Chapter 14: Setting Up the New Ambulatory Clinic (Mays Clinic) –And Redesigning It

Chapter 14: Setting Up the New Ambulatory Clinic (Mays Clinic) –And Redesigning It

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Description

In this chapter, Dr. Hill offers a comprehensive view of his work setting up the Ambulatory Care Clinics and serving as Director from 1974 to ’79 (noting that he learned to work with Dr. Clark’s leadership style effectively during this period). A new Clinic was needed to serve the crowds of patients standing around as if “in feedlots.” Dr. Hill discusses several topics: MD Anderson’s acquisition of the land and money to build the new clinic; the challenges of dealing with a new building whose architects had not planned well for specific medical uses and needs; personnel upheavals; evaluating the function of the building and staff once the departments moved in; his work writing educational materials for patients on the procedures they would undergo; change in the policy of allowing patients to handle their records. Dr. Hill also describes his working relationship with Dr. R. Lee Clark, president of the institution at the time. He talks about calling a key meeting held to address design elements of the clinic that resulted in dehumanizing treatment of patients that was “not the way that anyone here wants to practice medicine."

Identifier

HillCS_03_20120220_C014

Publication Date

2-20-2012

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; MD Anderson Culture; MD Anderson History; Building/Transforming the Institution; Multi-disciplinary Approaches; Portraits; Professional Practice; The Professional at Work; Patients

Transcript

Tacey Ann Rosolowski, PhD:

How did you go about setting up the services and planning for the entire service?

C. Stratton Hill, MD:

Well, Dr. Clark, when they started building that, he decided that he wanted me to be the director of the clinic. Well, Dr. Howe, who was head of medicine, was also the director at the clinic. He didn’t like that at all. He really didn’t like that, so that put me sort of at odds with Dr. Howe, although we remain friends and so forth.

Tacey Ann Rosolowski, PhD:

Why did Dr. Clark select you for that position?

C. Stratton Hill, MD:

I don’t know. I guess he thought I could do it. (laughs) Dr. [Robert] Hickey was in on that too, so both of them were. They called me in one day and said, “We want you to run the clinic, and we want you to start Monday.” At that time, I’d had an episode of diverticulitis, and it was something with my colon. I said, “Well, I’m going to have an operation on Monday,” and they said, “Well, we’ll have to put it off a while.” I had that operation, and they put it off until I got— And they said, “We’re going to make Dr. Howe”— See, at that time, he wasn’t called a president. He was called a director, so I was going to be the associate director for the clinic, and they were going to make Dr. Howe the associate director for the hospital. There was no hospital. It was just a smaller hospital. It wasn’t the new part. But Cliff Howe just did not like that. He liked this other deal, but they went ahead and did that anyway. He never did do anything. He just kind of— And it took them longer to build the hospital, so what I did was I started planning, organizing, and about that time Dr. Clark hired a management consultant. I don’t know whether you ever heard this name. His name was Pat Leon, and he came from Booz Allen. It’s a big management consultant firm. It’s still around. You can look it up, Booz Allen something and something. He hired him away from there. Well, he and I got along great because I had realized that Dr. Howe was just—it was too much for him. He just didn’t realize what was going on. Then Dr. Clark got real interested in this International Union Against Cancer, and I remember one of the local civic leaders saying “You know, Lee Clark is just out there fiddling while Rome burns.” He said, “He doesn’t realize that the place is burning up right in front of his face.”

Tacey Ann Rosolowski, PhD:

What was burning up? What were they referring to?

C. Stratton Hill, MD:

Everybody was just—I mean—it was so crowded. We were at the point of if somebody went to surgery, put somebody else in that bed, and sometimes you couldn’t get them out of the recovery room because there was no bed. That’s how bad it was. That’s what I took over.

Tacey Ann Rosolowski, PhD:

How did you work with Pat Leon to sort this all out?

C. Stratton Hill, MD:

We started making the plans. See, you had—how are you going to use—and actually, I wasn’t in on the deal of—the building was being built at the time that I took it over, and so I got together with the architects, and I said, “Wait a minute. Let’s look at all the different things that have already been laid out,” and nobody even asked us. Like for instance, nuclear medicine. What do you need for nuclear medicine? Well, we need a lot of lead. Now, for instance, on one of the floors, because of the radiation therapy run by Gilbert Fletcher—you’ve heard of him, haven’t you?—those doors were leaded. They had thick lead because they used radium, and they would put radium in the uterus for uterine cancer. You had to calculate how long you were going to leave it in there, and then you had to come in there and take it out, otherwise they’d get a lethal dose of radiation. Anyway, they didn’t make any of those plans to—

Tacey Ann Rosolowski, PhD:

Whoops, let me just pause this. (audio pauses )

C. Stratton Hill, MD:

They hadn’t done any of that stuff, so I got with these people, and we had to modify the plans. Then I said, “What kind of toilet facilities are you having for the pediatrics?” “Well, we just hadn’t had the toilet facilities.” “Okay, how about the drinking fountains?” They’re up this high for adults.

