
Chapter 29: The Evolution of Breast Medical Oncology and the Breast Center
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In this chapter, Dr. Hortobagyi continues to sketch the evolution of the Breast Service. He describes first, tiny Breast Clinic on the ground floor of the Bates Freeman Building, where about 800 patients per year were seen. From there, the Clinic moved (to where the Anderson Network offices are now located), then to the Rose building, then to the Faculty Tower. The faculty made a real effort to influence the design of the clinic when it moved to the 6th floor of the Rose Building. Dr. Blumenschein developed a list of what was needed, but he was unfortunately ignored, though they “got more real estate” and faculty offices were next to the Breast Clinic. Many more advances were made when the Clinic moved the new Cancer Prevention Building. Dr. John Mendelsohn requested input from administrators on design requirements, and Dr. Hortobagyi notes that his was a fairly public and transparent process. Dr. Hortobagyi wanted all functions located in the same area: offices, clinics, surgical suites, radiation therapy, and laboratory research related to breast cancer. (Not all of this was accomplished.)
Dr. Hortobagyi describes the “shift in your mind” that takes place when one adopts a logic of multi-disciplinary care for a service. He describes the importance of collegiality and “geography” for overcoming the “separate republics” that prevent physicians from working together. He reviews what is needed to get people working together, including the development of translational research projects and recognition of the importance of imagers and pathologists to what breast medical oncologists do. Dr. Hortobagyi notes that the Clinic was able to implement multidisciplinary care effectively for the first time when it moved to the Cancer Prevention Building.
Dr. Hortobagyi next notes that the practice of multi-disciplinary care would evolve if medical schools laid the foundation for inter-specialty interaction. He explains how MD Anderson’s compensation system fostered interdisciplinary. He comments on the current administration (of Dr. Ronald DePinho), stating that decisions have been made that will change MD Anderson culture to the detriment of research and education.
Identifier
HortobagyiGN_05_20130315_C29
Publication Date
3-15-2013
Publisher
The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center
City
Houston, Texas
Interview Session
Gabriel Hortobagyi, MD, Oral History Interview, March 15, 2013
Topics Covered
The University of Texas MD Anderson Cancer Center - An Institutional Unit Understanding the Institution Building/Transforming the Institution Multi-disciplinary Approaches Growth and/or Change Critical Perspectives on MD Anderson Institutional Processes The Clinician Professional Practice The Professional at Work Collaborations Institutional Mission and Values On Care Leadership Mentoring
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 Ann Rosolowski, PhD:
I would like to go back in time again and focus on breast medical oncology and that history again and kind of go from the point where—I don’t even know if I asked you where breast medical oncology was actually located in the beginning.
Gabriel Hortobagyi, MD:
0:33:04:2 Breast Medical Oncology used to be at the ground floor of—what is that called today? It’s not the central core but the Bates-Freeman Building, I think. So it is a long hallway that goes to the old library—the old library that used to be at the bottom of the Yellow Zone. It was in that hallway. The breast clinic was—have you seen those changing tables that are in public bathrooms that you just fold down?
Tacey Ann Rosolowski, PhD:
Oh, they fold down from the wall?
Gabriel Hortobagyi, MD:
So the Breast Clinic was one of those—or maybe two of those—side by side in the hallway.
Tacey Ann Rosolowski, PhD:
I’m sorry, I shouldn’t be laughing. It’s just a terrible image.
Gabriel Hortobagyi, MD:
Well, it is funny. It’s a terrible image, but that’s the way we did it. So there were two nurses, and there were the three or four physicians, and we had about four examining rooms. While some physicians were in the examining room seeing patients, the rest of us were writing longhand in these charts standing in the hallway with these fold-down trays. And then—well, I don’t remember where our offices were. I am sure we had offices somewhere. I remember later we graduated to offices on the ground floor, which is now the second floor, actually. But at that time it was the ground floor of that same area between the area where the old library was and where medical photography used to be. At that time, the Yellow Zone Building didn’t exist. I remember my office was a corner office that looked out on—what is the name of that street that goes between what is garage two and garage five and the old prevention building? What is that? I guess that would be the Mickey [Charles A.] LeMaistre building.
Tacey Ann Rosolowski, PhD:
I’m not as familiar with the streets here since I—and I have an office on campus.
Gabriel Hortobagyi, MD:
It was there. And then—
Tacey Ann Rosolowski, PhD:
How many patients did you see per year at that time?
Gabriel Hortobagyi, MD:
Probably about 800 or so, but it kept on increasing gradually. Then from there we moved further down—still on the ground floor. I guess it would be approximately where the Anderson Network office is now in the central core. Then our offices also moved, and my office went up to the tenth floor of the newly built—it wasn’t the Lutheran Pavilion, it was what became the Pink Zone or the Rose Zone. And from there we went down to the sixth floor of the same building. From there our offices moved across the street to the first faculty tower, but our clinic remained in the Rose Zone, and then eventually we moved here.
