Chapter 14: Challenges to the Division of Pediatrics
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Description
In this chapter, Dr. Kleinerman talks about her activities as Head of the Division of Pediatrics.
She explains how she came to be Division Head in 2001. She sketches the history of pediatric care at MD Anderson. She says that when she arrived at MD Anderson in 1984, it was challenging to care for pediatric patients in an adult facility. Dr. Kleinerman provides an overview of what is needed for pediatric care.
Next, Dr. Kleinerman talks about measures she first took as Division Head: holding a strategic planning retreat, developing a vision, hiring critical care staff. She talks about the process of gaining the trust of the faculty, then goes into more detail about the retreat and her strategies for developing the strength of the faculty. She gives an example of shifting the responsibilities of a faculty member who was suffering from burnout, enabling him to perform more effectively. She also notes that, with the new administrative (and billing) structures in place, it is not possible to use such creative approaches to problems
Identifier
KleinermanES_03_20140604_C14
Publication Date
6-4-2014
City
Houston, Texas
Interview Session
Eugenie Kleinerman, MD, Oral History Interview, June 04, 2014
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the InstitutionThe Administrator MD Anderson History Overview Patients Building/Transforming the Institution Leadership Understanding the Institution Critical Perspectives on MD Anderson
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:
Neat. Well, would you like to shift gears now—
Eugenie Kleinerman, MD:
Sure.
Tacey Ann Rosolowski, PhD:
—and talk about your administrative work?
Eugenie Kleinerman, MD:
Yes.
Tacey Ann Rosolowski, PhD:
Okay. Well, where would you like to start with that? I mean, certainly the key role is 2001 when you became division head, but I’m wondering did you want to talk at all about kind of an overview of treating children at MD Anderson and kind of what that means, or will that come out as you talk about your role as division head?
Eugenie Kleinerman, MD:
It probably will come out in my role as division head. Sure.
Tacey Ann Rosolowski, PhD:
Okay. Well, let’s kind of dive in, then. Why were you the person who was chosen to head the division?
Eugenie Kleinerman, MD:
Because they couldn’t get anybody else to take the job? (laughter)
Tacey Ann Rosolowski, PhD:
Now, why was that? What were you looking at as a project, stepping up to this role in 2001?
Eugenie Kleinerman, MD:
Okay. Okay. So I don’t know whether I told you this story, but I saw my dad become chief of pathology and all the aggravation, and I said to my dad once, “You know, Dad, I would never want to be chief. I would never want to do what you do.” And he said to me, “Genie, there’ll come a day where you know that you could do a better job with one hand tied behind your back than the people—.” He said—I won’t tell you what he said. “The people that are in charge now, and you will step up to the plate.” So, of course, having Texas Children’s across the street was very—you know, I don’t want to say difficult, but it was challenging.
Tacey Ann Rosolowski, PhD:
In what way?
Eugenie Kleinerman, MD:
Because they’re a big children’s hospital, their president was very aggressive in the market, liked to control things. It was a very well-run institution, a lot of philanthropy, a lot of money, and so he basically could buy talent and didn’t have to worry about clinical revenue offsetting expenses.
Tacey Ann Rosolowski, PhD:
Now, are you talking both from the perspective of building a strong pediatric program and also market share?
Eugenie Kleinerman, MD:
Market, yes, yes, yes, and all of the infrastructure that’s needed. So here we are, an adult hospital, and although from the time it opened, MD Anderson took care of children—and when we opened our new unit, I learned that the Ladies Auxiliary, which is the wives of men who were, I think, World War II or the foreign wars, they wanted to make a donation, but they wanted to make sure that MD Anderson had a place for children, so they donated $50,000 to make sure that there was a ward for children.
Tacey Ann Rosolowski, PhD:
And this was in 1955, right, when the inpatient unit was established?
Eugenie Kleinerman, MD:
Whenever—yeah. Yeah, yeah. Yeah, yeah.
Tacey Ann Rosolowski, PhD:
Wow.
