Paul Wallner, DO, FASTRO
By Adam Currey, MD and Eric Gressen, MD
The following interview of Paul Wallner, DO, FASTRO, was conducted on August 22, 2018 by Adam Currey, MD and Eric Gressen, MD.
Eric Gressen: Today we are going to interview Paul Wallner for the history committee. Adam, do you have the outline in front of you?
Adam Currey: I do.
Eric Gressen: Excellent. We’ll start and of course I’ll chime in if there’s something that I have to add, sometimes I’m pretty silent. So, let’s do it.
Adam Currey: All right, sounds good. Well, Dr. Wallner, thanks for doing this. I know you’ve done this yourself before, so you’re familiar with the process. But I guess to start off, can you tell us a little bit about where you’re from, where you grew up?
Paul Wallner: Sure. Well, I grew up not far from where I’m sitting now, I grew up in Philadelphia, Pennsylvania and spent my early years, my formative years in Philadelphia.
Adam Currey: Where did you go to undergrad?
Paul Wallner: Undergrad, it’s St. Joseph’s College on City Line in Philadelphia, which in my era was a basketball powerhouse but not so much anymore. I was a commuter student.
Adam Currey: You were a commuter student, okay. What did you study in undergrad?
Paul Wallner: I was a biology major. But St. Joseph’s is a Jesuit college so as with most of my colleagues - although I’m not Catholic, I went to a Jesuit college - I had enough credits to graduate as a philosophy major as well. So I was a dual, biology and philosophy major. Sadly, I’ve forgotten most of both.
Adam Currey: I hear you there. When did you decide that you are going to go to the medical school? Was that something you’d already always kind of grown up knowing you wanted to do or was that something you found later?
Paul Wallner: Well, I grew up with a very traditional sort of ‘20s, ‘30s family practitioner, general practitioner who made house calls and was just a superb guy and became a mentor. And I think I decided very early on that that’s what I wanted to do. There was a very brief period of time that I flirted with the law. I actually took the law school admission test or whatever they call it, the LSATs, and did well and actually applied to the University of Pennsylvania Law School and was accepted. But I was convinced not to do that by a close relative who was an attorney. Ultimately, I decided to stick with my original plan which was medicine.
Adam Currey: Where did you go to medical school?
Paul Wallner: I went to the Philadelphia College of Osteopathic Medicine. At that point in time, this was in the early ‘60s, to mid ‘60s, there were still quotas. I had a brother, an older brother who’s four years old older than I am who had gone to the Philadelphia College of Osteopathic Medicine and a cousin. It seemed like a reasonable path towards my goal and it worked out fine for me.
Adam Currey: Did you discover radiation oncology at that time or was it something that you knew about previously that you wanted to pursue? How did you get involved in the field?
Paul Wallner: Well, I actually joke about that sometimes because my original intention had been to go into diagnostic radiology. My brother was a diagnostic radiologist. Well, he was a resident in diagnostic radiology. We’re almost exactly 4 years apart, so he was finishing up a diagnostic radiology residency as I was finishing up at PCOM. I used to spend a lot of time in his department and I felt fairly comfortable with radiology and and actually started in what was then an osteopathic diagnostic radiology residency program.
The joke I made was that about three months or four months into the program as we were reporting, I used to fall asleep reporting films in the afternoon and knock a cup of coffee over on the films. We were using 14 by 11 films in those days. And the chairman of the department suggested I might be interested in another specialty. But what really happened was the chairman of the department who was a diagnostic radiologist really or a general radiologist, osteopathic radiologist, his real love was radiation oncology. He got me very interested in radiation oncology. And really, I began to learn radiation oncology on a Picker 240 kV orthovoltage device and an Ernst applicator for GYN. He happened to have been a good friend of Luther Brady, this was in Philadelphia. So of the four years I spent in radiology, most of it was really at Hahnemann in radiation oncology, and then it ended with a formal fellowship at Hahnemann.
So, ultimately, I had enough time in diagnostic radiology that I took the osteopathic boards in diagnostic radiology and have those, but took the ABR in radiation oncology or what was then called therapeutic radiology. Actually, I’m dual-boarded but separately in diagnostic radiology and nuclear medicine and radiation oncology. I’ve used mostly the nuclear medicine part of that training in some of the work that I’ve done subsequently.
Adam Currey: Oh, wow. That’s interesting. How long was your fellowship, the formal fellowship at Hahnemann?
Paul Wallner: The formal fellowship was a year. It was at the last year of my training at Hahnemann. And it was really --
Adam Currey: So, who are some of -- go ahead, sir.
Paul Wallner: I’m sorry. In those days, it was really more a faculty position than a junior fellowship. It was called a fellowship, but the way we work in the department was really essentially a senior instructor or faculty position.
Adam Currey: Who are some of the folks that were there at Hahnemann when you were doing your training there? Who were some of the folks who had an impact on your training at that time?
Paul Wallner: Well, I would say realistically Luther, Luther Brady, had the greatest impact. We worked in teams and he and I were on the same team. There was a senior faculty member named Don Faust who then went on to be chief of radiation oncology at Reading Hospital; John Antoniades who had left then and gone out to Lankenau Hospital to be chief; John Glassburn who went on to be chief of radiation oncology at Pennsylvania Hospital. John and I shared an office for five years so we got pretty close. In those days, Barbara Fowble - I’m dating myself now - was a resident when I was faculty at Hahnemann. She was one of our residents. But I would say that when you look at the totality, it was really Luther Brady who had the greatest impact.
Adam Currey: Is there something that he did that you can kind of point to that really kind of helped shape your career and helped to mentor you?
Paul Wallner: Well, I think what shaped my career most, and I tried to learn the good and the bad, for the people who knew Luther, there were some good and some great and some not so great. But I think his attitude toward the individual patient was really what struck me the most. When he was with an individual patient he was solely focused on that individual. I think his inquisitiveness was significant. I think his desire to publish, he pushed us all to publish and to present. And I think perhaps what had the biggest impact on my career subsequently was some of the administrative responsibilities he gave me early on in my career.
Adam Currey: Great. You mentioned the publishing. Can you talk about some of the things that you worked on during your early time there at Hahnemann? Or maybe even after because you stayed on as faculty, right, after you graduated, after you finished the fellowship?
Paul Wallner: Well, yeah, I didn’t stay on actually. When I finished my training in ‘72, I went directly into the Army and I practiced. So my first job was really working for the government. I was a major in the U.S. Army Medical Corps and ran the radiation oncology department at Madigan Army Medical Center in Tacoma, Washington, which at that time was a 1200 bed military hospital. It was a receiving hospital for all of the Northwest for the Pacific and for Vietnam. This was still the Vietnam era. By the time I left there in ‘74, the hospital was winding down, getting much smaller because the Vietnam War was winding down.
But it was an incredible experience there because it was sort of the golden era for oncology. The chief of medicine was an oncologist, the chief of orthopedic surgery was an oncologist, the chief of urology was a urologic oncologist, the chief of medical oncology went on to become the senior medical oncologist in the Army. So, it was just a really incredible period of time for me. Because of the nature of military medicine and the fact that I wasn’t overly burdened with work, I would go up to the University of Washington which was just a 30 minutes ride away and spent half a day or day a week there. Bob Parker was the chair then and he left then to go to be the chair at UCLA, but I spent a lot of time at the University of Washington. And then in ‘74, Dr. Brady twisted my arm to come back to Hahnemann. So after the Army, I rejoined the Hahnemann faculty.
Adam Currey: Wow. That’s interesting. I wasn’t aware of that. When you said you would drive over to the University of Washington, what were you doing there? Were you seeing patients? Were you conducting research?
Paul Wallner: No, mostly working with the residents and sitting in on conferences. Remember I was right out my fellowship and fellows and residents sort of look over their shoulders. It was very nice to have senior faculty members who were there to sort of lean on and ask their opinions. It was a superb department at the time and a lot of those people went on to be senior people around the country. So it was a great way to sort of polish the edges, if you will, right out of training.
Adam Currey: Wow. That’s very interesting.
Paul Wallner: So coming back to Hahnemann. I think in retrospect, it was well that I left Hahnemann. I always suggest to people that if you stay on where you’ve trained, you may never be seen as more than a resident or just an older resident. But leaving and then coming back I think established me as a real member of the faculty.
Adam Currey: Interesting. Then you went back to Hahnemann. Talk a little bit about your time there. How long were you there? Because I know eventually you left to go to the NCI but how long were you back at Hahnemann?
Paul Wallner: Well, the NCI was much later. I stayed at Hahnemann from ‘74 until ‘79. Most people don’t realize this, but I started my career doing a lot of things that people don’t recognize that I did. The chief of of gynecology at Hahnemann, OB-GYN at Hahnemann at the time was George Lewis who was the founding chair of the GOG. So, as a relatively modest-sized department at the time, we were treating between about 80 and 100 patients a day with about six or seven, eight faculty, something like that. So, none of us were killing ourselves with clinical work. But we had a huge volume of GYN because of George Lewis. So, I was doing probably 150 or so radium cases. We were using only radium in those days. I was doing 150 or so GYN cases myself, so I had a huge GYN volume.