Tacey Ann Rosolowski, PhD:
To here?
Gabriel Hortobagyi, MD:
Both the offices and the clinic.
Tacey Ann Rosolowski, PhD:
Now when you made the move over to the Rose Building and the Lutheran Pavilion, to what degree did you have input into what that all looked like—you know, what your facilities were going to look like? Zero?
Gabriel Hortobagyi, MD:
Yes.
Tacey Ann Rosolowski, PhD:
Yikes.
Gabriel Hortobagyi, MD:
Yeah, zero. Certainly our first couple of moves we had no input whatsoever. The third one—when we moved up to the sixth floor—Dr. [George] Blumenschein and I sat down with the architects and with hospital administrators, and we gave them a number of things that were on our wish list and what would be a good organization—physical organization of the clinic because we were less concerned about our offices. It was mostly to make our breast center more functional and more patient friendly. And then all of that was ignored. So they did whatever they pleased, and then we moved in.
Tacey Ann Rosolowski, PhD:
How did the facilities compare? I mean, were there improvements?
Gabriel Hortobagyi, MD:
There were improvements. Certainly we got a very substantial increase in real estate, so we had more examining rooms and a bigger waiting room, and we had little workrooms where we could write and dictate and fill out forms and do things—and chat and discuss cases and meet with the nurse and that. So it was—in that sense it was improvement. It was also improvement that our offices—when we moved to the sixth floor of the Rose Zone—were immediately next to the breast clinic. That was very helpful because it made jumping up to the clinic for a moment to take care of an emergency or something that needed to be done at that moment—it could be done without too much disruption to the other things we were doing. So that was helpful. But this is the first center where we really had a great deal of input.
Tacey Ann Rosolowski, PhD:
And so what was that process when you knew you were going to be moving to this building?
Gabriel Hortobagyi, MD:
By that time Dr. [John] Mendelsohn had been here for some time, and he was very good at getting input and getting buy in. So he requested that the relevant administrators and the administrators that head the development of the Mays Clinic and the [Cancer] Prevention Building were to really make an extra effort to take it as project managers, and all of the future occupants should have a say in how the building was designed. And we took several months to actually go through that process, and it was a fairly public process and a fairly transparent process. We got much of what we requested.
Tacey Ann Rosolowski, PhD:
I had greater ambitions. I was hoping that in addition to getting all of our offices and all of the clinics and surgical suites and radiology and radiation therapy in one building that we could also build a large enough building so as to include all of the laboratory-based research relevant to breast cancer, and that was shut down. And I understand it now because it is much more expensive to build a building to the specifications of a highly sophisticated modern lab than to build an office building. This is just a cube, and you just need four walls and a door and a window, and you’ve got an office. You don’t need to do anything terribly sophisticated. If this was a wet lab, then you would need to comply with a number of extra regulations. You would have to have much more plumbing, ventilation, much more electrical stuff. Yeah, so it’s much more expensive and complicated to do that, so I understand that. I was still disappointed because I wanted to have my way, but that wasn’t to be the case.
Tacey Ann Rosolowski, PhD:
So what—what were some of the details? You said—maybe I should ask it differently. What was the logic behind putting all of these things together and what ended up taking place in the breast center?
Gabriel Hortobagyi, MD:
As you create the concept of multidisciplinary care, there is this gradual shift in your thinking that takes place—and not only in mine but in everyone else’s that works with you. And as you increasingly see the benefit in truly working together in a collegial manner and developing the patient-centered approach, you realize that it is not just a state of mind but that the geography also contributes to that. As long as the medical oncologists were on the ground floor, the surgeons were on the fifth floor, the radiation therapists were in second basement, and the radiologist was on the second floor, we were like independent republics and that we really didn’t get that feeling that esprit de corps of we are all in this together for one single purpose.
(end of audio 1a)
0:00:00 (begin audio 1b)
Gabriel Hortobagyi, MD:
And then gradually you start to figure out that gee, wouldn't it be nice if I didn't have to send my patients up to the sixth floor but that I could just flag down Joe Blow and say "Hey Joe, would you mind taking a look at Mrs. Smith?" But from that initial realization—I can't tell you exactly when that happened, but it started to happen within the first few years, and as we tried to influence the development of the second then third breast center without much success, part of what we were thinking was wouldn't it be nice if we could bring the clinical disciplines together in the clinic? And initially our thought was really just the surgeons and the radiation therapists. And the surgeons, in principle, were easier because yes, they needed to go to the OR for their surgical act. But in the clinic it didn't matter where they were, so if there was space for both the surgeons and the medical oncologists, that was easier. With the radiation oncologists it was more complicated because their equipment requires insulation. It requires protection from radiation, so in most centers radiation therapy is in the basement for a very good reason. It simplifies the issue of preventing radiation from hitting innocent bystanders, the rest of the hospital staff, and patients. And then much of what they do has to deal with their equipment and with their nurses who have to be on site. So the radiation oncologists have to be on site much of the time, so it's not terribly practical for them to be away in a different floor, in a different clinic. And at that time, we were not even thinking about how important the pathologists and the radiologists were. And the radiologists, of course, also have the issue that where the equipment is that's where the radiologist needs to be in practical terms to read. Now today they can do it much more functionally because they can read x-rays being 200 miles away through the Internet. The same for pathologists, although that hasn't caught on as much. And it was the development of translational research that eventually led us to the realization of how important the role of the pathologists and the imagers was to what we did. And until that realization became really a strong realization, I guess we thought that the main members of the team were the surgeons, radiation oncologists, and medical oncologists, and that the other two disciplines were sort of auxiliary to this. And of course today we think that they are central to everything we do and that every member of the team is equally important in order to do this well. So that's how it sort of developed.
