Chapter 24: Mentoring, Career Support, and Education in Breast Medical Oncology

Chapter 24: Mentoring, Career Support, and Education in Breast Medical Oncology

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In this chapter, Dr. Hortobagyi discusses his efforts to support faculty careers via mentoring and administrative decisions. He begins by noting that the grant application process can be used strategically to encourage faculty to work together.

Dr. Hortobagyi notes that it is very challenging to lead bright people, and a leader must empower then and build on their strengths. He compares the “one size fits all” approach he took many years ago to his newer, nuanced approach of recognizing people’s different strengths. He notes how he developed listening skills. He gives an example of how he continuously challenges people in positive ways so they can stretch, and underscores how important it is for a leader to be transparent about the purpose and goals of decisions to reduce conflict and increase faculty/staff buy in.

Dr. Hortobagyi gives the example setting expectations for faculty on clinical contracts versus those on 75% research contracts. Every month a report shows how much income a faculty member generates. Transparency is important to motivate faculty and to guide them through tenure and promotion hurdles.

Leadership principles are the same in all organizations, Dr. Hortobagyi says. However, it is especially difficult to lead in academic institutions. Dr. Hortobagyi explains why medical academics are “fiercely independent.”

Identifier

HortobagyiGN_04_20130128_C24

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 Interview Subject's Story - The AdministratorThe Administrator Professional Practice The Professional at Work Leadership Mentoring On Research and Researchers On Leadership On Mentoring Building/Transforming the Institution Institutional Processes Understanding the Institution On the Nature of Institutions

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

Gabriel Hortobagyi, MD:

Well, and there’s the multitasking. Because if I’m the vice president for—I don’t know—new truck development at Ford, I focus on developing that new truck. And I’ve got some engineers working here and some marketing people and some people who are looking at cost and whatnot, but all of my focus is on that. Right? Here we have our focus on—we take care of a very large number of patients. And as a supervisor—as a department chair—I need to make sure that the quality of care is as high as can be, that all of my faculty members are providing the same or higher level of quality, that all of the support personnel—nurses and et cetera—are working in that direction, that my interactions as a department with the breast center—which is not directly under my control—is such that I can influence the development of the breast center. I am responsible for all of the research activities, making sure that the research productivity of the department is as high as can be and is the highest quality as it possibly can, making sure that the research enterprise breaks at least even and it doesn’t go in the red too often, making sure that I have the support research personnel that we need. I need to make sure that all of our research activities are actually coordinated and that there are no independent republics reinventing the wheel every so often. I need to make sure that each of my faculty members has a research activity so that their careers can be developed and that I can get them promoted, and I can get them rewarded for what they do. And I can hold them accountable for what they do. I need to make sure that we educate the next generation of physicians, that we mentor our younger faculty with the resources and knowledge of the older faculty, and that ultimately our entire budget as a department fits into the budget of the division and within the vice president—the line vice president of the institution. And during all of this I am writing papers, I am running my own research. I’m making presentations thirty, forty, fifty times a year around the globe; so the multitasking is quite considerable. You’re like the juggler—keeping as many of those objects in the air as you can.

Tacey Ann Rosolowski, PhD:

What support do you have in doing all of that? And obviously, you don’t do it alone. What do you rely on?

Gabriel Hortobagyi, MD:

Well, so you rely heavily on your immediate support, which is quite limited in terms of the support the institution provides. As the department chair you get an executive assistant. And your executive assistant deals with your schedule and your travel and your meetings and making sure you do not commit to things that you cannot accomplish and that your schedule is kept fairly coordinated. But with the evolution of technology, you end up doing much of what secretaries used to do in the past. I write all of my papers. I do not dictate anymore. I make all of my slides. To a large extent, I don’t rely on the travel agency to pick up the best schedule because I know the schedule with rare exceptions as well or better than the travel agency, especially to places where I go with some frequency. I know I need to take the 6:50 flight to Washington because that gets me there at 11:15 and gets me to the hotel in time so that I can get a good night’s sleep and get up by 6:00 the next morning—just as an example. And for all of the research activities, I have to generate resources and funds so that I can get an infrastructure for research. The institution doesn’t pay a penny for that. Education—well, it depends on how much we want to do in terms of education. Certainly for mentoring our younger faculty—as a department chair you get a little bit of funds from PRS for that. The fellowship program pays for some of the fellows if the fellows are involved with research with the department. We need to provide those resources to them if they are fortunate enough to have a paper accepted for presentation. We have to generate those resources so they can travel and they can do that. Those are just additional activities that you have to be involved in to generate the resources to run the group. And then many of the grant applications that you send out—which are multi-specialty, multi-disciplinary—you do that in part to enable your group to do the research, but a very important secondary objective is to bring people together. So you actually use the process of application to force people to work together. Well, force is the wrong word—to entice, to encourage, to foster interactions. And it works better that way than if you send out an edict that nobody will follow. And one of the first principles of leadership is never to give the order that someone will not follow. You have to be careful about how you go about managing or coordinating especially bright people. It is very—it’s very challenging because it’s—and especially academic centers do not work on dictatorial principles.

