Chapter 08: A New Role as Division Head at MD Anderson
Files
Description
He gives an overview of how he stepped into his role as head of the Division of Internal Medicine (2014). He begins by explaining that Dr. John Mendelsohn [oral history interview] began to organize departments around onco-medicine, and this included recruiting a critical mass of specialists to manage the Division of Internal Medicine. He sketches changes in division leadership.
Dr. Tweardy then explains how became aware of the job, the appeal of the position, and the vision he had for division. He then talks about differences in the culture at Baylor College of Medicine. He sketches leadership lessons he learned in his interim chair roles that would serve him at MD Anderson.
Next, Dr. Tweardy talks about his good working relationship with Ethan Dmitrovsky, MD [oral history interview], the provost, and the overlap in their ideas for developing the division: building service excellence, growing research, and recalibrating expectations.
Dr. Tweardy then talks about the “excessive siloism” at MD Anderson, the hierarchies among divisions, and the challenges of establishing the value of the Division of Internal Medicine. He explains the steps he took to address the visibility and perception of the Division’s value, discussing in particular the steps taken to improve and showcase financial accountability.
Identifier
TweardyDJ_02_20190320_C08
Publication Date
3-20-2019
City
Houston, Texas
Interview Session
David J. Tweardy, MD, Oral History Interview, March 20, 2019
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the Institution; Joining MD Anderson/Coming to Texas; MD Anderson Culture; Leadership; On Leadership; Portraits; The Institution and Finances
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey. A. Rosolowski, PhD:
Interesting. Well, tell me how the opportunity to come to MD Anderson came about.
David Tweardy, MD:
So Bob Gagel, my predecessor, was the first Chairman of the Medical Subspecialties Department, in what was then just Medicine, Division of Medicine. And that was essentially the nucleus for the Division of Internal Medicine. So John Mendelsohn [oral history interview], in his great wisdom, said, “We can’t manage all of the onco-medicine problems of our cancer patients and get the best results for our patients unless we really grow onco-medicine, the ability of all the subspecialties of medicine to care for the patients prior to their intervention, be it surgical, chemotherapy, or radiation, manage them through all the complications of those therapies, and then get them back on their feet and to the best status that they can be.” At that time, actually, the very first onco-medicine, if you will, was Abe Braude, infectious disease specialist, because the very first thing patients got when they got chemotherapy was febrile neutropenia. White count bottomed out, febrile—oh, no, what do we do? Well, and the oncologists, they managed them initially, and actually they did so when I was at Case Western, in Internal Medicine. But it clearly was clear that they couldn’t do both really effectively, and so the ID group became experts in management of that, and then all of the other infections that these patients get. So John said, “Let’s start this department.” And then he said, “You know what? We need to bring in more specialists, because they get pulmonary problems, they get renal problems, they get cardiology problems, and we need to bring in experts that can manage those problems, too.” And so the Division started in 2002. Bob, who was the Chairman of the Medical Subspecialties, became the interim, actually, Division Head, and then got the nod for the permanent position very shortly thereafter, and then recruited all the chairs that are there. Psychiatry, by the way, was the latest addition to our division. They joined us in 2015, ’16. Yeah, they were out there floating around, and we said, “Come join us.” So they did, and it’s been a great story ever since. But so that—so Bob grew it, and basically he was there during the linear growth phase, and then—
Tacey. A. Rosolowski, PhD:
And remind me his name again? Bob?
David Tweardy, MD:
Yeah, Bob Gagel, G-A-G-E-L. Robert Gagel. Endocrinologist par excellence, the describer of multi endocrine neoplasia syndrome, MEN.
Tacey. A. Rosolowski, PhD:
Okay. So he was the one who contacted you, or?
David Tweardy, MD:
No, no, no, no.
Tacey. A. Rosolowski, PhD:
Oh, okay, okay, I’m jumping the gun. Sorry.
