Chapter 22: Creating a Patient-Centered Breast Service

Chapter 22: Creating a Patient-Centered Breast Service

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Dr. Hortobagyi notes that there was huge resistance, at first, to integrating all services associated with the treatment of breast cancer. He then talks about what convinced people this was the best move, beginning with the case of Eva Singletary, a patient who was literally followed throughout her treatment, beginning with the moment she set foot in MD Anderson for a diagnosis. This exercise revealed that the institution was organized in a bureaucracy centered, rather than a patient centered, scheme. Dr. Hortobagyi explains that there was also a rise in patient load and a concurrent rise in MD Anderson’s reputation. MD Anderson faculty were also publishing important research, which drives growth and the institutions’ reputation, Dr. Hortobagyi says. He then goes on to explain how MD Anderson discoveries have indirect effects on patient referrals.

Dr. Hortobagyi explains that, when the new Breast Center was constructed, there was a “retrenchment” as physicians were afraid that they would give up their own territory in a situation based on collaboration. A decade later, the Breast Service is based on a mentality of sharing and shifting traditional ideas of how a service should be run.

Dr. Hortobagyi gives the example of making room utilization more efficient, then explains that in the new “pod” layout of the Breast Center, it is easy to find a specialist for a consultation, sharing weeks of works ups.

Identifier

HortobagyiGN_04_20130128_C21

Publication Date

1-28-2013

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 - MD Anderson Past Patients Building/Transforming the Institution Multi-disciplinary Approaches Growth and/or Change The Clinician Understanding the Institution The Business of MD Anderson The MD Anderson Brand, Reputation Professional Practice The Professional at Work The Clinician at Work On Care Understanding Cancer, the History of Science, Cancer Research The History of Health Care, Patient Care

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

We did that, and it turned out that this poor patient had to walk miles and miles towards the institution in order to go through all of her appointments for radiology and for the lab and to see the surgeon and to see the medical oncologist. It was a huge undertaking. It was a huge undertaking for a healthy person. Just imagine what it was for someone who was ill because of her cancer or because of some comorbid conditions. So that underlined the fact that we were not really patient centered, but we were bureaucracy centered because it was convenient to have all of the surgeons here. And we just happened to have space for the radiation oncologist there, and I do not think it was an intentional decision—to hell with the patient. No, I do not think it was that. It was just the thoughtless evolution of bureaucracy, you know? So with that in our back pocket, we then were more successful in getting our recommendations listened to, and they were incorporated into the plans of the Mays Clinic, and some if it was incorporated into the plans for this building.

Tacey Ann Rosolowski, PhD:

Can I ask you about the timing? You said that there was a certain moment when in the previous location you became too large.

Gabriel Hortobagyi, MD:

Right.

Tacey Ann Rosolowski, PhD:

What was the increase in patient load? And why was that increase happening?

Gabriel Hortobagyi, MD:

Well, the increase was the result of the fact that MD Anderson was coming out of its infancy. It was becoming better known not only locally but nationally and internationally. And then more and more patients were looking for our services, and this is a complicated phenomenon. Sometimes institutional leadership doesn’t understand this well. One way you grow is because you take good care of people. That patient goes and tells friends how happy they were with their treatment at MD Anderson, that spreads the news, and people come back because of patient satisfaction. That’s one thing. And another one is that as you do research, you publish research results, you present them to meetings. Other physicians listen to that, and the next time they see a patient who’s relevant to that meeting or to that presentation or the next time they see a patient with breast cancer they remember, “Oh, yes. There was that guy from the breast service at MD Anderson, and he seemed to be right on the ball in presenting that. So let’s get a consultation here.” So that’s another source of expanding the referral. And sometimes institutions think cheaply about how much research is costing us. But research, in reality, is what drives our growth. It is what drives patient access to this institution because people don’t come to get what they could get very well three blocks from here in a private office. It’s much easier to drive to their private physician’s office where there is plenty of parking. They don’t have to put up with this maze that the medical center is. And they are in and out in minutes, and they get done. They come because of our reputation, and our reputation is based on our research. And then the third part of it that is very important is that every year we have thousands of trainees of all sorts—physician trainees, technician trainees, nurse trainees. I think we train something like 3000 or more trainees every year between undergraduate students and postgraduate students and doctoral candidates and all of that. And many of those are from outside our community, of course. And when their friends, relatives, family members, and colleagues think of where to refer someone they say, “Ah, I trained at MD Anderson. It’s the greatest place on earth.” So all of those things contribute, and it’s sort of a geometric expansion.

