial to us as a specialty is what I call kind of bridging the local control chasm. Basically, there is a renewed focus now, I think, on local control, particularly as it relates to oligometastasis or oligoprogression, and I think we'll see a dramatic change in and who we treat going forward. I mean I was shocked by the findings of the Gomez lung oligomet trial. I thought treating of oligomets would benefit patients, but I didn't think it would work in a disease like lung cancer. But it does. We are on the verge or a whole new set of treatment paradigms in our approach to oligometastatic disease.
Then the final domain relates to optimizing value. You know, optimizing quality of life for the patient while minimizing costs, and along the way creating efficiencies. I think that describes future directions for our specialty at this point in time.
Paul Wallner: Do you want to weigh in on the current controversy as to the weighting of clinical knowledge versus physics knowledge versus biology knowledge perplexing the Board of Radiology right now?
Michael Steinberg: First of all, I am not sure what is behind this. Possibly fear about the job market. But, there are jobs. Our residents are getting good jobs. I don't think there is a glut. The thing I do know is every time we try to predict workforce needs particularly around radiation oncologist needs, we've been bad at it. Our predictions miss the mark every time. It's the same discussion we had in the late '90s, and then what happened? IMRT happened. The discussion existed even in the '80s as I recall as well.
So, the conversation is occurring again now. Contrary to what some of the anonymous blogs are saying, I don't think there is a glut of radiation oncologists at this point in time. I think there are good opportunities for these brilliant residents that we are training. Colleen, you may not have heard. As probably my last leadership hurrah, I will be on the radiation oncology RRC.
Colleen Lawton: Oh my god.
Michael Steinberg: Yes. So, I'm here for at least another six years because it's a six-year term for that.
Paul Wallner: I had heard.
Michael Steinberg: I feel strongly that if we maintain or raise the quality bar for our programs and demand a certain level of quality of our programs, and don't look the other way when programs aren't meeting the criteria that we already have set, that we can address some of these problems related to workforce and training. And, yes, I think a good radiation oncologist needs to understand didactic physics, and yes, you do need to understand didactic cancer biology and even some radiobiology. And I think most of those deleterious comments that - you and Lisa had to endure were inappropriate, anti-intellectual even anti-professional.
Colleen Lawton: Yeah, I see your point.
Paul Wallner: So, if Lev or Micah or Liam were interested in radiation oncology, would you encourage them or discourage them?
Michael Steinberg: They're all under three-years-old, Paul.
Paul Wallner: Yeah. But that could change.
Michael Steinberg: I'm not dodging the question, but right now I think all three of them want to be firemen.
Paul Wallner: They have good genes, so I expect great things from them.
Colleen Lawton: Well, I want to thank you personally for your time. Mike, I find this fascinating, so I really have enjoyed this. I hope that it's good for you, and I personally need to thank you for everything you've done. I'm learning things that I didn't even know that you had done, so way to go.
Michael Steinberg: Thanks for taking the time to listen to me pontificate.
Paul Wallner: Great. Thanks very much, Mike. We really appreciate it.
Michael Steinberg: Thanks guys.