Tacey Ann Rosolowski, PhD:

Way higher than kids can reach.

C. Stratton Hill, MD:

We did all that. That’s how come I got to know this Frances Goff. I think I mentioned her. She had these special projects, and the building stuff, she did all of that. That’s how I got to know her real well. We sat down—and then the closer we got to finishing the building— See, we’d have to have General Surgery, Urology, and maybe the Thyroid Clinic would all meet in the same place, so you had the nurses—one or two nurses is all you could have, and she had to do for all three of those services. Well, then the new building was going to be General Surgery here, Urology there, Gynecology here. Nobody thought about, well, they’re going to have different personnel. You’d say to the nurse “Who do you want to go with?” “I want to go with Urology.” And the guy from General Surgery said, “No, I want Ms. Smitherin.” “Well, Ms. Smitherin wants Urology.” “Oh, well, what am I going to do?” We had meetings every week on that part of how we were going to—all the things that we had to do about getting that organized, and then Dr. Clark— And then the other thing was people would come in to the— When I first took over, it was before we were moved into that new place, so I began to look at how the thing was working. We had this woman who was the first one to greet the people as they came in. I think in the old days of one of the radio shows, the local undertaker was called Digger O’Dell. Well, she was Mrs. Digger O’Dell. I mean, she looked like the malach ha-mavis, the Jewish angel of death. She had this deadpan look, and I mean, here, fill this out, fill this out. She didn’t say a word to these people. And I’d go in. I went down and looked at people sitting there, waiting to be called or something. Nothing—they were just sitting there, nobody saying anything. I decided, well, we’re going to have to get some literature to say what’s going to happen. We started developing that, but in the meantime, I went down, and I would address these people and say, “Welcome to MD Anderson. You’re going to be here, and we’re going to try to get you to your doctor as fast as we possibly can and take care of you.” I gave them a little spiel like that. Then I decided maybe we can make a videotape, which we did. I don’t know whether I’ve got any of those videotapes or not, but we made videotapes, and they did a really good job of that. Then we designed cubicles for people to come into to be interviewed for getting everything done and so forth, and then I began to develop literature. One time, see, Developmental Therapeutics, they were using BCG, which is a Tim Burroughs-vaccine -type of thing, to do some testing. It took about a month to get the patient ready for this. And see, Dr. Clark wasn’t keeping up with all of this, so I wrote all the copy for those brochures, and I wrote the ones for radiotherapy and diagnostic radiology and all that kind of stuff. I put in there that you’re going to go into a room, it’s going to be dark, and this is what’s going to happen. You’re going to hear these strange sounds, and that’s just the machine doing this and this and this. Then I got—well, look, you guys do that. I said to Radiology “You guys write that up.” Anyway, I put in there that we would work you up anywhere from one day to one month. Well, I soon learned that you really had— Dr. Clark was gone a lot, so I learned that nothing was final until Dr. Clark said that it was okay. But I went ahead and wrote that up. Marion Wall was his secretary. I don’t know if you heard about her. She was his right-hand gal, and she got it, and she saw that one month. We were having a meeting up in Dr. Clark’s conference room, and he looked over at me and he says, “Burn up every goddamn one of those brochures you printed up.” I said, “Why?” “You say it takes us a month to work somebody up.” I said, “Yes, sir, I do.” He said, “It does not.” I said, “Here, let me show you.” Okay, he was okay.

Tacey Ann Rosolowski, PhD:

So you didn’t have to burn them up.

C. Stratton Hill, MD:

I didn’t have to burn them up, but—

Tacey Ann Rosolowski, PhD:

Was it an advantage sometimes that Dr. Clark wasn’t around keeping close tabs on things?

C. Stratton Hill, MD:

No, because he’d reverse it. He would reverse it. So what I did, I thought, “Well, every time we have a meeting, I’m going to send him a memorandum of understanding.” This is what I understood we decided. That solved a lot of problems, because he could look at that and say, “No, no, that’s not what I meant.” And then nobody had taken any action on it until that had happened.

Tacey Ann Rosolowski, PhD:

It’s always key to learn how to communicate with your boss.

C. Stratton Hill, MD:

That was a very essential part of dealing with Dr. Clark. And the other thing he didn’t want to do, he didn’t want to close the clinic down.