Tacey Ann Rosolowski, PhD:

I was wondering, too, just about timing because wasn’t it 1994 that the breast cancer gene was discovered?

Gabriel Hortobagyi, MD:

Uh-hunh (affirmative).

Tacey Ann Rosolowski, PhD:

And I know I talked with Dr. Strong—Louise Strong—about how that had a considerable impact in at least the conversations about who was going to be handled here and what kinds of services were going to be provided. Was that a factor at all?

Gabriel Hortobagyi, MD:

A very small one probably, and to a large extent it is because the breast cancer genes are responsible for less than five percent of breast cancers, and second because we did not discover the breast cancer gene here. We contributed to the literature that led to the discovery of the breast cancer genes, but we did not actually do that ourselves, so we cannot claim credit for that. Now what I think did attract people is the conglomerate of research—the results that were emerging at that time. So that was the time in the late ’80s, early ’90s when we were starting to see the results of a lot of research in basic biology. And we were starting to understand better that, and eventually ten, fifteen years later came the completed Human Genome Project, the oncogene gene story, the monoclonal antibodies, tyrosine kinase inhibitors, and all of these new drugs. So all of that started in the later part of the ’80s, and among that I am sure would be that BRCA1 and BRCA2 mutation became part of that story. A little bit before that the p53—they discovered p53 and the cloning of that—so every scientific discovery adds to what we know. How much each individual scientific discovery contributes to our referral is much harder to determine unless there is a clear sign that the discovery happened here, and it’s given a lot of press. But I was always interested in finding that discoveries have indirect effect, too—at least in patient referral. So suppose that I or one of my colleagues stands up at a meeting, and we say, “We just found that we have this great treatment for patients who are blond and under age twenty-five with breast cancer. And we have this great thing, and this is our experience, and this is the result of our research.” So this gets great press. It is written up by Gina Kolata in the New York Times and it is misinterpreted, as usual. So the next day—or the next Monday—you get this torrent of phone calls from physicians and patients about either wanting advice or wanting to come to be seen. And only a tiny minority of those calls come from or are relevant to patients who are under age twenty-five and are blond. The rest are totally unrelated to it, and it’s just a visibility issue. “Oh, ah ha. I read this very interesting thing about MD Anderson and breast cancer and women under the age of twenty-five and with blondes and what not. But I’ve got this patient who’s got sarcoma and has chronic obstructive lung disease. Let me call MD Anderson.” And it’s the most bizarre association, but it happens every single time. And most of the calls we get as a consequence of publicity are just more calls but not necessarily relevant to what we just published.

Tacey Ann Rosolowski, PhD:

Have you gotten to the point where you anticipate that?

Gabriel Hortobagyi, MD:

Oh, yes. Absolutely. Absolutely. So we know that anything that gets us in the public eye—unless it is really something very bad—will just generate phone calls; and more recently, of course, it generates emails. But it is not necessarily focused on what was important at that moment.

Tacey Ann Rosolowski, PhD:

So tell me about what happened when the breast center was moved into this new service where everything was pretty much close, you pretty much got what you wanted, and you had a real model of a center that was patient centered. What did you observe?

Gabriel Hortobagyi, MD:

Well, yes. That was very nice. And then we saw this retrenchment from all parties. It was interesting because we had this great opportunity to actually work together, but everybody wanted his own little corner. And then there were discussions about which part should be the surgeons and which part should be the medical oncologists and which part should be—you know. We had to push very hard to convince people that this was not about us, and it was not about establishing a new private property there. But this was about sharing, and this was about sharing for the benefit of the patients that we were there to treat.