And then because of some problems at Temple University in their radiation oncology program, I was going up to Temple to do radiation for what was then called Temple Skin and Cancer Hospital. It was a, I think, internationally unique freestanding cutaneous disease hospital. The program that I was participating in was a mycosis fungoides, cutaneous lymphoma program. We were following about 800 active patients with mycosis fungoides. And I’ve done book chapters and papers on MF early in my career.
And then we were doing some work with Wills Eye Hospital, and the chief of ophthalmologic oncology was a young guy at the time named Jerry Shields who now is probably the senior and most widely read ophthalmologic oncologist in the world. He has written several textbooks. Jerry and I did the first 50 cases of ocular melanomas with cobalt plaques. So I had a rather varied five years, rather eclectic five years clinically but it was pretty exciting for me.
Adam Currey: Then in ‘79 you say you then left to go to the NCI?
Paul Wallner: Nope. That was much later. At ‘79, I was approached by a member of the Jefferson faculty, a phenomenal guy named George Zinninger. George was a Harvard or Mass General graduate or what was then the Joint Center for Radiation Therapy. He was also a classically trained radiation biologist and physician who joined Simon Kramer at Jefferson. As part of the Jefferson faculty, he was doing radiation oncology at Cooper Hospital in Camden, New Jersey which is right across the river from Philadelphia.
George then, when Cooper was leaving the Jefferson relationship in ‘78, ‘79 and becoming a part of Robert Wood Johnson Medical School, it was Robert Wood Johnson Medical School, Camden, George approached me about joining the faculty there. I had started work on a textbook on bone diseases, radiation oncology of bone tumors. That was going slowly at Hahnemann because of some of my other responsibilities. He basically lured me with the fact that I would have a low clinical load, I would have time to write the book, I would try to get a residency program started. It was all very alluring so I went to Cooper, Robert Wood Johnson, Camden the day after Labor Day, 1979, and it’s sort of emblazoned in my mind.
In 1979, ASTRO was about four weeks later at that time in New Orleans. I decided not to go because I was so new, I didn’t want to just leave the department after I’d only been there four weeks. But George Zinninger went to the ASTRO meeting. When he came back, it was clear to me that he was very ill. I saw him in an examining room. It was clear he was in congestive failure. At age 46 he died, never getting out of the hospital. So, here I was in a new department then with a 46-year-old chair who I really liked and respected who died and not knowing then what would happen to the department or to me. As a formal part of Robert Wood Johnson Medical School, there was a year-long academic search. At the end of that year, so it would have been in late ‘80 or early ’81, I was finally named the chair.
People asked would I leave if I weren’t named the chair. My point was I had never gone there to be the chair. That was not my end goal to work for a 46-year-old guy you like and respect. If you want to be a chair, you go to work for a 65-year-old person I’m not so thrilled with. So I was named the chair and I remained as chair there. I became an associate professor, then a professor at the medical school and remained through 1998. When I went to the University of Pennsylvania. I was recruited to Penn to become the vice chair for operations and administration at Penn. My primary responsibility was to be the creation of the proton center. Just to show you how poor I am at due diligence, about four weeks after I got to Penn, they announced that they had lost $300 million that year. So, any discussion of a proton beam project ground to a halt.
I stayed at Penn for five years, which was the commitment I had originally made to them. And then was lured to the National Cancer Institute, this would’ve been in 2003, by Norman Coleman. So, I stayed at the National Cancer Institute for a little over a year and then left.
Adam Currey: And then left there. All right. I didn’t realize the course of events there. What were some of the challenges and things you faced serving as the chair in Camden? What were some of the things that sort of, I don’t know, impacted your career, your research, your practice in that area when you served there for chair for that period of time?
Paul Wallner: Well, there were a couple of major sort of cataclysmic events, some within the department, some within the hospital and some within the greater community at large. Within the hospital, the hospital had been a 450, 500 bed or so, very sophisticated community hospital and affiliate of Jefferson but was then essentially morphing into a medical school. We had the final two-year medical students. The basic science program wasn’t there until recently. So they would take their basic sciences in New Brunswick, Piscataway, at the main Robert Wood Johnson campus and then come down to Cooper for the final two years.
I became a new chair at the time when the entire institution was changing from what had been primarily a private practice institution to what then became probably 60 or 70 percent full-time faculty institution. And all the cataclysmic events that went with that, the recruiting, the recriminations, the town-gown kinds of issues. So that was a rather significant time for me. There was a period where there were so many transitions of chairs that bizarrely I became the senior chair and the representatives of the clinical chairs to the Board of Trustees. So I was a member of the board there. That was one issue.
A second issue was within the department was that I really felt that I wanted to fulfill George Zinninger’s commitment to develop an academic program. So I proceeded to do additional recruitment of faculty and we began a residency program which ultimately had I think it was six or eight residents with a research program, a dedicated research division and a physics division. We ultimately had eight physicists. So that was one of the internal challenges. I remained as a program director for several years and then turned that over to one of the junior faculty as I get busier with academic affairs and my own clinical practice.
And then external to the institution, George had been very involved with the American Cancer Society. I sort of felt a responsibility to pick up where he had left off when he died. So I got very involved with the American Cancer Society and ultimately became president of the New Jersey division. And then as I got more involved in New Jersey oncology affairs, I was asked to chair the New Jersey Commission on Cancer Research, which was at that time the only state tax funded cancer research entity in the country. We actually gave several million dollars a year for cancer research through grants and stipends. So I chaired that for a number of years, sat on the commission for a number of years.
And then as part of that, because as chairman of the commission you sort of get to know people in the state legislature and state government, I served as chair of what was called the Core Clinical Advisory Group which reported directly to the New Jersey Commissioner of Health. I did that through about three different commissioners. It was not a partisan appointment. It was more of a staff-like appointment.
In those days, New Jersey had a waiver from Medicare to do an all-patient all-payor DRG system. So I was involved in development of that system. New Jersey had a strong certificate of need law and the Core Clinical Advisory Group was presumably a neutral party that made recommendations to the Commissioner of Health directly as to what should be done about certificates of need. They would call upon us for specific kinds of problems. There was a question regarding a possible cancer cluster in New Jersey and along the Jersey shore and they called us to deal with that.
And then the other big sort of cataclysmic event for me at the time was in the early ‘80s, ‘81, ‘82, ‘83, when New Jersey got the Medicare waiver to do this all-patient all-payor DRG system, a prospective payment system. I just happened to be chair at the time of the radiation oncology section of the Radiological Society of New Jersey. We had the largest department in state at the time at Cooper and the only training program in the state. And I just happened to be the chair, so with all the transitions in reimbursement, I was tasked to essentially negotiate with the Medicare carrier in New Jersey, which was Prudential at the time, a change in the payment system for radiation oncology.
Adam Currey: When was all this taking place?
Paul Wallner: In ‘82, ‘83.
Adam Currey: Kind of early ‘80s.
Paul Wallner: Yes, the early ‘80s. At that time, we were paid primarily on the back-end, which was clinical management and paid a daily management fee. It was daily treatment management. It occurred to me in looking at the gestalt of our reimbursement that the clinical part of what we did looked regrettably like primary care or internal medicine. That was not a good way to reimburse radiation oncology. That the best way, I believed, with some external support and consultation, was to really have most of our funding on the front-end which was the uniqueness of what we do, which was the treatment planning aspects and simulation and those kinds of issues.
So I essentially went to Medicare, went to Prudential and said let us redesign the system and I’ll make it revenue neutral. They accepted that and they accepted the system which essentially converted us to a front-end loaded payment system which meant that we were getting paid much more for treatment planning than we were, let’s say, for the clinical management at the end.
I had one significant flaw in my reasoning which I never accounted for and I don’t really talk about it a lot publicly, but I never anticipated the incredible growth in radiation oncology. So what happened was that the first year indeed was revenue neutral but then shortly thereafter that radiation oncologist were doing significantly better than they had ever been doing. And I was getting calls from people around the state of New Jersey about what should they do because their charges were now lower than the reimbursement rates. I never went on the record in writing as what they should do but they all raised their charges.
But at that point, I got called from the American College of Radiology. I had never really been involved with them other than being a member. They said, you sort of did this so well and survived and really won out in New Jersey in what we thought would be a disaster. This may be the model for the rest of the country. Would you be willing to get involved in socio-economic affairs at the ACR and talk to people around the country on how you did it? And little by little, I began to do that.
So none of my socio-economic activities with ASTRO or the ACR were ever intended or by design. It just sort of happened because I was sort of doing some of these things at the time there were these cataclysmic changes in the profession and in reimbursement, at least in New Jersey. The New Jersey model which we all believe was going to become universal never did. It was abandoned at some point, but they never asked me to stop speaking.
Adam Currey: But it sounds like there were elements from that, though that have been adopted, I mean, obviously in the practice long after that period, but it sounds there were elements of that that entered in the reimbursement model for today. Wouldn’t that be accurate?