Tacey Ann Rosolowski, PhD:
But the first time we could actually implement that well was here in the Mays building, because it really takes long-term planning. And you need to take all of the cultural and specialty needs into consideration from the ground up, from the moment you start planning the building, in order for this to work. So you can't just design a generic building and say, "Okay, we're just going to herd all of you guys in there and you figure out how you're going to work." So it took a concerted effort to do that, and then it took a concerted effort for us—who were the small leadership group of the breast center—to distribute the space in a way that would actually force people to interact. All right? Because the initial instinct was—and this is now three decades after we've been practicing multidisciplinary care—the initial instinct was for the surgeons to say, "Okay, these two hallways are ours and then you guys can go there." And we said, “No, that's not the way it is going to happen. We are going to be all intermixed, and we are going to be elbow-to-elbow every day all day because that will force us to actually realize that we have much more in common within the breast center than the breast surgeons have with the colorectal surgeons and I have with the leukemia doctors across the street.” Because it's much more important for me to interact with the breast surgeons than to interact with the leukemia doctors. It's not that it's not important for me to learn what the leukemia doctors do and for them to learn what I do, but it's secondary to some extent, because for my principal mission the other members of the breast cancer team are the critical relationships.
Tacey Ann Rosolowski, PhD:
What still needs to occur, do you think, to bring that collegiality and that esprit de corps to an even more perfect form, if you will?
Gabriel Hortobagyi, MD:
Well, perfection is the worst enemy of good. You realize that. So I think we are very close to about eighty to eighty-five percent of perfection, and the next fifteen to twenty percent will take a huge effort, and I'm not sure it is likely to happen anytime soon. So what it would take—it would have to start from medical school to lay the foundations of interspecialty interaction and the realization and the active teaching of that's the way people need to function. And that's not how physicians, and especially specialists, are trained today. Specialists are trained within just the specialty, and they are taught everything within that specialty almost to the exclusion of what other specialties do. And I think it’s important to break down those barriers. The second thing is that something that has helped us enormously in this institution to achieve what we have accomplished in multidisciplinary care is our compensation system, that until recently didn't depend on how many patients we saw and cared for. And the stark contrast is, for instance, with another great institution with is Memorial Sloan-Kettering, where physicians are actually compensated based on their volumes. And being a private hospital Memorial, of course, wants to incentivize the generation of revenue. So with much logic, the administrators say, "You know, if we give a certain commission for each individual patient or unit of service or something to the physicians, they will react to that by increasing their volume," and especially younger physicians who have kids going to college or they're building a house or they're buying a new car—I don't know.
Tacey Ann Rosolowski, PhD:
Med school debt?
Gabriel Hortobagyi, MD:
Yeah. And so it incentivizes that type of behavior at the cost of interactions because then you're competing with your colleague next door for patients, because the more patients you take perhaps the fewer patients are left for your colleague. And then there's competition between the various specialties. And perhaps most importantly for the mission of this institution and what should be the mission of Memorial, too, it competes with your dedication of effort and time to the other missions, especially research and teaching. Because of course, if you spend fifty percent of your time in patient care and fifty percent in research and education that's one thing. But if you spend eighty percent of your time in patient care, guess how much you're going to spend in research and education? So while we maintained a delicate balance about keeping all our missions at an equivalent level, I think we did very well, and those were the golden years of this institution. In recent years for a variety of reasons, there has been much more emphasis placed on increased generation of revenue, and this past couple of years our administrative leadership has implemented some steps that will incentivize individual physicians to increase generation of revenue. And I think that is a major mistake. It's a major mistake, and it will translate on the long term in a major change in our culture, and it will be to the detriment of our research and education.
Recommended Citation
Hortobagyi, Gabriel N. MD and Rosolowski, Tacey A. PhD, "Chapter 29: The Evolution of Breast Medical Oncology and the Breast Center" (2013). Interview Chapters. 1134.
https://openworks.mdanderson.org/mchv_interviewchapters/1134
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