Tacey Ann Rosolowski, PhD:

You mean the old clinic?

C. Stratton Hill, MD:

He didn’t want to close the clinic down to move. I said, “Dr. Clark, we can’t do it without that. We’ve got to shut it down for a couple of days,” because he didn’t realize that there would be new nurses that would go into a section that the doctors would have to— I think some of the doctors told him. And another thing was—

Tacey Ann Rosolowski, PhD:

So he finally agreed that you could shut down?

C. Stratton Hill, MD:

Oh, yeah. He did.

Tacey Ann Rosolowski, PhD:

What was that process like, when you shipped it over from the existing kind of ad-hoc clinic to the brand-new facility?

C. Stratton Hill, MD:

Well, it was like a shakedown cruise of a ship. I mean, I think I told you about the fact that they built into this clinic—there was supposed to be a method of moving the chart from one section to the other automatically. That didn’t work. And then, too, the distances of where we were before were not very great. It would be like almost from here to the room over there.

Tacey Ann Rosolowski, PhD:

Only 25 feet or something.

C. Stratton Hill, MD:

So the thing that you wrote on here, and it transcribed it over there, worked pretty well.

Tacey Ann Rosolowski, PhD:

That automatic transcription thing.

C. Stratton Hill, MD:

Yeah, but then if you were on the second floor and you went up to the eighth floor, that was different. There were just a lot of bugs to— And some of the elevators didn’t work. I mean, it had worked, but on the day that we opened there were still bugs in the thing.

Tacey Ann Rosolowski, PhD:

How many departments were represented in the new clinic, and how many patients did you serve when you first opened?

C. Stratton Hill, MD:

We were serving right at 1000 a day. I believe 1200 was probably what it was, and then, too, we had— Another thing that I did that Dr. Clark didn’t like was that traditionally a patient was not allowed to see their record, so the problem I saw that we were running into was that in order to keep a patient from doing that— Say, for instance, you’re going to have a radioactive iodine scan, and that’s in the basement, and you’ve got to go to the X-ray Department, and that’s on the second floor. Okay, you’ve got to have an escort to take you from downstairs to the second floor. Now, maybe after a day or two, somebody that was with that patient would say, “Well, I know where to take her. I can take her up there to the second floor.” Oh, no. We have to have somebody take the chart, so you can’t see it. I said, “Baloney.” I said, “We’re going to let the patient take the chart, and what we’ll do, we’ll buy some big envelopes, and we’ll color code them, and from this part it will be this color. That part will be this color,” and so forth. And they could put a little string on it. We did that, because they’d say, “I’ve been waiting here for two hours to take me to the X-ray Department.”

Tacey Ann Rosolowski, PhD:

And it’s just there were no personnel available.

C. Stratton Hill, MD:

It was just we didn’t have enough. It would take a ton of people to do things like that.

Tacey Ann Rosolowski, PhD:

What was the rationale at the time behind not allowing the patient to see his own records?

C. Stratton Hill, MD:

That was traditional in medicine. You hear about that now, that they don’t want people to see their record. So finally we quit putting them in those envelopes. We just said, “Here, here’s the record.” Then Dr. Clark found out about it, and he was madder than hell. He called me up there, and I said, “Wait a minute, Dr. Clark. I’ve been doing that for a year and a half. You haven’t heard a single complaint.” He just said, “Okay.” So then another thing that happened was that— I made it clear that people who had complaints come to me. I had a complaint one time from this lady who said, “I didn’t like what that social worker put in my record.” She had read it, and it said something about how she was sitting in the waiting room with her favorite son. This woman says, “I have three sons. How does she know that that was my favorite son? I resent that she put that in the record.” I called the social worker in, and I said—not before her but later on. I said, “No editorials in the record.” We got together with the social work people, and I said, “You put editorial remarks in there, it’s your own peril, so just don’t editorialize. If you think something is something, unless you’ve got some real proof and it’s germane to your note, don’t put anything in there extraneous to this.” I had one guy tell me—one of the doctors said that back in the old days, when syphilis was around—what was that?—STS. That was the serum test for syphilis. You got a number. It gave a score. He said he devised a thing where he called it by his name and this name, and this score was higher than the STS, it meant that his STS score was higher than his IQ. (laughs) And he said he had to testify in court, and then he had to explain what that meant.

Tacey Ann Rosolowski, PhD:

Did you find with the new policy of letting patients take their own records that a good many patients actually read them?