David Tweardy, MD:
So the way it works—yeah, no, no, no, no, no. Actually, did he ever make any contact with me? I don’t think he did. What happened is—in departments of medicine, which this is really essentially … The more standard approach is you go to the dean, or the dean equivalent, and you say, if you’re the Division Chair or Division Head, as Bob was, you say, “I’m thinking of retiring. I want to step down.” And so this is a major—it’s like any other Division Head, but we’re the second or third largest. So what—at that time that was—yeah, Ethan Dmitrovsky [oral history interview] was the Provost, equivalent of the dean essentially. So he did the usual thing: he started the process for a search. And, actually, I was contacted by one of the members of the search committee. At that time I had a close relationship with Issam Raad, because Issam is the Chair of Infectious Disease here. I was the division head equivalent across the street. And we had a joint program, actually, in the ID fellowship program, so I was known to the community over here, particularly the ID community. And I wouldn’t be surprised if the ID community here kind of gave Cortes, --actually Jorge Cortes is now—who left the institution just recently, who was on the committee, a heads-up, and said … And actually, I saw the ad, too. And so I was already getting interested in it, and Jorge said, “Can I answer any questions about it?” I said, “Hmm. Yeah.” I asked him a few questions, but then I—so I think at that time I either had already sent a letter of interest or I was about to, so I sent the letter. And so went through the usual interview process. I made it to the finals, and, frankly, I had a vision for the Division, as you might expect, that it was a requirement for the finalists to do. And, fortunately, I was chosen. I mean, the one thing that, again, just surprised me—this is where the cultural differences became apparent. And people gave me a heads-up in advance, my people like Javier Adachi, who is an ID here, and I’d worked with him, because he was the Program Director here, and he and Barbara Trautner, who was my program director over there, kind of had lots—reasonable numbers of conversations with Javier. He said, “You’ve got to be careful. MD Anderson is not Baylor.” And I, during my interview process, realized that. But the thing that—it’s kind of like that old Joni Mitchell song: “You don’t know what you’ve got till it’s gone.” I mean, I came here and realized, guys, gals, you’ve got an amazing situation here. And while clearly no place is perfect, I was very excited about how we could tweak it. Not a gross overhaul, because this division was well run by Bob, and the chairs, they were well-oriented. They were a little spoiled, if you will, because MD Anderson allowed you basically—so if you lost this person, you could immediately rehire. That concept is not generally out there. You lose a person, you need to reevaluate whether you really needed that person. Well, that was foreign. When I came here—you may know this—that was a foreign concept four years ago, four and a half years ago. You lost somebody, (snaps) it was like (snaps) boom, a person reappeared, somebody popped up and replaced them, just like whack-a-mole. (laughter) But it was a foreign concept to me, and I said, well, if that’s the way it is, that’s great. I mean, I can work with that, because it’s the opposite. You wouldn’t be able to resource people. I was very used to that at Baylor. So I looked at the position. I immediately realized ahead it was a great place for me to be. It would allow me to move into the role equivalent of a department chair, which I kind of—and this is the other thing: the curse of the chief medical resident. For some reason if you’re a chief medical resident you sort of get somewhere embedded in your head that you should be chair of medicine. So, yeah, (laughter) you can talk to other chief medical residents, see if that’s true. I’ve talked to a few, and that tends to be a trend. And so it allowed me to do something I sort of had envisioned as a career. It allowed me to also mentor and facilitate on a higher level, with a group of chairs here, or I had taken a position elsewhere. And I looked at a number of chair positions over the course of the last five years before taking this one. You want to mentor division heads --over at anywhere else here would be chairs. And the thing that I was fortunate, by being interim chair at Baylor, it made me sensitive to how different the different disciplines of medicine treat and think, and their perspectives. It was shocking the first time. I kind of—you’re just naïve, is what it is. When I became the interim Chair, it actually was the first time I really got exposed to this, when I was asked to chair the search for the new pulmonary head across the street, and I got to know the pulmonary faculty very well. I just thought, boy, these people think differently than ID colleagues that I’ve been exposed to throughout my career at Case, Pittsburgh, and Baylor. And then when I became interim Chair of Medicine, I got that in spades, is that everybody, all of these different disciplines of medicine, they view the world differently, and you had to be able to up your game in terms of synthesis of information and perceptions, that you didn’t have to. I mean, you had to change your vocabulary a bit. You had to recalibrate what was important, and why it was important, and how patient care and patient care [synthesis?] was translated by pulmonary versus infectious disease versus cardiology. I mean, infectious disease—this is going to be a big jingoistic, but infectious disease is always the first consultant on the case, because if we don’t get there and diagnose and manage that patient with the right antibiotics, we know that if it’s strep pyogenes infection they’re going to die in four hours. So that just changes your mindset as a consultant. So if you look across the country about who has the best show rate once you call a consult, it’s in the infectious diseases. And the second is usually cardiology, for similar reasons. The heart can stop functioning for four minutes before you die, and so cardiology (laughs) also gets there fast, and maybe, arguably, even faster than ID. But everybody else, you can argue, doesn’t necessarily feel that urgency. So that’s the thing that I had to digest and realize is that the sense of urgency isn’t necessarily part and parcel to every subspecialty in medicine. That’s one thing I had to learn. But so bottom line, though, when I saw the incredible potential here, this was far and away the best leadership job, as Head/Chair of Medicine, that I ever saw. And so I clearly was gunning for this one, and, fortunately, got it.
