Chapter 21: The Breast Cancer Service: From Section to Department

Chapter 21: The Breast Cancer Service: From Section to Department

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In this chapter, Dr. Hortobagyi first compares the formal processes by which Section Chiefs are recruited today with the informal process by which Dr. Hortobagyi first came to serve as Alternative Section Chief of the Breast Medical Oncology Service under Dr. George Blumenschein. Dr. Hortobagyi became Chief in 1984 when Dr. Charles LeMaistre removed Dr. Blumenschein. Dr. Hortobagyi then explains how, in 1992, institutional politics drove the re-classification of the Breast Medical Oncology as a Department.

Dr. Hortobagyi explains how his understanding of his administrative role evolved, beginning with his role as Alternative Section Chief, when he was “so junior that he didn’t know much.” Dr. Hortobagyi explains that as he matured, he came to understand that he had his own ideas of how work should be organized. He lists some of his first contributions to the Section/Department: he recruited the first three research nurses to the service; he and Dr. Benjamin worked with the Texas legislature to pass a bill in support of physicians’ assistants and nurse practitioners; he was the first to recruit nurse practitioners; he recognized the need to grow the department to grow the number of grants and research support and he visited other institutions to better understand what a breast center should look like. He describes his “gradual awakening” to the idea that the breast center should be re-thought from a patient-centered perspective. He then strengthened the Department to support clinical research, moved on to build up the educational mission of the Department, and finally integrated translational research into the Department and into the process of recruiting new faculty.

Identifier

HortobagyiGN_03_20130123_C21

Publication Date

1-23-2013

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the InstitutionProfessional Path Contributions to MD Anderson Career and Accomplishments Growth and/or Change MD Anderson History Leadership The Administrator at Work On Leadership

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 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

Chapter 21

Tacey Ann Rosolowski, PhD:

Now from 1979 to 1984, you were alternative chief of the Breast Medical Oncology Service and then in 1984 and until 1992 you served as chief of the Breast Medical Oncology Service. So, I wonder if you could tell me how you came to take on that role and what it meant ultimately.

Gabriel Hortobagyi, MD:

Today when we look for someone in an administrative position we go through a search. We consult everybody and his uncle. We go through interviews. We go through a search committee. We go through deliberations. Then we make an offer, and the person comes back with requests and this, that, and the third. Eventually there is a formal appointment, a formal announcement, and the person takes possession of his or her new position. Well, none of that happened there. So, we were—George Blumenschein, Charlie Tashima, Aman Buzdar, and I, and then eventually we recruited a couple of other junior people—but Buzdar and I were doing essentially all the research in the department. Buzdar even then was known to be a little bit more abrasive. I was a little bit more diplomatic, so George Blumenschein, who was the section chief, relied very much on me for a variety of things. Eventually he started talking about me as the alternate section chief. So when he left town, it was sort of understood that I would cover for him and I would take care of those things that needed to be covered. I’m not sure that there was ever a process of would you like to, or what does that mean, and what are the expectations, and you get a salary increment of X, or these are your duties. One day I just started to be referred to as that, and I guess the next year in my contract there was a one-liner that said I was that. In 1984, Dr. Blumenschein, I think, got into a tussle with Dr. LeMaistre, who was the president, and was eventually removed as section chief. So on a Friday afternoon, I was called in by the then head of medicine because by then we had—so prior to that, sometime in the late ’70s, the then physician in chief and VP for patient care—

Tacey Ann Rosolowski, PhD:

Was that Dr. Cox? James Cox?

Gabriel Hortobagyi, MD:

No. No.

Tacey Ann Rosolowski, PhD:

Oh, that must have been before.

Gabriel Hortobagyi, MD:

It was [Fred] Conrad.

Tacey Ann Rosolowski, PhD:

Oh, okay.