Tacey Ann Rosolowski, PhD:

So help me understand how this was so different from those meetings where people began to see perspectives change. What was so threatening?

Gabriel Hortobagyi, MD:

You have to realize that you might change people’s behavior to some extent without necessarily changing their underlying reactions. And people would—at the beginning of this breast center, individual physicians still wanted their name on a room—on an examining room. Not literally, but they wanted to know that they were the ones who’d always see patients in that room. And that was their room, they wanted it furnished exactly to their specifications, and they didn’t want anyone else to fool with that room even though they were there half a day a week or two half days per week. And we had to push very hard. And at the beginning we were able to sort of comply with that a little bit, but I didn’t want to because that was giving the wrong message, because the message was we are going to share this entire space. And we are going to have to—as we grow, we will fill this, and we can’t afford to have a room reserved for Dr. X simply because Dr. X wants it. And that process actually took years, and it wasn’t really completed until the past—I would say three or four years.

Tacey Ann Rosolowski, PhD:

Really?

Gabriel Hortobagyi, MD:

Yeah.

Tacey Ann Rosolowski, PhD:

So—and just to be clear—you moved into the center in the Mays Center [Mays Clinic or Ambulatory Clinic Building]. What was the year when the breast center opened there?

Gabriel Hortobagyi, MD:

I think 2002 probably.

Tacey Ann Rosolowski, PhD:

Wow. So we’re talking a decade.

Gabriel Hortobagyi, MD:

Yeah. Yeah. So it took growth to get us to the situation where we could no longer afford to have any room unoccupied at any time of the day during the week, but we had to sort of move people around so as to use and occupy rooms whenever they became available. And it was only last year that my original vision of—because I remember when we moved in. I talked to the then head nurse or clinic administrative director and said, “You know, whenever I go out to the airport I look at this board—this electronic board—in every airport, and it shows all the flights. And it shows all the gates, and it shows times in and out and what not. And when I pull up my reservation online I can see my name there, and I can see where I sit. And presumably others can do the same thing, and presumably the airline can see where all of us sit. And they fill planes, and they have food, and they remove food and beverages, and this whole thing is an enormously complex puzzle. Why can Continental Airlines do it and MD Anderson can’t? So let’s put up one of these electronic boards, and let’s feed the information.” My God, it’s as if I had threatened to murder someone’s mother, you know? “No, you can’t do that, and you can’t share that information with anyone.” And so we struggled with that for years—probably for the best part of about five years—until we were finally getting to the point where I started to ask for more space for the breast center. They said, “Well, we have no more space. We would have to build another building, and we don’t have the money to build another building.” So I said, “Okay, then you need to play ball, and we need to use technology to improve our room utilization.” Because when we moved—well, even five years ago, the average number of patient visits per room—per examining room—in the breast center was about three.

Tacey Ann Rosolowski, PhD:

That is remarkably low.

Gabriel Hortobagyi, MD:

Oh, it’s horrible. Yeah.

Tacey Ann Rosolowski, PhD:

I’m shocked.

Gabriel Hortobagyi, MD:

If you go out to Intercontinental Airport, probably each gate gets used—I don’t know—fifteen times a day, twenty times a day depending on the turnaround and whatnot. And the actual patient contact in each room is probably ten, fifteen, sometimes twenty minutes. A very complicated situation may take an hour occasionally, but we don’t see that many in any particular day. So finally last year, after millions of consultations and millions of conferences and millions of interactions and discussions and getting engineering to look at our efficiency and getting time studies—finally we put up these electronic boards where you can now see who checked in, where is that patient—is she in the lobby, is she sitting in a room—whose patient that is, who’s the nurse responsible for that, where is that going, how long has the patient been sitting there. And the patients on the outside—to some extent, I think—can see where they stand in terms of their waiting and all of that.

Tacey Ann Rosolowski, PhD:

So does it have the patient’s name or is there a number or—?

Gabriel Hortobagyi, MD:

I have to look at the waiting room because there would be HIPAA considerations on the outside. From the inside, of course, we have number and chart number not name.