Tacey Ann Rosolowski, PhD:

What are some of the other strategies you’ve found for successfully leading very bright people—enticing them rather than sending down edicts?

Gabriel Hortobagyi, MD:

Well, probably the most effective one is to empower them—to figure out what their strengths are and build on their strengths. So in my early years, for instance, I tried to set expectations for all of my faculty members, which was good, and I still do that. But I tried to set sort of one-size-fits-all expectations, and I expected everybody to take care of patients, everybody to do research, everybody to teach, and everybody to do service to the institution in the same measure. And it didn’t work, of course. There were some of my faculty members who were and still are wonderful physicians, but they do not have the knack for—or the interest for doing research. And trying to force them to do research was a disaster because every year during their evaluation I would end up with this heated discussion about I asked you to do this and you didn’t do—I didn’t have the time because I was—it was a totally nonproductive thing. So after a while I figured out that I had to recognize that different people have different strengths, and we all have weaknesses. And there was no point in harping on weaknesses when I could build on their strengths. So to the person who did not want to do research but was a good doctor I would just say, “Okay. So let’s make a deal. You do fifty percent more or a hundred percent more patient care than your colleagues who want to do research. And I will be very happy for that.” And they were very happy for that. That allowed me to empower the others—who really wanted to spend more time on research—to do research, less patient care, and have a little bit more protected time. And similarly for those who wanted to spend more time on education—great. I have some colleagues who are great at committee work—fabulous. And then for as long as the unit, the overall department, and the overall faculty accomplishes what we as a unit want to do or as we as a unit are expected to do—for instance financially—I’m happy. So I think that’s an important part of it—building on people’s strengths. The other part is to become a good listener and really try to understand what is behind issues. What really drives two people to go at each other? What is their disagreement and what is the disagreement based on? And what are potential areas of commonality that they can come together on and sort of reduce the tension on the disagreements by building on the agreement. So that’s an important part. The third part is to continuously challenge people in a positive way. Challenge them to stretch, to reach for things that they don’t think they can reach. An example is someone comes and shows you a review paper they have written. You read it, and you say, “This is very nice but I think you can do better than this by doing X, Y, Z.” Or someone who wants to come see you with a project and says, “Can you get me some money to do this project?” And you say, “Yes, I can, but I think it would look a whole lot better on your CV if you applied for a federal grant and you got it. Furthermore, that would allow me to give you a little bit more protected time so that you can spend it on this wonderful project. If I give you the money, that doesn’t help you. It just—it’s a short-term Band-Aid. So why don’t you apply for that grant?”

Tacey Ann Rosolowski, PhD:

So that’s really mentorship by showing people how to look at the big picture—how to fit into the big picture of their career.

Gabriel Hortobagyi, MD:

And all of those things are important ways to make people—to deal with personalities, deal with the faculty and to recognize that each of your faculty members—and for that matter each of your office personnel—is a unique individual. And the more you know about them the more you understand them, the better able you are to keep peace. And more than peace, make the group as productive as possible. So that works. And the other part of it is transparency so that all of the decisions that have an impact on your faculty or your office personnel come with information. So it’s not just you are going to say, “As of next week, you’re going to work twice as hard as this past week because I say so.” But you say, “You know, we need to increase the number of patients we see because we need to recruit more patients in our clinical trials to pay for our research infrastructure; otherwise, we’ll have to let several research nurses go. Or we need to see more patients because we are behind budget, and this what we put in the budget. This is what we were requested to produce, and we are twenty percent behind.” People understand that, and for as long as that is a continued process as opposed to coming out of the blue, that’s something they understand. And especially when you explain to them why—while all of them are treated individually—this is sort of the standard. And for instance, I tell every year to my faculty, “If you are here on a full-time clinical contract, my expectation is you spend three full days in the clinic. You are expected to see this many patient visits, this many new patients and consults, and generate in charges this amount. If you dedicate seventy-five percent of your time to research and you have the grants to support that, then I prorate my expectations from the full-timer down to this. And everybody who spends seventy-five percent or more in research gets that same expectation. And if you are fifty-fifty because you have a huge committee assignment and administrative tasks and whatnot, then the prorate means this.” And then everybody has a clear idea of what is expected of them and why.