Eugenie Kleinerman, MD:
So there was a unit, and I think Dr. Wat Sutow was the first chair of Pediatrics. He also was very well known in osteosarcoma. He was a survivor—I think he was a survivor of Hiroshima, and he was probably one of the pioneers that used combination chemotherapy in solid tumors for children. But the service was very, very small, and when I came here, there was no critical care area for children, children had to be sent across the street to Children’s Memorial Hermann or to Texas Children’s. You sort of had to beg the radiologists to do your studies if you had somebody who—there always was somebody that you could find, but it really was challenging from the standpoint that you were in an adult facility. From the standpoint of treating cancer, it was great, because everything’s focused on cancer. And when I recruit, that’s what I say. If you’re a physician, if you’re a cancer physician that treats children, there’s no better place here. If you’re a pediatrician who treats children with cancer, then you’re better off going to a children’s hospital.
Tacey Ann Rosolowski, PhD:
So what are the special challenges that have to be met in setting up for comprehensive pediatric oncology care?
Eugenie Kleinerman, MD:
So you have to have—clearly you need surgeons that have pediatric experience. We just don’t treat the patient; we treat the whole family. Now, you could argue in adults, yeah, they have a wife or they have children, but it’s not the same. These are children who are in a very vulnerable part of their life. We think it’s very important to make sure that they maintain their education and they don’t get left behind. You could say, “Oh, well, let them stop going to school for two years while they’re being treated.” Okay. So then you get cancer when you’re in third grade and you finish your cancer and you come back, and all your friends are in fifth grade and you go back to third grade? Not really good. Since we cure such a high percentage, there are long-term effects of chemotherapy. We need to monitor them. We need to make sure that we look for the signs that we know: cardiac, bone density, things like that. Support services, and catheter sizes, just little things like that, trachs, you need pediatric trachs, you need pediatric crash carts, you need a different pain scale. When you talk to a patient in terms of explaining therapy, you know, it has to be different. You have to talk in a way that the child understands, as well as the family. So, emergency room, when your child is fever and you’re worried that it—and you come into and all we have is an adult emergency room, what happens? The adults say, “It’s a child. I can’t take care of it.” Well, who’s going to take care of it? Well, call the pediatricians. Well, you know, but we’re in the ward. We can’t be everywhere until we get down to—so there are a lot of challenges, lot of challenges. And the care was not as good as it should be, for those reasons, and it was trying to get the administration to listen. So at the time, I looked around and I said, “I’ve been here for, what, ’84, ’94, so, seventeen years. I know the culture. I’ve built relationships. People respect me. If I really want to make a contribution, I’d better step up to the plate.” I think a lot of people that came down were not interested in because of the challenges and because they had the thousand-pound gorilla across the street and I don’t want to fight with him. David Poplack was across the street. And probably they wanted resources. I mean, I don’t know. But it took two years. The search was for two years.
Tacey Ann Rosolowski, PhD:
Wow. Okay.
Eugenie Kleinerman, MD:
So I think—and I’m being realistic. I mean, I think I was the best person for the job, but I think the reason why I probably got it, because I wasn’t a clinician, really. I was viewed as a basic scientist. And so I think the perception of a lot of the faculty at the time was, “She’s a basic scientist. She’s not going to have any respect for what we do. She’s not going to fight for what we need. She’s not going to be our voice.”
Tacey Ann Rosolowski, PhD:
Interesting. Yeah. So why do you think, in the end, that perception didn’t hold sway? What was it that people understood, came to understand about you that enabled you to get that, to step into that role?
Eugenie Kleinerman, MD:
Well, one of the things I did was we had a retreat. I took a leadership course and I learned that—I always thought, “Oh, it’s my job to do.” I learned it’s not your job to do; it’s your job to facilitate other people doing, and guiding the ship and getting a consensus of where people want to go.
Tacey Ann Rosolowski, PhD:
So what was this retreat?
Eugenie Kleinerman, MD:
So it was a day-and-a-half retreat. I got an outside facilitator, and the question was what do we want to be, what’s our vision, what’s our mission, what do we want to be known for.
Tacey Ann Rosolowski, PhD:
And this was held in 2001?
Eugenie Kleinerman, MD:
It may have been 2002. It may have been 2002.
Tacey Ann Rosolowski, PhD:
Yeah, maybe it was, because I had you in 2002 you did the Faculty Leadership Academy. Oh, there it is; 2003 was the retreat to develop the strategic plans, right?
Eugenie Kleinerman, MD:
Yeah. In the beginning, you know, there were just so many things. I mean, the fellowship program was a mess. I think we had two applicants to our fellowship program.
Tacey Ann Rosolowski, PhD:
Wow.