Tacey. A. Rosolowski, PhD:
So what was your vision? I mean, and I always ask this as a two-part question, because someone at this level—I mean, most levels—comes in with a mandate, the official mandate—
David Tweardy, MD:
That’s right, that’s right.
Tacey. A. Rosolowski, PhD:
—from the institution, but then there’s your personal mandate. And so I’d kind of like to hear both sides of that.
David Tweardy, MD:
Well, it’s interesting: I really got along with Ethan [Dmitrovsky; oral history interview]. I liked him a lot. I knew Ethan, actually, through his work back in the late ’90s, because while he ended up, and still is, working in lung cancer, his first area of work was actually in acute promyelocytic leukemia, a type of AML. And so I knew—and his particular tool, if you will, and expertise is the use of retinoids, or retinoic acids, to manage both diseases, and I think he moved into lung because there was just more unmet medical need, really. And he was a consummate academician. He had succeeded all the way up to the level of dean. He was a phenomenally well-funded investigator, extraordinarily well-regarded in the NCI. And so he and I, we spoke very much the same language. So what he wanted of the new Head of Medicine was a realization that the kind of continual expansion that was existing in the Bob Gagel era, that was unsustainable, and there needed to be sort of not necessarily a consolidation but at least a plateauing, and a bit of a reality resetting around, like we talked about, do we really need that position, and let’s justify it from a clinical, educational, research perspective and see if we have the financial resources to pay for it. And so I was totally prepared for that, because I’d been at two institutions where that was the rule of the day. And I think he wanted me to kind of organize and get some of the rough edges of the division smoothed over. There were certain—we had—there were three super-sections in the division at that time. A super-section is a discipline of medicine that is distinct from any other discipline, but is not large enough, because of the faculty, to be declared a department, so they were embedded in departments. So benign hematology, which is the study of coagulation, mediated by clotting factors and platelets, as well as premalignant AML syndromes, was managed—there was a group of four faculty, and they were embedded in Benign Hem, in part because the head of Benign Hem was a VA physician before he moved over, and pulmonary medicine is headed by a VA physician who came over to be chair of the department there. So there was a familiarity. And also maybe the other is clots go to the lung and cause pulmonary emboli, so there was that relationship, too. Nephrology went into General Internal Medicine, which was not a bad place to put it, but there was real friction between the chair of that department and the head of Nephrology, so they ended up in Emergency Medicine, of all places. (laughter) Yeah. No really easy way to justify that. And then Rheumatology was in General Internal Medicine, and is still there. We actually created a fourth subspecialty, or super-section, I should say, and that’s Hospital Medicine, and they’re actually the largest—if they were a department, they’d be the largest department in the division. They’d be 21 faculty this September. So what I think Ethan wanted me to do was kind of recalibrate expectations for those super-sections, because they were told—two of them, at least, were told—“You’ll be a department; just be patient.” And so I had to recalibrate that. And, like I say, there are a few other little bit jagged edges to smooth out, and just continue the service-orientedness of the department, grow research as I could. So it wasn’t really a hugely challenging charge. It really wasn’t, not for me. I mean, part of it was also, obviously, just being accepted as the new head. The challenge, maybe, for me was coming into a division that the only head of the division since its inception was Bob Gagel, and so I had to make certain that I didn’t offend Bob or in any way make people wish for the Bob Gagel days. But I’d done that before with, actually, ID. Dan Musher, who was a giant in infectious disease, I replaced him and I was able to negotiate that skill (inaudible), if you will, without too much difficulty, in part because Dan was really very much in favor of a smooth transition. Bob, to his credit, was similarly interested in not having that be a rocky start for me. So the challenges were there, but not huge. It was something I was more than willing to accept. I was coming into a well-resourced division, and well-run division, with really good leadership, so it was really a no-brainer for me, and it allowed me to continue my research and moving our small-molecule probes into actually convert them to drugs that potentially—
Tacey. A. Rosolowski, PhD:
Were there any surprises on the administrative side?