Tacey Ann Rosolowski, PhD:

It is not personal and arbitrary.

Gabriel Hortobagyi, MD:

It’s not personal. It’s not arbitrary. I’m not taking it out on you. It’s not that I don’t like you or that I like that person better. It has nothing to do with it. These are the expectations. I estimate we will reach these calculations on the basis of our budget and on the basis of last year’s productivity and based on the previous year and it’s transparent. So my faculty now get every month the numbers of where they are. And of course at the beginning of the year, they have their expectations that they signed on, that we discussed, so halfway along the year they know that they are ten percent ahead or five percent behind or thirty percent behind. And if they are thirty percent behind they know that they are going to be in trouble unless they pull up their socks because the expectations are not going to change. So transparency in that sense is better. The same with promotions. The same with who gets to go to meetings. There are three meetings throughout the year where everybody wants to go, and of course not everybody can go because someone has to stay here and take care of patients and take care of patient service and be here to answer the phones and whatnot. So one day many years ago I said, “Who should have the first priority for going to the meeting?” Well, obviously someone who has an oral presentation and has a very prestigious presentation of research done within the department. Everybody agreed. Who should be the second priority? Well, someone who has a poster presentation—again, for the same reason. Who should have the third priority? Well, someone who has important business connections and needs to interact with colleagues and representatives of the NCI and the pharmaceutical companies so that we can get more resources for research and more collaborations and whatnot.

Tacey Ann Rosolowski, PhD:

So this was actually a conversation you had at a meeting.

Gabriel Hortobagyi, MD:

Right. Absolutely.

Tacey Ann Rosolowski, PhD:

So it was really—it was one of those consensus moments where people were generating those priorities themselves.

Gabriel Hortobagyi, MD:

Right. Right. Who should be the lowest priority? Well, the person who just wants to go there and sit in the audience and do nothing except learn. That’s a worthy thing, but when push comes to shove that person will have the lowest priority.

Tacey Ann Rosolowski, PhD:

Right. How are we distributing resources?

Gabriel Hortobagyi, MD:

That’s right.

Tacey Ann Rosolowski, PhD:

Yeah.

Gabriel Hortobagyi, MD:

And that worked beautifully, so two months or three months before any of those meetings, the executive assistant circulates a table saying, “I need to know who wants to go and what are the reasons you want to go and what days you want to go.” Then on the basis of that, we get a list of people who want to go and why they want to go. We prioritize it. Only those who really need to be there want to go, and there are six or seven people who want to stay. There’s no problem. If everybody signs up because they want to go then some at the bottom will be cut off and say, “Sorry, Charlie. You need to stay home because someone needs to mind the cash register—or the equivalent in the breast center. So transparency is very important. And I bet you that it’s no different in any enterprise. There are many other enterprises different from academic organizations that tend to be top down; and while in the short term they might work, they probably don’t work as well as if you really got buy in from everybody who works in the group. In academic organizations it’s even worse. And physicians—by training—throughout history have been fiercely independent. And it’s very hard to lead physicians from the top down by telling them, “Thou shalt do this because I say so.” And, “Thou shalt not do this because I prohibit you from doing that.” Because they will just do it exactly because they want to show that they are independent, and you don’t rule their lives.

Tacey Ann Rosolowski, PhD:

And is that an intellectual thing? Or is it something that this specialty selects for in personality?

Gabriel Hortobagyi, MD:

Both. So if you think about that, to get into medical school you have to do—you have to be at the top of your classes. Essentially you have to do very well on your MCAT. You have to do very well starting from high school in order to get into the right college. And then there’s a selection process throughout that. And throughout training you are encouraged to compete. And when you compete, of course, the emphasis is looking out for number one. I don’t necessarily think that’s the best way to choose candidates for physicians, but that’s the way it has been. And to some extent, I think that came from the civil rights movement and trying to avoid discriminatory behavior and selection. So because of that, instead of the classical personal interview and trying to figure out who has the humanistic qualities that would best fit a physician, we select on the basis of grades and the basis of test performance. And I don’t—that might be great for an engineer, but I’m not sure that that’s great for people in service professions where they need to actually serve human beings. But that’s the rule of the land at the moment.

Tacey Ann Rosolowski, PhD:

We have about five minutes before our time today is over. And I do have additional questions. I know that you have spent a lot of time with me. I’m hoping maybe we can schedule one more session to finish up.

Gabriel Hortobagyi, MD:

Okay.

Tacey Ann Rosolowski, PhD:

Okay. Would you like to close off for today, and then we can resume next time?

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Chapter 24: Mentoring, Career Support, and Education in Breast Medical Oncology

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