Paul Wallner: Absolutely. What happened, again, this was not necessarily because I knew any more than anybody else but I was sort of at the right time in the right place with the right people who really allowed me to grow and I would keep my mouth shut and listen and learn. But in the late ‘80s, early ‘90s, it became apparent -- well, I guess it would be about ‘91, ‘92 that Congress mandated that all of medicine go to a resource-based relative value system. At that point in time, about five of us in the ACR, led by Bob Bogardus really, well, really three people who were leaders. Bob Bogardus in radiation oncology, a fellow named Jerry Brickner, Theodore Brickner in radiation oncology and Jim Moorefield in diagnostic radiology, put our heads together and actually came up with a radiology resource-based relative value system that we developed before the Hsaio (Harvard) system was adopted. So when the Hsaio system was adopted by Medicare as the RBRVS, we presented immediately a resource-based relative value system for radiology which was very, very beneficial to radiology and radiation oncology. Essentially all of those upfront charges were embedded in that system so we did very well for years.
Then through that I got involved. I was asked to participate in the relative value system, the RUC committee and became a member of the RUC committee which did all the relative values for physician reimbursement. And then through that, because I got to know the Medicare people, was named to the first of the APC Medicare committees that did the outpatient prospective funding meant for hospitals. I chaired that research subcommittee effort. We were the founding advisory committee for the APC system., We developed the research methodology for the development of the outpatient funding for hospital prospective payment, HOPPs system. So I was sort of in the middle of all that.
I stepped back from all that in 2003 when I went to the NCI. But at that point, because I was an insider and they felt comfortable with me, the CMS people reached out on numerous occasions. The FDA people asked me to begin doing some device reviews, so for about five or six years I did FDA device review. It’s sort of been an interesting ride.
Adam Currey: Interesting. Wow. When you were on the RUC committee, you were doing this under the auspice of the ACR. What was your title during that time with the ACR, your formal position?
Paul Wallner: I think it was really no formal title, just a member of the Socio-Economic or Clinical Practice Committee. But then those were the years and I’m guessing now that it was late ‘80s that the young turks within ASTRO decided that the ACR was not representing them well. So ASTRO, which was really then an appendage of the ACR, ASTRO was ASTR, American Society for Therapeutic Radiology in those days, it was staffed entirely by the ACR people. The executive director of ASTRO was an ACR employee, a fellow named Nick Croce. At that point, the question was how do you do a smooth transition for not only educational and scientific affairs but what was equally important socio-economic affairs. So a joint, what was called the JEC, Joint Economics Committee, was formed. I was a co-chair for several years of the Joint Economics Committee and at that point became really close with Chris Rose and Mike Steinberg and the cadre of younger ASTRO leadership who were really creating a totally separate society. And then ultimately when I became a member of the RUC, it was through my ASTRO membership and not through ACR. So, I did RUC primarily as an ASTRO representative, as a radiation oncologist.
Adam Currey: All right. I see. So that took you up to 2003 and you said going over to the NCI. Can you talk a little bit about your time there?
Paul Wallner: Yeah. We, when I say “we,” technically if you look at all the acronyms it was NCI DCTD,RRP, so it was Division of Cancer Therapy and Diagnosis, Radiation Research Program. So I reported to Norman Coleman. The Radiation Research Program is the extramural side. I don’t know if you’re familiar with how the NCI is divided, there are a number of divisions obviously and centers. But the NCI is basically intramural and extramural. The extramural people do review and management of the external grant funding. And intramural people do their own research.
Most people at the NCI, almost all of the people at the NCI are not allowed to do both. There is this sense that you can’t do your own research on the intramural side while you’re managing other people’s research on the extramural side. But when Norman Coleman had left Harvard or the Joint Center, he was very friendly with Rick Klausner who was the director of the NCI and essentially reached a deal where a number of people in the Radiation Research Program could do both intramural and extramural work. This may have been because the group was so small and because he was personally involved in both the clinic and lab, as well as extramural programs.
So when I was at the NCI, I was one of only I think three or four people there who were doing both. So I spent two-and-a-half or three days a week on the extramural side in an office in Rockville, Maryland managing grants and scientific projects and working with CTEP on the collaborative and cooperative group projects and the disparities programs and international programs, and then two to two-and-a-half days a week on the intramural side on the main campus in Bethesda doing some of my own research with a fellow named Martin Brechbiel, who was a radio-chemist. That’s where some of my nuclear medicine training came in. We were doing some targeted radionuclide work. I at that point was doing some clinical work in breast cancer as well.
Adam Currey: Can you talk a little bit more about that targeted radionuclide work? What was it, what were you working towards, what came out of that?
Paul Wallner: Well, there were two things, and I left before either of them could really come to fruition. One was we were trying to develop a radioactive cisplatin. And the other was that we were trying to target tamoxifen or label tamoxifen with radionuclides and see if we can use it for radiotherapy, for systemic radiotherapy. For a number of years I chaired ASTRO’s what was called STaRT, it was systemic target radionuclide therapy, because it was one of my interest. I had a notion 30 or 40 years ago that targeted radionuclide therapy was the wave of the future. Well, shows you how wrong I was. But, you know, now we’re sort of putting another toe in the water with that. So that was some of the research work I was doing. But as I say, it didn’t amount to much because I wasn’t there really long enough to carry this forward and I was doing some clinical work with breast cancer.
Adam Currey: When you say clinical work, you mean clinical research or that was the main patient volume that you were saying?
Paul Wallner: No. It was mostly patient care at the time. There were no real active protocols in breast cancer at the time, not at least that involved radiation.
Adam Currey: So what happened after that? You said you left the NCI after a short time.
Paul Wallner: Yeah. In 2004 or ‘05 it became clear to me that it was not what I had hoped it would be, that I was not cut out for government work. And Dan Dosoretz was the CEO of 21st Century Oncology at the time. Dan had been trying to recruit me for many years. We had met each other on various committees and panels and presentations and over the years he kept saying why don’t you join 21st Century Oncology? I kept saying I was happy doing what I was doing and I had no interest in doing that. I said that when he approached me when I went to Penn and then he approached me when I went to the NCI.
When I went to the NCI he said you’re not going to be happy and I’ll call you in a year or two. And he called me in a year or two on an especially unhappy day. I said maybe it’s time that we talked. At that point, he wrote a job description. Well, he actually said write a job description of what you’d like to do. I did that and he ultimately attracted me to 21st Century Oncology. That would’ve been late 2004 and I’ve been with them ever since.
And then in 2009, with his blessings, I was approached by the American Board of Radiology to consider the post of Associate Executive Director for Radiation Oncology. And Dan blessed my doing that as a part-time role which I continue to do that.
Adam Currey: That was actually where I was going next. Can you talk a little bit about your time at the ABR? That’s when my interactions with you have always come. Can you talk about that a little bit?
Paul Wallner: Yes, sure. I had been an examiner and I examined in lung cancer for a number of years and got to know the process and got to know the people. An individual who I thought was just an incredible guy named Gary Becker had been a colleague at the NCI. He was head of the interventional imaging branch and our offices were right across the hall. We would talk and became very good friends. He ultimately left the NCI around the time I did and went to Tucson to become associate executive director of the ABR and then executive director and ultimately sort of lured me to the post.
Larry Davis who was chair at the time at Emory had been an ABR trustee and then the associate executive director and had been involved for about 29 years actually, many, many years. Larry and I knew each other very well from American College of Radiology and from the RTOG and from Patterns of Care. Larry thought that it would be an interesting role for me and encouraged me to throw my hat in the ring and helped in the transition. So for about six or eight months, we served in parallel and then he retired from that post. And since 2009 I’ve done it alone. Not alone, I mean obviously there’s a significant staff and fabulous trustees who I work with. But as associate executive director it’s been a terrific time for me.
Adam Currey: That’s great. We’re kind of coming toward the end of our time. As you reflect about all these different posts and positions you’ve had, what would you say you’re most proud of? What would you say is your biggest contribution to the field of radiation oncology? You’re tooting your own horn a little bit. I know it’s uncomfortable.
Paul Wallner: Probably two. One would be the reimbursement. As people have said, a lot of people put their kids through colleges and bought various toys and homes through reimbursement programs that I was helpful in initiating with others, played a role. I think my work at the ABR with program directors and residents and chairs and as part of that was the Residency Review Committee, what’s really now called a review committee. And sort of writing now, my wife tells me I should stop writing editorials, but sort of writing editorials, looking in the mirror of where we are as a specialty.
I think one of the roles I think I was very helpful in ASTRO in creating Emerging Technologies Committee - the founding co-chair with Andre Konski - and getting that up and running and really getting ASTRO involved in looking at new technologies and how we deal with new technologies, and then the ASTRO CME MOC committee which I co-chaired for five or six years. I think it’s not a single role, but I think I, ultimately, I’d like to say my educational role has been the most rewarding for me personally.
Adam Currey: That’s great, excellent. So kind of along the same lines, reflecting on the past and then looking towards the future, what do you see as the future of the specialty? Where are we going?
Paul Wallner: Well, I’ve raised concerns I had shared. At the request of the board, I chaired a task force with Kevin Camphausen of the NCI, looking at the radiation oncology research enterprise. We were concerned that we were not training our young people for the next generation, that we were not looking at targeted therapies well enough. We were not developing agents that were specific for radiation, whether they were sensitizers or protectors. We were looking at agents that were in the pipeline developed by medical oncologists for medical oncologists or by drug companies for drug therapy. And we were taking them to see if they were were beneficial or not so beneficial for radiation. But we weren’t looking at things that really maximize the inherent properties of radiation. That was one concern.