Gabriel Hortobagyi, MD:

Conrad. He preceded Jim Cox. So Conrad was a flight surgeon from the Air Force. He was a very organized, very bright oncologist who had flown I don’t know how many missions in Vietnam. He was appointed as VP for patient care and physician in chief, and he picked me and appointed me as associate vice president for patient care. I lasted in that for about—I don’t know—maybe six months, maybe a year. I didn’t like the job, and it was just piled on to whatever else I was doing without any real benefit. So I essentially stepped down and moved on. But my first—one of my first tasks was to merge the two training programs: developmental therapeutics and medicine. That was the first step—to merge the two departments. So around that time, they also recruited Irv [Irwin H.] Krakoff. For Irv Krakoff, they did an administrative reorganization in which they removed the department chairs from developmental therapeutics and medicine and created a new structure called the Department of Medicine or the Division of Medicine—something like that. They appointed Irv Krakoff as the head, and when Irv Krakoff— under the orders of Mickey LeMaistre [Dr. Charles LeMaistre]—removed George Blumenschein from his section chief position, he called me in Friday afternoon at 4:30 saying, “I just fired your boss. You are going to be the section chief from now on.” I said, “Irv, please think about it over the weekend.” He says, “Well. No not really.” (laughing) So I was it.

Tacey Ann Rosolowski, PhD:

I am not asking for indiscreet disclosures, but I’m curious. Was the difference of opinion between George Blumenschein and Dr. LeMaistre—did that have something to do with decisions about the section?

Gabriel Hortobagyi, MD:

Oh, absolutely.

Tacey Ann Rosolowski, PhD:

Is there something that’s relevant to an understanding of how the section evolved? As I said, I don’t want you to be indiscreet. But I’m just curious if there is information that—

Gabriel Hortobagyi, MD:

In that sense, no. It had nothing to do with the section. Dr. Blumenschein—remember he was also the director for education.

Tacey Ann Rosolowski, PhD:

Oh, okay.

Gabriel Hortobagyi, MD:

He was a very outspoken person. I think what happened is that somewhere in public he either challenged or said something that Dr. LeMaistre was not very happy about.

Tacey Ann Rosolowski, PhD:

Uh-hunh (affirmative).

Gabriel Hortobagyi, MD:

It had nothing to do with the internal functioning of the section.

Tacey Ann Rosolowski, PhD:

Uh-hunh (affirmative). So that following Monday when you suddenly came to work and were (laughing) section chief—

Gabriel Hortobagyi, MD:

Tacey Ann Rosolowski, PhD:

I was it.

Tacey Ann Rosolowski, PhD:

Tacey Ann Rosolowski, PhD:

—how did you think about that role? Because suddenly you have a different kind of mandate to make decisions.

Gabriel Hortobagyi, MD:

Well, yes and no. Again, today when we recruit—for instance, we are recruiting for my replacement as a department chair. So there is a thoughtful group of senior faculty members who are a search committee. We request applications from all over the country. They come for visits. They make presentations. They interview with dozens of people. They have a job description about what is expected of them. They have a number of resources that are given to them. These are the positions you can recruit to. This is space you have. These are areas where we would hope you could work to improve the department and build out these. This is what the future looks like, but we also want you to give us your ideas about where you would like to take this department. That didn’t happen in 1984. We just told them, “You’re it.” There was not a job description. There were not a these are the resources you have. The resources I got were what was there. There was no discussion of, “Would you like some more space?” or “Would you like more secretaries?” or “Would you like an additional position?” None of that was—that was not discussed. Even later in 1990-something when we were made from a section into a department, that was sort of Dr. Krakoff’s swansong before he retired. He made us into a department, and he made us into a department because of political reasons not because he was necessarily thinking of us. So at that time in the executive committee of the medical staff, there were five or six surgical departments but only one Department of Medicine. So whenever a vote came—or that was controversial—the surgeons sort of drowned the voice of medicine. So he said, “I can deal with this by making many of our sections departments.” And in fact, at that time leukemia became a department, sarcoma became a department, GI became a department, GU became a department, lung became a department, and breast became a department. All of a sudden, there were more medical departments than surgical departments, so we gained a little bit of greater balance within the staff leadership or the faculty leadership in the institution. But were we asked as section chiefs, “What are your needs?” or “This is your job description. This is what I expect from you.” None of that. It was just a change in name.

Tacey Ann Rosolowski, PhD:

Uh-hunh (affirmative).