C. Stratton Hill, MD:

Absolutely, and that My Word Against Theirs, David Baldridge, the manufacturer in jewelry, said that he saw in there where Dr. [Nicholas] Papadopoulos—well, we blanked that out—put in there—or one of the doctors said that he was a drug addict. He said, “I wanted that taken out of my record.” Oh, yeah, you’d just see them walking along reading their chart or see them sitting there—usually when they got to the clinic station they would turn that record in. But they could read their— We never had any serious problems whatsoever with that. We had another incident, and this was before I was in charge of the clinic. It kind of upset Dr. Clark, but we had these guys— The University of Minnesota had a big Master of Hospital Administration program, so we hired—because one of the guys that Dr. Clark brought down from the Mayo Clinic had connections up there. He hired several of these guys that just had instead of an MBA it was an MHA. I’m not even sure they give that degree anymore. They were master’s of Hospital Administration. Boy, we had one in particular that thought, “I know how to run a hospital. I know all about all this stuff.” And I said, “You know, I never have heard of anybody that’s got a master’s of Exxon Administration that they made him, right out of college, president of Exxon because he’d learned how to do Exxon.” Anyway, this one guy decided, with the administrator of the hospital, that he had to have the configuration of the clinic sections so that the clerks could do their job and so forth. So he built a wall up so people that were sitting in the waiting area couldn’t see anybody. Whenever the people would come out from behind, over there— And of course, we were having waiting areas like crazy. I mean, people standing up, like I said, and we didn’t even have enough places to take chest x-rays. So we set up a thing in the clinic where we had a chest x-ray machine in there, and then we built these little cubicles. You’d undress and go and get this and come back and redress. We said, “You can’t do that,” because then you had to wait until they finished and come back and so forth. It just slowed us. I said, “Look, let’s get some plastic garbage bags, and they’re going to put their clothes in the garbage bag. They’re going to come in, change, put on a gown, go get the chest x-ray, come back, and take the garbage bag with the clothes. When the one thing opens up, they go in there and change and so forth.” That was how crowded we were, and it was ridiculous.

Tacey Ann Rosolowski, PhD:

How long did it take before the bugs in the new clinic were really worked out and it began working pretty smoothly?

C. Stratton Hill, MD:

Well, it got a lot better within the next couple of months. It never was where it was real smooth. The other thing was the same guy that built these things up— Oh, yeah. And what I did at that time I was—I mean—people would get lost, and they couldn’t say anything to anybody or anything, so I looked up the bylaws, and I said, “Let’s call a meeting of the staff,” and we did. And to me, that was just the thing to do. It shocked the hell out of everybody else, and they said, “Are you sure you want to do it? You haven’t talked this over with Dr. Clark?” “No, I haven’t. Let’s do this.” And I got this [Richard] Dr. Jesse, who was head of Head and Neck Surgery. He was kind of a maverick, too, and he was very much against what all they’d been doing because the administrative people didn’t talk to the doctors at all. They just did it, and you’d have patients that didn’t get their appointment card until the next day. I mean, it was just horrible.

Tacey Ann Rosolowski, PhD:

Your idea was to get everybody in one room and kind of sort it all out.

C. Stratton Hill, MD:

Well, we didn’t have a room big enough to get everybody in, but we called that meeting and that was in the auditorium of the hospital at the time, and I had prepared a—well, whoever was chairman of the medical staff called the meeting, and we got it going. Then he called on me, and I laid out the reason why I called them. And then—

Tacey Ann Rosolowski, PhD:

What did you tell them?

C. Stratton Hill, MD:

I told them that— I cited a lot of the things that had happened and that this was dehumanizing, that this was not the way that I wanted to practice medicine—I don’t think it’s the way that anybody here wants to practice medicine—and that something has got to be done. Well, after I made that pitch, I was expecting somebody to come up. Nobody said a word. I said, “Hey, come on. What’s the matter with you guys? I mean, I talked to you before.” And then I sort of said, “Hey, how about you, Dick?” And then they started, started coming, they started coming, and they reversed everything. They tore down those walls, but still we didn’t have the new building. But at least they could communicate. What this guy was saying, well, the clerks can’t get their work done because the people are always interrupting them. That’s who we’re there to serve.

Tacey Ann Rosolowski, PhD:

Did that meeting kind of set—I don’t know—set a new tone, where people felt they could talk about these issues in a more open—?

C. Stratton Hill, MD:

Actually, I don’t know whether it did or not. I’ll say this: We got results as a consequence of that meeting. But I remember being down there talking to Dick Jesse in his clinic, and Dr. Clark walked in, and he said to me, “You really want to do this?” And I said, “Yes.” I said, “Dr. Clark, you wouldn’t practice medicine like this.” He didn’t say anything. He came to the meeting.

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Chapter 14: Setting Up the New Ambulatory Clinic (Mays Clinic) –And Redesigning It

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