Another concern I think is that whether we are training our young people for those, that kind of multimodality care. I mean, we talk about multimodality care but it’s really at the macro or gross level with surgery and chemotherapy. I think we need to look more to the molecular level. I think that we have not yet scratched the surface, and I’m not sure I can prophesize all this but where scientific developments will take the specialty. I mean, we already see that hyperfractionation is having an impact on the number fractions we treat. That’s having an impact on reimbursement and having an impact on workforce. We don’t know how minimally invasive surgical procedures and disruptive technologies and disruptive targeted therapies will impact the profession.
I was very active in the late ‘70s and early ‘80s when the medical oncologists thought that CMF, cyclophosphamide, methotrexate and fluorouracil, would cure breast cancer. So there was a period of years where patients had surgery and then CMF therapy. We were just never seeing them until they had their recurrences, their local recurrences, and then we got back into treating early-stage breast cancer. But now we see that with the changes in DCIS and LCIS and active surveillance in prostate cancer, the field is changing and I’m not sure that we are ready for it. I’m ready for retirement but I’m not sure with the specialty.
When I talk to young people around the country, which I do in my ABR role primarily, they always say, you know, do you have any good news? I say, yes, I’m close to retirement and my pension is funded.
Adam Currey: So how do we fix that, I guess? What would your advice be for the groups to try to improve, the group that govern resident education to try to improve that?
Paul Wallner: Well, what I’m encouraging now the Accreditation Council for Graduate Medical Education, Residency Review Committee, Radiation Oncology Review Committee next year will be looking at the requirements for training. I’m encouraging the various stakeholders, ASTRO, ACRO, ACR, SCAROP, ADROP, ARRO, to consider creating some kind of a national dialogue to look at where we are in research and where we are in training and sort of position us better for the next generation. If you look at the details of radiation oncology training, is it right? I mean is 450 new simulations, the right number for radiation oncology residence and training? And is there a right number? Should the right number be outcomes-based rather than a simple number? Should we be training everyone in pediatric radiation oncology when only 5 percent or fewer of radiation oncologists are doing any pediatrics? Should we be training everyone in brachytherapy when brachytherapy volumes are declining precipitously except in real brachytherapy centers? I’m not saying I have the answers to that. I am suggesting what some of the questions are that we should be sort of addressing as a specialty not sort of in isolated silos.
Adam Currey: Interesting. Well, we’re running short on time, Eric. Did you have anything you wanted to ask, anything else that I missed that we should talk about?
Eric Gressen: Well, did we talk about your family and your kids?
Paul Wallner: No.
Adam Currey: You mentioned your wife earlier. Tell us a little bit about your wife and your kids and your personal life if you’re willing.
Paul Wallner: Sure. No, I’m perfectly happy to do that. My wife and I, I was a fellow at Hahnemann and she was actually in the PhD psychology program at Hahnemann. We were introduced by a mutual friend who was a psychiatry resident at Hahnemann. Whether that says something about him or about us, I’m not sure but he introduced us. When we got married, as I was finishing my training - she never got to finish her PhD - our honeymoon was basic training in San Antonio at Fort Sam Houston. And then when we got to the Pacific Northwest, she finished a master’s in psychology in the Northwest. When we came back to Philadelphia, she worked as a clinical psychologist for several years. And then responded to a blind ad for an adolescent pregnancy program, which actually turned out to be director of an adolescent program or a grant writer for an adolescent pregnancy program which turned out to be part of the OB-GYN department at Cooper Hospital.
So she actually left her clinical psychology position to be a staff member at Cooper Hospital. She wrote a grant for adolescent pregnancy at Camden. It is a very poor area of the country, probably the poorest city in the country with a lot of adolescent pregnancy. She wrote a grant that was funded by the NIH and then became the administrator of the Obstetrics and Gynecology Department. And then went on for a master’s in health care administration, became vice president at the hospital,. Actually, all that happened before I got there. So she was an administrator before I got there and having nothing to do with recruiting me.
She then went on to become the senior administrator at Temple Health Sciences Center and left that when her father developed Alzheimer’s disease. She left to care for him and then ultimately became a health care consultant which she’s done for many, many years. That has been great for us because it allowed her to travel when I’m traveling to interesting places. We have one child, she’s not a child, she’s an adult, who is a daughter who lives and works in Washington.
Adam Currey: Washington State?
Paul Wallner: Washington, D.C.
Adam Currey: What does she do?
Paul Wallner: She works in the Washington industry which is politics. She was on the inside and she’s now on the outside. She’s a senior campaign consultant. She’s a principal of a campaign consulting firm, a national campaign consulting firm.
Adam Currey: How do you balance all that? I mean, both you and your wife had very active careers, were very successful. How did you balance the family life with the demands of work in there for the two of you?
Paul Wallner: Well, in the early years when I was very involved in New Jersey, it was harder. It was very hard because our daughter was young and my wife actually had a more rigorous schedule than I did. As a department chair, I had a little bit more control of my time than she did as a hospital administrator. Sometimes, I’d be out two or three nights a week for American Cancer Society or hospital functions or ACR work and on the road. That was not easy. She really picked up the load and my associates, colleagues at Cooper picked up the load when I when out of town, and they were very gracious about that.
Then subsequently, it’s become a lot easier partially because of technology and partially because as you get more senior you have a little bit more control of your time. So we now savor the time that we have together a little more. We’ve kept a small apartment in Washington so we get down there. I still do a little bit of work in Washington. Our daughter and son-in-law are in Washington now so we try to spend time down there as well.
Adam Currey: Do you have grandkids?
Paul Wallner: No, we do not. We have a step-grandson.
Adam Currey: That’s great. We have maybe five minutes left, what do you like to do for fun when you’re not influencing major policy decisions on reimbursement rates?
Paul Wallner: Well, we’re trying to travel a little bit more. We’ve just recently done a couple of National Geographic expeditions which were a little bit out of our comfort zone, one to the Galapagos and one to Iceland. I have all the gear. If you ever need gear depending on what size shoe you wear because I doubt that I’ll ever wear waterproof boots again, hopefully not. We love classical music. We spent a lot of time at Tanglewood over the years in the Berkshires. I’ve taken to writing, the editorials for PRO and the Red Journal as a grumpy old man.
Adam Currey: All right. You mentioned the advice you give to trainees through the ABR and such, is there any last words of wisdom you want to share for the purpose of this interview?
Paul Wallner: Well, I’ll tell you the wisdom that I got. Fortunately when I was first interested in radiation oncology, I was directed by a family friend to the fellow who was then running radiation oncology at Albert Einstein Medical Center in Philadelphia, a fellow named David Sklaroff. I said as an osteopathic physician, “Do you think there’s a future for me in radiation oncology?” And he said, “We’re a young and a small profession and if you take good care of your patients and are honest and caring with your colleagues and work hard and participate, you’ll be fine.” That’s what I would tell anyone. First of all, I think the first thing is to take good care of your patients and that’s the single most important thing. And to take good care of your staff and the people you work with but then to participate, whether it’s ASTRO, ACRO, the ACR or volunteer for the ABR.
People say how did you get to do the things you’re doing?” I said I was sort of there and people ultimately trusted me to give me some responsibilities, but you have to be there, you have to participate.
Adam Currey: Sure. It’s great advice. Well, anything else, anything else, Eric, any other questions that you have? Dr. Wallner, anything else you want to tell us? Anything we missed?
Paul Wallner: I don’t think so. I think there is a future I think we need to sort of make a few revisions in where we’re going, but I think there is a strong future for us.
Eric Gressen: Well, excellent. I knew Paul was going to be an excellent interview because every time I talk to him, he ends up going on a topic and I end up listening to him for like a half hour. Paul, did you say you had any hobbies during this entire time except for working on physician reimbursement which clearly was a hobby of yours?
Paul Wallner: I wouldn’t say a hobby really. I do a huge amount of reading. I’m an avid reader of history and political science. I would say that’s about as close to a hobby as anyone would describe.
Adam Currey: What’s the last thing you read for fun?
Paul Wallner: The last thing I read for fun? What I’m reading now is a book called A Certain People which is the history of anti-Semitism in the United States. Right before that I read a fascinating book which I think unfortunately is out of print right now, called In Sickness and in Wealth: American Hospitals 1900 to 2000, about the changes in health care and hospital specifically.
Adam Currey: Interesting.
Eric Gressen: Very good. Well, thank you so much for doing this interview. You already know the process with Adam and I about getting you typed up and reviewed. And Adam, thank you so much. You conducted an excellent interview.
Adam Currey: No, I just have a good subject.
Eric Gressen: You and I at least knew a little bit about Paul so we weren’t shocked when he went from one thing to the other very rapidly. Dr. Wallner might have had the most chairmanships from so many different facilities than anyone.
Adam Currey: Yes, pretty remarkable.
Eric Gressen: Thank you, Paul, for your time.
Adam Currey: Yeah, take good care, we really appreciate.