David Tweardy, MD:
Within the division?
Tacey. A. Rosolowski, PhD:
Yeah, or just—or at MD Anderson, too. This is a transitional space between—yeah.
David Tweardy, MD:
Yeah. Well, in the department, division itself, not so much, because maybe by that time I was good at quickly sizing up leadership, and nobody surprised me. And really, we managed—we actually have four new chairs. With Cardiology, we’ll have four new chairs within our ten departments. But no, I mean, there were no huge surprises. In the institution, yes. I mean, again, I was fortunate to come into the institution in a time when this excessive silo-ism that had been created and I wouldn’t say fostered, but enabled, maybe, or at least developed without interference by John Mendelsohn and then Ron, that silo-ism was declining. And actually I think it’s largely because of Ethan’s efforts. I mean, one of the things you will know, and you probably already sense, is I really thought very highly of Ethan, and I think he was critically important to the leadership of this institution in its transition. And I think Ethan was already beginning to sort of look for emotionally intelligent leaders, not just academically strong or intellectually strong content experts as leaders. He brought in Carin Hagberg, which was a brilliant choice, I think, for Division Head for Anesthesiology. I mean, let’s face it: he brought Steve [Hahn] in; he brought me in; and Richard Gorlich, Carin Hagberg—and the existing chair, Tom Feeley, left right before I came. And, actually, Ki Hong [oral history interview] had stepped down, and there was an interim. Dick Champlin was the interim Division Head until Patrick Hwu took the job permanently. And because of a couple interims, because of the couple new --and I was new, the surprise wasn’t that—well, the surprise was that there was such a silo-ism. The good news, though, is there was a real effort to move in a different direction, and if … For instance, probably the most fortuitous thing of my arrival in the division head community was the absence of Ki Hong, because if Ki Hong had been here when I came, there would’ve been some difficult discussions going on at the division head level, I think, because—
Tacey. A. Rosolowski, PhD:
What would have been the nature of those discussions?
David Tweardy, MD:
I think that Ki was there when the Division of Internal Medicine was still a department in his division. I think he was interested in maintaining the Division of Internal Medicine in a subjugated, sort of secondary role. Everybody I know who I’ve interacted with who is from that era, I’ve had to assiduously work to eliminate that, or to remove that, or to change that point of view.
Tacey. A. Rosolowski, PhD:
Where do you think that comes from?
David Tweardy, MD:
I think it comes from the silo building, the—I mean, and the ironic sense of zero-sum game, which still does exist a little bit here, even though it needn’t, which is that if I get something it means he can’t or she can’t, and if he does get something it means I can’t. That sort of sense of one-upmanship. And maybe it’s more one-upmanship, really, than the zero-sum game notion here. And, in a way, it’s kind of the younger brother syndrome. If you’re the younger brother, you’re not the first, and you’re not going to—it’s not expected you’re going to get regarded in the same way. And it’s also, frankly, a very—there’s a truth to it, which is, let’s face it, the big upstream players in this institution are Oncology, or Cancer Medicine, and Surgery. And they deserve a rightful high regard. I think my job would have been harder to sort of convince the institution—and I’m still working on this, and that is the value added by Division of Internal Medicine is substantial, and includes all of onco-medicine, basically getting the patients to the highest performing status so they can withstand their therapy, getting them through their therapy, and then allowing them to have the best results getting out of their therapy, because they have all the support of the subspecialties of Internal Medicine, the departments of Internal Medicine. And we do that very well. We are the premier onco-medicine group in the country. And the reason that they have the outcomes that they have is, in part, due to our efforts, and optimizing the function of all the critical organs that get damaged as they get their therapies. That’s just our medical piece. I think what has happened, which … You always look for opportunities, in a way, if you’re in the situation where you’re not necessarily going to be the top position. So let me back up. If you go to any medical center in the country, the number one department is medicine, with few exceptions, okay, and that’s like—actually, Baylor. The number one department, arguably, at Baylor is Pediatrics, because of Texas Children’s, and the fact that they have a clinical venue that absolutely overlaps and aligns with the Department of Pediatrics there, and it’s a huge enterprise. And the former president was both the—President of