Tacey Ann Rosolowski, PhD:

I am just thinking because in a lot of DMVs you get a number and you’re waiting to do something with your driver’s license, and your number comes up, and you know where to go, and you’re being tracked.

Gabriel Hortobagyi, MD:

We have also proposed what a number of restaurants do today. You walk in with your reservation, and they give you a beeper, and they say, “Go to the bar and have a drink, and when your table is ready we’ll beep you.” No name necessary. No privacy issues violated. You go and have your margarita, then this thing starts lighting up, and you go and have your room or your table.

Tacey Ann Rosolowski, PhD:

Yeah, I have had that actually in radiology services.

Gabriel Hortobagyi, MD:

Yeah.

Tacey Ann Rosolowski, PhD:

Yeah.

Gabriel Hortobagyi, MD:

Yeah. And I think—I’m very private, and I hate it when I go to a doctor’s office and the nurse comes out, “Hortobagyi!” You know—and everybody turns around and says, “Who is that?” I really dislike that. It’s not that I have anything to hide, but it’s nobody’s business that I’m there. You know?

Tacey Ann Rosolowski, PhD:

Yeah. Yeah. And in a situation where you’re maybe frightened and—

Gabriel Hortobagyi, MD:

Right. Right. Right. Right.

Tacey Ann Rosolowski, PhD:

—you’re ill. You don’t—yeah.

Gabriel Hortobagyi, MD:

Right. Right. Right. So finally we got to that point. So that’s a long evolution of all of this. Right now we are in a situation where we are in these pods, and each pod consists of several specialists. And we work sort of side by side. And I can just finish seeing a patient of mine, and if I need a surgical opinion I just walk next door. I say, “Hey, would you mind taking a look at this patient? It’s a very simple issue. I’ll send you a formal consultation later. I just need your very simplistic ballpark view so that I can plan.” And that shaves weeks off the workup and getting ready and then making decisions. And that is working out very well. And we also then have an immediate—the immediate ability of saying, “You know, I hear you, but I don’t think that’s a good idea because of A, B, and C. Have you considered that?” And then instead of waiting three weeks to get to that point and then having to make an extra phone call and then playing phone tag with the other doctor, we just resolve this over just a few minutes.

Tacey Ann Rosolowski, PhD:

So what do you think made the difference when you had—when you first moved in and there was all this retrenchment and people feeling threatened? You know—what broke the dam? What enabled people to move into this mindset of sharing?

Gabriel Hortobagyi, MD:

Well, first the fact that we kept on sharing information with them. Your private property, your room is being used on the days you are there only three times per day. The days you are not there it’s not being used at all. In the meantime, there are physicians who are clamoring for rooms because they can’t—they don’t have space to see patients. And then we kept on hammering on the same idea. We need to share. We are a team. We need to share. We are a team. And repetition often serves to get a message eventually across. So that was that part. The research part was—research is always an evolving issue, and probably our very first research activities we did in breast medical oncology were the development of clinical trials. And we mentioned in one of our earlier conversations the combination of chemotherapy with the FAC regimen and the locally advanced and inflammatory breast cancer protocols. And then we got more and more into new drug development, so we started to do Phase II and Phase I clinical trials with new drugs. And that provided us with some resources because most of those drugs came from industry—pharmaceutical industry that had developed drug A, B, or C—and we would get access to that for doing a clinical trial, and the company would pay for the cost of doing that clinical trial. And you usually overestimate your costs a little bit so that you can be sure that the hospital doesn’t get shortchanged for that. And then sometimes there is a little bit of money left, and then you use that for reinvestment into research. And most of the costs of clinical trials are based on making sure that everything that the clinical trial calls for actually takes place and that all of the data are collected prospectively in the cleanest and most accurate fashion. For that you need research nurses, you need data managers, so much of the cost is related to personnel. And as the number of clinical trials we performed increased we had, of course, the need to have more and more personnel for that. So eventually we built out a group at the beginning—one and then two and then three—and eventually we got up to what we have now which is about fifteen or eighteen research nurses and about ten data managers and whatnot.

Tacey Ann Rosolowski, PhD:

Wow.

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Chapter 22: Creating a Patient-Centered Breast Service

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