Paul Wallner: Thanks, guys. It was good talking to you.
The following interview of Paul Wallner, DO, FASTRO, was conducted on August 22, 2018 by Adam Currey, MD and Eric Gressen, MD.
Eric Gressen: Today we are going to interview Paul Wallner for the history committee. Adam, do you have the outline in front of you?
Adam Currey: I do.
Eric Gressen: Excellent. We’ll start and of course I’ll chime in if there’s something that I have to add, sometimes I’m pretty silent. So, let’s do it.
Adam Currey: All right, sounds good. Well, Dr. Wallner, thanks for doing this. I know you’ve done this yourself before, so you’re familiar with the process. But I guess to start off, can you tell us a little bit about where you’re from, where you grew up?
Paul Wallner: Sure. Well, I grew up not far from where I’m sitting now, I grew up in Philadelphia, Pennsylvania and spent my early years, my formative years in Philadelphia.
Adam Currey: Where did you go to undergrad?
Paul Wallner: Undergrad, it’s St. Joseph’s College on City Line in Philadelphia, which in my era was a basketball powerhouse but not so much anymore. I was a commuter student.
Adam Currey: You were a commuter student, okay. What did you study in undergrad?
Paul Wallner: I was a biology major. But St. Joseph’s is a Jesuit college so as with most of my colleagues - although I’m not Catholic, I went to a Jesuit college - I had enough credits to graduate as a philosophy major as well. So I was a dual, biology and philosophy major. Sadly, I’ve forgotten most of both.
Adam Currey: I hear you there. When did you decide that you are going to go to the medical school? Was that something you’d already always kind of grown up knowing you wanted to do or was that something you found later?
Paul Wallner: Well, I grew up with a very traditional sort of ‘20s, ‘30s family practitioner, general practitioner who made house calls and was just a superb guy and became a mentor. And I think I decided very early on that that’s what I wanted to do. There was a very brief period of time that I flirted with the law. I actually took the law school admission test or whatever they call it, the LSATs, and did well and actually applied to the University of Pennsylvania Law School and was accepted. But I was convinced not to do that by a close relative who was an attorney. Ultimately, I decided to stick with my original plan which was medicine.
Adam Currey: Where did you go to medical school?
Paul Wallner: I went to the Philadelphia College of Osteopathic Medicine. At that point in time, this was in the early ‘60s, to mid ‘60s, there were still quotas. I had a brother, an older brother who’s four years old older than I am who had gone to the Philadelphia College of Osteopathic Medicine and a cousin. It seemed like a reasonable path towards my goal and it worked out fine for me.
Adam Currey: Did you discover radiation oncology at that time or was it something that you knew about previously that you wanted to pursue? How did you get involved in the field?
Paul Wallner: Well, I actually joke about that sometimes because my original intention had been to go into diagnostic radiology. My brother was a diagnostic radiologist. Well, he was a resident in diagnostic radiology. We’re almost exactly 4 years apart, so he was finishing up a diagnostic radiology residency as I was finishing up at PCOM. I used to spend a lot of time in his department and I felt fairly comfortable with radiology and and actually started in what was then an osteopathic diagnostic radiology residency program.
The joke I made was that about three months or four months into the program as we were reporting, I used to fall asleep reporting films in the afternoon and knock a cup of coffee over on the films. We were using 14 by 11 films in those days. And the chairman of the department suggested I might be interested in another specialty. But what really happened was the chairman of the department who was a diagnostic radiologist really or a general radiologist, osteopathic radiologist, his real love was radiation oncology. He got me very interested in radiation oncology. And really, I began to learn radiation oncology on a Picker 240 kV orthovoltage device and an Ernst applicator for GYN. He happened to have been a good friend of Luther Brady, this was in Philadelphia. So of the four years I spent in radiology, most of it was really at Hahnemann in radiation oncology, and then it ended with a formal fellowship at Hahnemann.
So, ultimately, I had enough time in diagnostic radiology that I took the osteopathic boards in diagnostic radiology and have those, but took the ABR in radiation oncology or what was then called therapeutic radiology. Actually, I’m dual-boarded but separately in diagnostic radiology and nuclear medicine and radiation oncology. I’ve used mostly the nuclear medicine part of that training in some of the work that I’ve done subsequently.
Adam Currey: Oh, wow. That’s interesting. How long was your fellowship, the formal fellowship at Hahnemann?
Paul Wallner: The formal fellowship was a year. It was at the last year of my training at Hahnemann. And it was really --
Adam Currey: So, who are some of -- go ahead, sir.
Paul Wallner: I’m sorry. In those days, it was really more a faculty position than a junior fellowship. It was called a fellowship, but the way we work in the department was really essentially a senior instructor or faculty position.
Adam Currey: Who are some of the folks that were there at Hahnemann when you were doing your training there? Who were some of the folks who had an impact on your training at that time?
Paul Wallner: Well, I would say realistically Luther, Luther Brady, had the greatest impact. We worked in teams and he and I were on the same team. There was a senior faculty member named Don Faust who then went on to be chief of radiation oncology at Reading Hospital; John Antoniades who had left then and gone out to Lankenau Hospital to be chief; John Glassburn who went on to be chief of radiation oncology at Pennsylvania Hospital. John and I shared an office for five years so we got pretty close. In those days, Barbara Fowble - I’m dating myself now - was a resident when I was faculty at Hahnemann. She was one of our residents. But I would say that when you look at the totality, it was really Luther Brady who had the greatest impact.
Adam Currey: Is there something that he did that you can kind of point to that really kind of helped shape your career and helped to mentor you?
Paul Wallner: Well, I think what shaped my career most, and I tried to learn the good and the bad, for the people who knew Luther, there were some good and some great and some not so great. But I think his attitude toward the individual patient was really what struck me the most. When he was with an individual patient he was solely focused on that individual. I think his inquisitiveness was significant. I think his desire to publish, he pushed us all to publish and to present. And I think perhaps what had the biggest impact on my career subsequently was some of the administrative responsibilities he gave me early on in my career.
Adam Currey: Great. You mentioned the publishing. Can you talk about some of the things that you worked on during your early time there at Hahnemann? Or maybe even after because you stayed on as faculty, right, after you graduated, after you finished the fellowship?
Paul Wallner: Well, yeah, I didn’t stay on actually. When I finished my training in ‘72, I went directly into the Army and I practiced. So my first job was really working for the government. I was a major in the U.S. Army Medical Corps and ran the radiation oncology department at Madigan Army Medical Center in Tacoma, Washington, which at that time was a 1200 bed military hospital. It was a receiving hospital for all of the Northwest for the Pacific and for Vietnam. This was still the Vietnam era. By the time I left there in ‘74, the hospital was winding down, getting much smaller because the Vietnam War was winding down.
But it was an incredible experience there because it was sort of the golden era for oncology. The chief of medicine was an oncologist, the chief of orthopedic surgery was an oncologist, the chief of urology was a urologic oncologist, the chief of medical oncology went on to become the senior medical oncologist in the Army. So, it was just a really incredible period of time for me. Because of the nature of military medicine and the fact that I wasn’t overly burdened with work, I would go up to the University of Washington which was just a 30 minutes ride away and spent half a day or day a week there. Bob Parker was the chair then and he left then to go to be the chair at UCLA, but I spent a lot of time at the University of Washington. And then in ‘74, Dr. Brady twisted my arm to come back to Hahnemann. So after the Army, I rejoined the Hahnemann faculty.
Adam Currey: Wow. That’s interesting. I wasn’t aware of that. When you said you would drive over to the University of Washington, what were you doing there? Were you seeing patients? Were you conducting research?
Paul Wallner: No, mostly working with the residents and sitting in on conferences. Remember I was right out my fellowship and fellows and residents sort of look over their shoulders. It was very nice to have senior faculty members who were there to sort of lean on and ask their opinions. It was a superb department at the time and a lot of those people went on to be senior people around the country. So it was a great way to sort of polish the edges, if you will, right out of training.
Adam Currey: Wow. That’s very interesting.
Paul Wallner: So coming back to Hahnemann. I think in retrospect, it was well that I left Hahnemann. I always suggest to people that if you stay on where you’ve trained, you may never be seen as more than a resident or just an older resident. But leaving and then coming back I think established me as a real member of the faculty.
Adam Currey: Interesting. Then you went back to Hahnemann. Talk a little bit about your time there. How long were you there? Because I know eventually you left to go to the NCI but how long were you back at Hahnemann?
Paul Wallner: Well, the NCI was much later. I stayed at Hahnemann from ‘74 until ‘79. Most people don’t realize this, but I started my career doing a lot of things that people don’t recognize that I did. The chief of of gynecology at Hahnemann, OB-GYN at Hahnemann at the time was George Lewis who was the founding chair of the GOG. So, as a relatively modest-sized department at the time, we were treating between about 80 and 100 patients a day with about six or seven, eight faculty, something like that. So, none of us were killing ourselves with clinical work. But we had a huge volume of GYN because of George Lewis. So, I was doing probably 150 or so radium cases. We were using only radium in those days. I was doing 150 or so GYN cases myself, so I had a huge GYN volume.