Gabriel Hortobagyi, MD:

We were in the same office, in the same clinic space. No more positions. No more salary. No more nothing. It was just a change—an administrative change. Clip A: The Administrator A: Professional Path A: Contributions to MD Anderson A: Career and Accomplishments B: Growth and/or Change B: MD Anderson History C: Leadership C: The Administrator at Work D: On Leadership B: MD Anderson History Learning to Lead Breast Medical Oncology

Tacey Ann Rosolowski, PhD:

Where I want to go with this is how you feel within the various roles that you served—within the section, within the department—whatever that is—how you felt you’ve worked to kind of reshape breast medical oncology administratively or functionally within the department to make it stronger in all of the ways. How would you characterize how your role evolved? Even if no one was giving it to you, you were kind of making it up as you were going along.

Gabriel Hortobagyi, MD:

Initially when I eventually became—what was that word—alternate section chief?

Tacey Ann Rosolowski, PhD:

Yeah. Alternate section chief. Uh-hunh (affirmative).

Gabriel Hortobagyi, MD:

Well, I was so junior I had no concept of where this was going and what I was supposed to do. I understood that my role was there when the boss wasn’t there and that I had to carry on. Then as you mature, you realize that you have different ideas about how the group should grow. As you start to understand the size of it better and as you become more confident about your role as a physician and as a specialist, you start to be productive, and you start getting feedback both from inside and outside the institution. You become more self-confident. Your horizons open up. Then you start proposing changes and proposing improvements. I did that even as an alternative chief. I was the first one to recruit a research nurse—in fact, the first three research nurses—because I was at that time essentially the only one who had grant funding. Then I was the first one to recruit—well, first of all, Dr. [Robert S.] Benjamin, who is the chair or the ex-chair—past chair of the Sarcoma Department—and I worked with the Texas legislature to pass a bill that approved the concept of nurse practitioners and physician assistants. We were then the first to recruit a physician assistant to work in our respective departments or sections at that time. So then this opens up, and then you realize that in order to support your research nurses you need to grow to a certain minimum size because you need a certain number of grants in order to support the extra expenses. The only way you can do that is by increasing your volume and getting more grants. Then you start understanding the administrative intricacies of this. Then you start to understand better the interactions with the other departments. Then you start visiting other places. You see how they function. You see those things that they do better. You see those things that they don’t. Gradually you develop a better-rounded idea of what a breast center should look like. When I came here, even though we had a very strongly collaborative approach where we developed that, we didn’t think of ourselves as a breast center. The breast center concept came later. But it came, again, as a gradual awakening of, you know, we are not doing this for ourselves. We are doing this for our patients. Therefore, let’s rethink this process in a patient-focused manner. That’s how eventually over several iterations of the breast center, it evolved. Because at the beginning, the breast surgeons worked in one area. The breast radiotherapists worked in another area of the building. The medical breast worked—in fact, our first clinic in medical breast—we were just in a hallway, and we had one of those down-foldable shelves on which we wrote notes, and there was a phone. That was our clinic. Eventually we had a nicer one with rooms dedicated just for what we did. There was at least a conference room, which doubled up as a working room. Then we grew to a larger size and then we helped to design that one. And eventually the fourth or fifth medical breast or breast medical oncology clinic was more according to our specs. What happened here at the Mays Clinic was entirely developed by us as a joint effort. We essentially requested and required all of the things that are there. So it was the first time that we actually had all the resources and all the tools at the right place, and we were truly working in a joint enterprise with all of the specialties needed to achieve that. So that evolves gradually. At first you start to understand what you need in terms of patient care because that’s how you are trained as a physician. Then you start making improvements for that. Then because of my interest in clinical research, I started to identify those areas where I thought we could do a better job or could make our research work more efficient. Then you start to expand the educational part. Then you organize the training of fellows and residents and visiting scientists. Then the last part was—in my evolution, I guess—the integration of translational research and the longstanding struggle to actually recruit some laboratory-based investigators within the department, within the section of the department. And only within the past ten years was I really successful in getting a critical mass of translationally thinking physicians into the department. So it’s an evolution. If I could start my academic life over with everything I know, I’m sure that process would be much shorter. But I was learning on the job.

Tacey Ann Rosolowski, PhD:

Well, I notice we are at 3:00, and so our official time is over. Would you like to close off for today? We do have another session scheduled.

Gabriel Hortobagyi, MD:

Let’s do that because I have to take care of few things this afternoon.

Tacey Ann Rosolowski, PhD:

All right. It’s one minute after 3:00, and I’m turning off the recorder.

(end of audio)

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Chapter 21: The Breast Cancer Service: From Section to Department

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