Baylor College of Medicine—this is Ralph Feigin—he was the President of Baylor College of Medicine; he was the Chief of Pediatrics, or the Chair of Pediatrics at Baylor College of Medicine; he was the physician-in-chief at Texas Children’s Hospital. It’s a wonderful alignment to have for a department. Medicine, well, actually, had that for a while until the Methodist split. And so adult medicine is always—is the exception there, [in?] medicine. Everywhere else, though, it’s the largest department. Numerically, it’s the largest; has the largest research budget; and largely has the largest influence, for the most part. So coming to MD Anderson, that was, perhaps, the one thing I had to deal with, which is I was coming to head up a Division of Internal Medicine where I wasn’t necessarily—the department, or the division, in this case, wasn’t necessarily the sort of leading academic division, okay. And I was more than willing to accept that, because I totally bought into the notion of onco-medicine, and the importance of what onco-medicine did in terms of patient care, and saw an opportunity to, I think, raise the sort of image and the portfolio of medicine here, because of the timing, that it was past its growth phase. It was, at that point, the third or second—actually, the second-largest division in the institution, second to Cancer Medicine and one step ahead, just a little bit, to Surgery. And I realized that if Ki Hong had been here, I think that there would have been—he would have sensed what I was trying to do, and it would have probably put more of an effort to sort of undermine that effort. And he was very well-connected at that point. And so it would have been more of a struggle. I think we would have prevailed in the end, but, in other words, allowing us to get to the level of regard I think we should have been, and should be, in the institution. But I think that would have made it harder—
Tacey. A. Rosolowski, PhD:
What are some steps that you took to start to make that happen?
David Tweardy, MD:
Yeah, to make that happen. I think the immediate step I took was just a financial accountability understanding. I took that seriously because of my two institutions I’d been in previously. And Bob, to his great credit, had already pretty much put the Division of Internal Medicine a good distance away and ahead of the rest of the divisions in terms of financial prudency, being prudent financially, and also accountable. So I built on that. And then we had the Epic—I think the thing that really changed the dynamics for us, and the way we were perceived, was Epic implementation. The inevitable happened with Epic, which was revenues disappeared that were formerly there. Because of my financial interest, because of trying to squeeze blood out of a stone at Baylor for 12 years, and just realizing if you’re going to—you had to—if you wanted to be accountable and transparent, you had to tell everybody, and they had to believe that you were doing everything you could to make certain that you were getting all the resources you deserved for the effort you were putting in. So that notion of being basically paid for the work you did was deeply embedded, probably from the time I was three years—third grade. I think I told you my first paying job was a paperboy. So that worked, that —I was tapping into that. And so when I came here, and Epic implementation went forward, and we were starting to lose money, certainly some of it was expected, but Bill and I—he was an administrator here—we became aware that some of these money losses just didn’t make sense, that there were things we were doing that we were no longer billing for. And so Erica had moved into the Office of Finance as our Financial Director, and so we built the tools to essentially maximize and optimize revenue capture, and we distributed them to everybody in the institution. So those tools—they’re called the Cogito Cubes—and the Five Demandments that Bill developed to answer the question: is the financial loss that you’re suffering, is it identifiable, trackable, and correctable? We managed to basically correct the Division of Internal Medicine’s financial books within two months, and everybody else took four. And the reason it took four is that they started implementing our tools on the third month, and once they did they were back on track. So we immediately established our credibility in the financial aspects of the new world of MD Anderson, which is where we are now. The crisis, of course, was Epic implementation, but, frankly, everybody knew that that was just one of the bumps on the road to a leaner and meaner financial picture for MD Anderson moving forward. So that was probably—that was really—that made people stand up, I think, and take a little more attention.
Recommended Citation
Tweardy, David J. MD and Rosolowski, Tacey A. PhD, "Chapter 08: A New Role as Division Head at MD Anderson" (2019). Interview Chapters. 1390.
https://openworks.mdanderson.org/mchv_interviewchapters/1390
Conditions Governing Access
Open