And then because of some problems at Temple University in their radiation oncology program, I was going up to Temple to do radiation for what was then called Temple Skin and Cancer Hospital. It was a, I think, internationally unique freestanding cutaneous disease hospital. The program that I was participating in was a mycosis fungoides, cutaneous lymphoma program. We were following about 800 active patients with mycosis fungoides. And I’ve done book chapters and papers on MF early in my career.
And then we were doing some work with Wills Eye Hospital, and the chief of ophthalmologic oncology was a young guy at the time named Jerry Shields who now is probably the senior and most widely read ophthalmologic oncologist in the world. He has written several textbooks. Jerry and I did the first 50 cases of ocular melanomas with cobalt plaques. So I had a rather varied five years, rather eclectic five years clinically but it was pretty exciting for me.
Adam Currey: Then in ‘79 you say you then left to go to the NCI?
Paul Wallner: Nope. That was much later. At ‘79, I was approached by a member of the Jefferson faculty, a phenomenal guy named George Zinninger. George was a Harvard or Mass General graduate or what was then the Joint Center for Radiation Therapy. He was also a classically trained radiation biologist and physician who joined Simon Kramer at Jefferson. As part of the Jefferson faculty, he was doing radiation oncology at Cooper Hospital in Camden, New Jersey which is right across the river from Philadelphia.
George then, when Cooper was leaving the Jefferson relationship in ‘78, ‘79 and becoming a part of Robert Wood Johnson Medical School, it was Robert Wood Johnson Medical School, Camden, George approached me about joining the faculty there. I had started work on a textbook on bone diseases, radiation oncology of bone tumors. That was going slowly at Hahnemann because of some of my other responsibilities. He basically lured me with the fact that I would have a low clinical load, I would have time to write the book, I would try to get a residency program started. It was all very alluring so I went to Cooper, Robert Wood Johnson, Camden the day after Labor Day, 1979, and it’s sort of emblazoned in my mind.
In 1979, ASTRO was about four weeks later at that time in New Orleans. I decided not to go because I was so new, I didn’t want to just leave the department after I’d only been there four weeks. But George Zinninger went to the ASTRO meeting. When he came back, it was clear to me that he was very ill. I saw him in an examining room. It was clear he was in congestive failure. At age 46 he died, never getting out of the hospital. So, here I was in a new department then with a 46-year-old chair who I really liked and respected who died and not knowing then what would happen to the department or to me. As a formal part of Robert Wood Johnson Medical School, there was a year-long academic search. At the end of that year, so it would have been in late ‘80 or early ’81, I was finally named the chair.
People asked would I leave if I weren’t named the chair. My point was I had never gone there to be the chair. That was not my end goal to work for a 46-year-old guy you like and respect. If you want to be a chair, you go to work for a 65-year-old person I’m not so thrilled with. So I was named the chair and I remained as chair there. I became an associate professor, then a professor at the medical school and remained through 1998. When I went to the University of Pennsylvania. I was recruited to Penn to become the vice chair for operations and administration at Penn. My primary responsibility was to be the creation of the proton center. Just to show you how poor I am at due diligence, about four weeks after I got to Penn, they announced that they had lost $300 million that year. So, any discussion of a proton beam project ground to a halt.
I stayed at Penn for five years, which was the commitment I had originally made to them. And then was lured to the National Cancer Institute, this would’ve been in 2003, by Norman Coleman. So, I stayed at the National Cancer Institute for a little over a year and then left.
Adam Currey: And then left there. All right. I didn’t realize the course of events there. What were some of the challenges and things you faced serving as the chair in Camden? What were some of the things that sort of, I don’t know, impacted your career, your research, your practice in that area when you served there for chair for that period of time?
Paul Wallner: Well, there were a couple of major sort of cataclysmic events, some within the department, some within the hospital and some within the greater community at large. Within the hospital, the hospital had been a 450, 500 bed or so, very sophisticated community hospital and affiliate of Jefferson but was then essentially morphing into a medical school. We had the final two-year medical students. The basic science program wasn’t there until recently. So they would take their basic sciences in New Brunswick, Piscataway, at the main Robert Wood Johnson campus and then come down to Cooper for the final two years.
I became a new chair at the time when the entire institution was changing from what had been primarily a private practice institution to what then became probably 60 or 70 percent full-time faculty institution. And all the cataclysmic events that went with that, the recruiting, the recriminations, the town-gown kinds of issues. So that was a rather significant time for me. There was a period where there were so many transitions of chairs that bizarrely I became the senior chair and the representatives of the clinical chairs to the Board of Trustees. So I was a member of the board there. That was one issue.
A second issue was within the department was that I really felt that I wanted to fulfill George Zinninger’s commitment to develop an academic program. So I proceeded to do additional recruitment of faculty and we began a residency program which ultimately had I think it was six or eight residents with a research program, a dedicated research division and a physics division. We ultimately had eight physicists. So that was one of the internal challenges. I remained as a program director for several years and then turned that over to one of the junior faculty as I get busier with academic affairs and my own clinical practice.
And then external to the institution, George had been very involved with the American Cancer Society. I sort of felt a responsibility to pick up where he had left off when he died. So I got very involved with the American Cancer Society and ultimately became president of the New Jersey division. And then as I got more involved in New Jersey oncology affairs, I was asked to chair the New Jersey Commission on Cancer Research, which was at that time the only state tax funded cancer research entity in the country. We actually gave several million dollars a year for cancer research through grants and stipends. So I chaired that for a number of years, sat on the commission for a number of years.
And then as part of that, because as chairman of the commission you sort of get to know people in the state legislature and state government, I served as chair of what was called the Core Clinical Advisory Group which reported directly to the New Jersey Commissioner of Health. I did that through about three different commissioners. It was not a partisan appointment. It was more of a staff-like appointment.
In those days, New Jersey had a waiver from Medicare to do an all-patient all-payor DRG system. So I was involved in development of that system. New Jersey had a strong certificate of need law and the Core Clinical Advisory Group was presumably a neutral party that made recommendations to the Commissioner of Health directly as to what should be done about certificates of need. They would call upon us for specific kinds of problems. There was a question regarding a possible cancer cluster in New Jersey and along the Jersey shore and they called us to deal with that.
And then the other big sort of cataclysmic event for me at the time was in the early ‘80s, ‘81, ‘82, ‘83, when New Jersey got the Medicare waiver to do this all-patient all-payor DRG system, a prospective payment system. I just happened to be chair at the time of the radiation oncology section of the Radiological Society of New Jersey. We had the largest department in state at the time at Cooper and the only training program in the state. And I just happened to be the chair, so with all the transitions in reimbursement, I was tasked to essentially negotiate with the Medicare carrier in New Jersey, which was Prudential at the time, a change in the payment system for radiation oncology.
Adam Currey: When was all this taking place?
Paul Wallner: In ‘82, ‘83.
Adam Currey: Kind of early ‘80s.
Paul Wallner: Yes, the early ‘80s. At that time, we were paid primarily on the back-end, which was clinical management and paid a daily management fee. It was daily treatment management. It occurred to me in looking at the gestalt of our reimbursement that the clinical part of what we did looked regrettably like primary care or internal medicine. That was not a good way to reimburse radiation oncology. That the best way, I believed, with some external support and consultation, was to really have most of our funding on the front-end which was the uniqueness of what we do, which was the treatment planning aspects and simulation and those kinds of issues.
So I essentially went to Medicare, went to Prudential and said let us redesign the system and I’ll make it revenue neutral. They accepted that and they accepted the system which essentially converted us to a front-end loaded payment system which meant that we were getting paid much more for treatment planning than we were, let’s say, for the clinical management at the end.
I had one significant flaw in my reasoning which I never accounted for and I don’t really talk about it a lot publicly, but I never anticipated the incredible growth in radiation oncology. So what happened was that the first year indeed was revenue neutral but then shortly thereafter that radiation oncologist were doing significantly better than they had ever been doing. And I was getting calls from people around the state of New Jersey about what should they do because their charges were now lower than the reimbursement rates. I never went on the record in writing as what they should do but they all raised their charges.
But at that point, I got called from the American College of Radiology. I had never really been involved with them other than being a member. They said, you sort of did this so well and survived and really won out in New Jersey in what we thought would be a disaster. This may be the model for the rest of the country. Would you be willing to get involved in socio-economic affairs at the ACR and talk to people around the country on how you did it? And little by little, I began to do that.
So none of my socio-economic activities with ASTRO or the ACR were ever intended or by design. It just sort of happened because I was sort of doing some of these things at the time there were these cataclysmic changes in the profession and in reimbursement, at least in New Jersey. The New Jersey model which we all believe was going to become universal never did. It was abandoned at some point, but they never asked me to stop speaking.
Adam Currey: But it sounds like there were elements from that, though that have been adopted, I mean, obviously in the practice long after that period, but it sounds there were elements of that that entered in the reimbursement model for today. Wouldn’t that be accurate?
Paul Wallner: Absolutely. What happened, again, this was not necessarily because I knew any more than anybody else but I was sort of at the right time in the right place with the right people who really allowed me to grow and I would keep my mouth shut and listen and learn. But in the late ‘80s, early ‘90s, it became apparent -- well, I guess it would be about ‘91, ‘92 that Congress mandated that all of medicine go to a resource-based relative value system. At that point in time, about five of us in the ACR, led by Bob Bogardus really, well, really three people who were leaders. Bob Bogardus in radiation oncology, a fellow named Jerry Brickner, Theodore Brickner in radiation oncology and Jim Moorefield in diagnostic radiology, put our heads together and actually came up with a radiology resource-based relative value system that we developed before the Hsaio (Harvard) system was adopted. So when the Hsaio system was adopted by Medicare as the RBRVS, we presented immediately a resource-based relative value system for radiology which was very, very beneficial to radiology and radiation oncology. Essentially all of those upfront charges were embedded in that system so we did very well for years.
Then through that I got involved. I was asked to participate in the relative value system, the RUC committee and became a member of the RUC committee which did all the relative values for physician reimbursement. And then through that, because I got to know the Medicare people, was named to the first of the APC Medicare committees that did the outpatient prospective funding meant for hospitals. I chaired that research subcommittee effort. We were the founding advisory committee for the APC system., We developed the research methodology for the development of the outpatient funding for hospital prospective payment, HOPPs system. So I was sort of in the middle of all that.
I stepped back from all that in 2003 when I went to the NCI. But at that point, because I was an insider and they felt comfortable with me, the CMS people reached out on numerous occasions. The FDA people asked me to begin doing some device reviews, so for about five or six years I did FDA device review. It’s sort of been an interesting ride.
Adam Currey: Interesting. Wow. When you were on the RUC committee, you were doing this under the auspice of the ACR. What was your title during that time with the ACR, your formal position?
Paul Wallner: I think it was really no formal title, just a member of the Socio-Economic or Clinical Practice Committee. But then those were the years and I’m guessing now that it was late ‘80s that the young turks within ASTRO decided that the ACR was not representing them well. So ASTRO, which was really then an appendage of the ACR, ASTRO was ASTR, American Society for Therapeutic Radiology in those days, it was staffed entirely by the ACR people. The executive director of ASTRO was an ACR employee, a fellow named Nick Croce. At that point, the question was how do you do a smooth transition for not only educational and scientific affairs but what was equally important socio-economic affairs. So a joint, what was called the JEC, Joint Economics Committee, was formed. I was a co-chair for several years of the Joint Economics Committee and at that point became really close with Chris Rose and Mike Steinberg and the cadre of younger ASTRO leadership who were really creating a totally separate society. And then ultimately when I became a member of the RUC, it was through my ASTRO membership and not through ACR. So, I did RUC primarily as an ASTRO representative, as a radiation oncologist.
Adam Currey: All right. I see. So that took you up to 2003 and you said going over to the NCI. Can you talk a little bit about your time there?
Paul Wallner: Yeah. We, when I say “we,” technically if you look at all the acronyms it was NCI DCTD,RRP, so it was Division of Cancer Therapy and Diagnosis, Radiation Research Program. So I reported to Norman Coleman. The Radiation Research Program is the extramural side. I don’t know if you’re familiar with how the NCI is divided, there are a number of divisions obviously and centers. But the NCI is basically intramural and extramural. The extramural people do review and management of the external grant funding. And intramural people do their own research.
Most people at the NCI, almost all of the people at the NCI are not allowed to do both. There is this sense that you can’t do your own research on the intramural side while you’re managing other people’s research on the extramural side. But when Norman Coleman had left Harvard or the Joint Center, he was very friendly with Rick Klausner who was the director of the NCI and essentially reached a deal where a number of people in the Radiation Research Program could do both intramural and extramural work. This may have been because the group was so small and because he was personally involved in both the clinic and lab, as well as extramural programs.
So when I was at the NCI, I was one of only I think three or four people there who were doing both. So I spent two-and-a-half or three days a week on the extramural side in an office in Rockville, Maryland managing grants and scientific projects and working with CTEP on the collaborative and cooperative group projects and the disparities programs and international programs, and then two to two-and-a-half days a week on the intramural side on the main campus in Bethesda doing some of my own research with a fellow named Martin Brechbiel, who was a radio-chemist. That’s where some of my nuclear medicine training came in. We were doing some targeted radionuclide work. I at that point was doing some clinical work in breast cancer as well.
Adam Currey: Can you talk a little bit more about that targeted radionuclide work? What was it, what were you working towards, what came out of that?
Paul Wallner: Well, there were two things, and I left before either of them could really come to fruition. One was we were trying to develop a radioactive cisplatin. And the other was that we were trying to target tamoxifen or label tamoxifen with radionuclides and see if we can use it for radiotherapy, for systemic radiotherapy. For a number of years I chaired ASTRO’s what was called STaRT, it was systemic target radionuclide therapy, because it was one of my interest. I had a notion 30 or 40 years ago that targeted radionuclide therapy was the wave of the future. Well, shows you how wrong I was. But, you know, now we’re sort of putting another toe in the water with that. So that was some of the research work I was doing. But as I say, it didn’t amount to much because I wasn’t there really long enough to carry this forward and I was doing some clinical work with breast cancer.
Adam Currey: When you say clinical work, you mean clinical research or that was the main patient volume that you were saying?
Paul Wallner: No. It was mostly patient care at the time. There were no real active protocols in breast cancer at the time, not at least that involved radiation.
Adam Currey: So what happened after that? You said you left the NCI after a short time.
Paul Wallner: Yeah. In 2004 or ‘05 it became clear to me that it was not what I had hoped it would be, that I was not cut out for government work. And Dan Dosoretz was the CEO of 21st Century Oncology at the time. Dan had been trying to recruit me for many years. We had met each other on various committees and panels and presentations and over the years he kept saying why don’t you join 21st Century Oncology? I kept saying I was happy doing what I was doing and I had no interest in doing that. I said that when he approached me when I went to Penn and then he approached me when I went to the NCI.
When I went to the NCI he said you’re not going to be happy and I’ll call you in a year or two. And he called me in a year or two on an especially unhappy day. I said maybe it’s time that we talked. At that point, he wrote a job description. Well, he actually said write a job description of what you’d like to do. I did that and he ultimately attracted me to 21st Century Oncology. That would’ve been late 2004 and I’ve been with them ever since.
And then in 2009, with his blessings, I was approached by the American Board of Radiology to consider the post of Associate Executive Director for Radiation Oncology. And Dan blessed my doing that as a part-time role which I continue to do that.
Adam Currey: That was actually where I was going next. Can you talk a little bit about your time at the ABR? That’s when my interactions with you have always come. Can you talk about that a little bit?
Paul Wallner: Yes, sure. I had been an examiner and I examined in lung cancer for a number of years and got to know the process and got to know the people. An individual who I thought was just an incredible guy named Gary Becker had been a colleague at the NCI. He was head of the interventional imaging branch and our offices were right across the hall. We would talk and became very good friends. He ultimately left the NCI around the time I did and went to Tucson to become associate executive director of the ABR and then executive director and ultimately sort of lured me to the post.
Larry Davis who was chair at the time at Emory had been an ABR trustee and then the associate executive director and had been involved for about 29 years actually, many, many years. Larry and I knew each other very well from American College of Radiology and from the RTOG and from Patterns of Care. Larry thought that it would be an interesting role for me and encouraged me to throw my hat in the ring and helped in the transition. So for about six or eight months, we served in parallel and then he retired from that post. And since 2009 I’ve done it alone. Not alone, I mean obviously there’s a significant staff and fabulous trustees who I work with. But as associate executive director it’s been a terrific time for me.
Adam Currey: That’s great. We’re kind of coming toward the end of our time. As you reflect about all these different posts and positions you’ve had, what would you say you’re most proud of? What would you say is your biggest contribution to the field of radiation oncology? You’re tooting your own horn a little bit. I know it’s uncomfortable.
Paul Wallner: Probably two. One would be the reimbursement. As people have said, a lot of people put their kids through colleges and bought various toys and homes through reimbursement programs that I was helpful in initiating with others, played a role. I think my work at the ABR with program directors and residents and chairs and as part of that was the Residency Review Committee, what’s really now called a review committee. And sort of writing now, my wife tells me I should stop writing editorials, but sort of writing editorials, looking in the mirror of where we are as a specialty.
I think one of the roles I think I was very helpful in ASTRO in creating Emerging Technologies Committee - the founding co-chair with Andre Konski - and getting that up and running and really getting ASTRO involved in looking at new technologies and how we deal with new technologies, and then the ASTRO CME MOC committee which I co-chaired for five or six years. I think it’s not a single role, but I think I, ultimately, I’d like to say my educational role has been the most rewarding for me personally.
Adam Currey: That’s great, excellent. So kind of along the same lines, reflecting on the past and then looking towards the future, what do you see as the future of the specialty? Where are we going?
Paul Wallner: Well, I’ve raised concerns I had shared. At the request of the board, I chaired a task force with Kevin Camphausen of the NCI, looking at the radiation oncology research enterprise. We were concerned that we were not training our young people for the next generation, that we were not looking at targeted therapies well enough. We were not developing agents that were specific for radiation, whether they were sensitizers or protectors. We were looking at agents that were in the pipeline developed by medical oncologists for medical oncologists or by drug companies for drug therapy. And we were taking them to see if they were were beneficial or not so beneficial for radiation. But we weren’t looking at things that really maximize the inherent properties of radiation. That was one concern.
Another concern I think is that whether we are training our young people for those, that kind of multimodality care. I mean, we talk about multimodality care but it’s really at the macro or gross level with surgery and chemotherapy. I think we need to look more to the molecular level. I think that we have not yet scratched the surface, and I’m not sure I can prophesize all this but where scientific developments will take the specialty. I mean, we already see that hyperfractionation is having an impact on the number fractions we treat. That’s having an impact on reimbursement and having an impact on workforce. We don’t know how minimally invasive surgical procedures and disruptive technologies and disruptive targeted therapies will impact the profession.
I was very active in the late ‘70s and early ‘80s when the medical oncologists thought that CMF, cyclophosphamide, methotrexate and fluorouracil, would cure breast cancer. So there was a period of years where patients had surgery and then CMF therapy. We were just never seeing them until they had their recurrences, their local recurrences, and then we got back into treating early-stage breast cancer. But now we see that with the changes in DCIS and LCIS and active surveillance in prostate cancer, the field is changing and I’m not sure that we are ready for it. I’m ready for retirement but I’m not sure with the specialty.
When I talk to young people around the country, which I do in my ABR role primarily, they always say, you know, do you have any good news? I say, yes, I’m close to retirement and my pension is funded.
Adam Currey: So how do we fix that, I guess? What would your advice be for the groups to try to improve, the group that govern resident education to try to improve that?
Paul Wallner: Well, what I’m encouraging now the Accreditation Council for Graduate Medical Education, Residency Review Committee, Radiation Oncology Review Committee next year will be looking at the requirements for training. I’m encouraging the various stakeholders, ASTRO, ACRO, ACR, SCAROP, ADROP, ARRO, to consider creating some kind of a national dialogue to look at where we are in research and where we are in training and sort of position us better for the next generation. If you look at the details of radiation oncology training, is it right? I mean is 450 new simulations, the right number for radiation oncology residence and training? And is there a right number? Should the right number be outcomes-based rather than a simple number? Should we be training everyone in pediatric radiation oncology when only 5 percent or fewer of radiation oncologists are doing any pediatrics? Should we be training everyone in brachytherapy when brachytherapy volumes are declining precipitously except in real brachytherapy centers? I’m not saying I have the answers to that. I am suggesting what some of the questions are that we should be sort of addressing as a specialty not sort of in isolated silos.
Adam Currey: Interesting. Well, we’re running short on time, Eric. Did you have anything you wanted to ask, anything else that I missed that we should talk about?
Eric Gressen: Well, did we talk about your family and your kids?
Paul Wallner: No.
Adam Currey: You mentioned your wife earlier. Tell us a little bit about your wife and your kids and your personal life if you’re willing.
Paul Wallner: Sure. No, I’m perfectly happy to do that. My wife and I, I was a fellow at Hahnemann and she was actually in the PhD psychology program at Hahnemann. We were introduced by a mutual friend who was a psychiatry resident at Hahnemann. Whether that says something about him or about us, I’m not sure but he introduced us. When we got married, as I was finishing my training - she never got to finish her PhD - our honeymoon was basic training in San Antonio at Fort Sam Houston. And then when we got to the Pacific Northwest, she finished a master’s in psychology in the Northwest. When we came back to Philadelphia, she worked as a clinical psychologist for several years. And then responded to a blind ad for an adolescent pregnancy program, which actually turned out to be director of an adolescent program or a grant writer for an adolescent pregnancy program which turned out to be part of the OB-GYN department at Cooper Hospital.
So she actually left her clinical psychology position to be a staff member at Cooper Hospital. She wrote a grant for adolescent pregnancy at Camden. It is a very poor area of the country, probably the poorest city in the country with a lot of adolescent pregnancy. She wrote a grant that was funded by the NIH and then became the administrator of the Obstetrics and Gynecology Department. And then went on for a master’s in health care administration, became vice president at the hospital,. Actually, all that happened before I got there. So she was an administrator before I got there and having nothing to do with recruiting me.
She then went on to become the senior administrator at Temple Health Sciences Center and left that when her father developed Alzheimer’s disease. She left to care for him and then ultimately became a health care consultant which she’s done for many, many years. That has been great for us because it allowed her to travel when I’m traveling to interesting places. We have one child, she’s not a child, she’s an adult, who is a daughter who lives and works in Washington.
Adam Currey: Washington State?
Paul Wallner: Washington, D.C.
Adam Currey: What does she do?
Paul Wallner: She works in the Washington industry which is politics. She was on the inside and she’s now on the outside. She’s a senior campaign consultant. She’s a principal of a campaign consulting firm, a national campaign consulting firm.
Adam Currey: How do you balance all that? I mean, both you and your wife had very active careers, were very successful. How did you balance the family life with the demands of work in there for the two of you?
Paul Wallner: Well, in the early years when I was very involved in New Jersey, it was harder. It was very hard because our daughter was young and my wife actually had a more rigorous schedule than I did. As a department chair, I had a little bit more control of my time than she did as a hospital administrator. Sometimes, I’d be out two or three nights a week for American Cancer Society or hospital functions or ACR work and on the road. That was not easy. She really picked up the load and my associates, colleagues at Cooper picked up the load when I when out of town, and they were very gracious about that.
Then subsequently, it’s become a lot easier partially because of technology and partially because as you get more senior you have a little bit more control of your time. So we now savor the time that we have together a little more. We’ve kept a small apartment in Washington so we get down there. I still do a little bit of work in Washington. Our daughter and son-in-law are in Washington now so we try to spend time down there as well.
Adam Currey: Do you have grandkids?
Paul Wallner: No, we do not. We have a step-grandson.
Adam Currey: That’s great. We have maybe five minutes left, what do you like to do for fun when you’re not influencing major policy decisions on reimbursement rates?
Paul Wallner: Well, we’re trying to travel a little bit more. We’ve just recently done a couple of National Geographic expeditions which were a little bit out of our comfort zone, one to the Galapagos and one to Iceland. I have all the gear. If you ever need gear depending on what size shoe you wear because I doubt that I’ll ever wear waterproof boots again, hopefully not. We love classical music. We spent a lot of time at Tanglewood over the years in the Berkshires. I’ve taken to writing, the editorials for PRO and the Red Journal as a grumpy old man.
Adam Currey: All right. You mentioned the advice you give to trainees through the ABR and such, is there any last words of wisdom you want to share for the purpose of this interview?
Paul Wallner: Well, I’ll tell you the wisdom that I got. Fortunately when I was first interested in radiation oncology, I was directed by a family friend to the fellow who was then running radiation oncology at Albert Einstein Medical Center in Philadelphia, a fellow named David Sklaroff. I said as an osteopathic physician, “Do you think there’s a future for me in radiation oncology?” And he said, “We’re a young and a small profession and if you take good care of your patients and are honest and caring with your colleagues and work hard and participate, you’ll be fine.” That’s what I would tell anyone. First of all, I think the first thing is to take good care of your patients and that’s the single most important thing. And to take good care of your staff and the people you work with but then to participate, whether it’s ASTRO, ACRO, the ACR or volunteer for the ABR.
People say how did you get to do the things you’re doing?” I said I was sort of there and people ultimately trusted me to give me some responsibilities, but you have to be there, you have to participate.
Adam Currey: Sure. It’s great advice. Well, anything else, anything else, Eric, any other questions that you have? Dr. Wallner, anything else you want to tell us? Anything we missed?
Paul Wallner: I don’t think so. I think there is a future I think we need to sort of make a few revisions in where we’re going, but I think there is a strong future for us.
Eric Gressen: Well, excellent. I knew Paul was going to be an excellent interview because every time I talk to him, he ends up going on a topic and I end up listening to him for like a half hour. Paul, did you say you had any hobbies during this entire time except for working on physician reimbursement which clearly was a hobby of yours?
Paul Wallner: I wouldn’t say a hobby really. I do a huge amount of reading. I’m an avid reader of history and political science. I would say that’s about as close to a hobby as anyone would describe.
Adam Currey: What’s the last thing you read for fun?
Paul Wallner: The last thing I read for fun? What I’m reading now is a book called A Certain People which is the history of anti-Semitism in the United States. Right before that I read a fascinating book which I think unfortunately is out of print right now, called In Sickness and in Wealth: American Hospitals 1900 to 2000, about the changes in health care and hospital specifically.
Adam Currey: Interesting.
Eric Gressen: Very good. Well, thank you so much for doing this interview. You already know the process with Adam and I about getting you typed up and reviewed. And Adam, thank you so much. You conducted an excellent interview.
Adam Currey: No, I just have a good subject.
Eric Gressen: You and I at least knew a little bit about Paul so we weren’t shocked when he went from one thing to the other very rapidly. Dr. Wallner might have had the most chairmanships from so many different facilities than anyone.
Adam Currey: Yes, pretty remarkable.
Eric Gressen: Thank you, Paul, for your time.
Adam Currey: Yeah, take good care, we really appreciate.
Paul Wallner: Thanks, guys. It was good talking to you.