Eugenie Kleinerman, MD:
And so we took both of them. There were silos. And the first thing I wanted to conquer was hiring a pediatric intensive care person, so it took me a while, and that’s the format that I ran on, or whatever. When I first took the job, when I made my speech, I said, “I have a vision. I have a plan to get us there. It isn’t going to be easy. There are going to be times when you’re going to be really mad at me, but if you stick with me, when we get there we’ll have something that you’ll be proud of.”
Tacey Ann Rosolowski, PhD:
So what was your vision?
Eugenie Kleinerman, MD:
My vision was that we were going to be excellent in clinical care, in translational research, in clinical research. And what I immediately did was form committees. I knew the faculty was so desperate to get critical care, so I formed a committee. “Okay. You tell me what are the important things that you need for critical care, what are the issues.” I formed another committee, Fellowship Program. Clearly, our fellowship program was faltering. “You’re down there. Well, what do we want? Clinic, what are the things, what are the issues in the clinic? Tell me what they are.” And so I think people said, “Hmm. She’s asking us, and she’s charging us with telling her what she wants.” And so then I began to—so critical care, and I was told—I went to see Tom Feeley, and he said, “You know, I’ve tried to recruit a pediatric critical care person, and they will never come. Give it up.” And I said, “Okay. How about if you give me the slot?” He said, “Sure. Take the slot. Who cares? I mean, you’re never going to be able to do it.” And so I took over in March, and by September I had two critical care physicians.
Tacey Ann Rosolowski, PhD:
Wow.
Eugenie Kleinerman, MD:
What I did was I went back to somebody that I had done my residency with, who had just started the critical care department at Children’s Hospital National Medical Center in D.C., and he had—I don’t know. There was some falling-out or something. Anyway, so he was no long there and he was in a community hospital, and he wasn’t happy. So I said, “Alan, would you consider?” He said, “Are you kidding? No way I’m leaving. No, I’m not going to come to Houston.” I said, “Okay, tell you what, Alan. Come down as my consultant. Come down, look over, tell me what you need, tell me what I need, what I should be looking for, because I don’t know. I’m not in critical.” He came down. I took him through. It was March. The weather was gorgeous. I took him to play golf. He met Feeley, he met everybody, you know, all the faculty. And at the end of the visit, he said, “Um, I’d like to apply for the position.”
Tacey Ann Rosolowski, PhD:
And Alan’s last name?
Eugenie Kleinerman, MD:
Fields. I said, “Alan, you got it.” So he was here a few months later. That was March. He was here by September.
Tacey Ann Rosolowski, PhD:
Wow. That’s amazing.
Eugenie Kleinerman, MD:
And now we have four critical care faculty, and we’ve just built our own critical care unit on our floor, nine-bed pediatric critical care unit.
Tacey Ann Rosolowski, PhD:
Wow. Wow. That’s interesting.
Eugenie Kleinerman, MD:
So I think when the faculty saw that I was able to recruit a pediatric critical care faculty and was building a critical care unit that nobody had been able to do before, I think I gained their trust.
Tacey Ann Rosolowski, PhD:
Hmm. I’m curious, because you came in with a strong vision and were able to articulate that vision, and then in 2003 you did the retreat, which was refining that. So tell me about that retreat. I mean, was that retreat an important milestone in your early [unclear]?
Eugenie Kleinerman, MD:
Oh, absolutely.
Tacey Ann Rosolowski, PhD:
So tell me about that event.
Eugenie Kleinerman, MD:
So, again, what I learned from that retreat was everybody was looking to me and saying, “You tell us what to do.” And I was sitting there thinking, “I cannot believe that—no, I’m not going to tell you what to do. I want you to tell me where you want to go. Let’s have a dialogue.” But it was interesting. They wanted me to make every decision, and yet of course I knew if I made every decision, then they’d complain. So that was an eye-opening experience to say, “No. What do you think? What are our strengths? What do we need to focus on? We can’t do everything. What are we going to do first?” And I think it was the first time that the faculty had ever been asked and brought together. And we wrote a shared vision and what our five-year plan was and our goals were. And the other thing I tried to do was look at the strength of each faculty member, particularly the more senior ones, and say what did they love to do, what did they do that’s excellent, and make that their job. For example, there was one sarcoma physician, and he clearly loved to teach. He wrote book chapter after book chapter and review article. So I said, “Bev, I’d like you to take over Tumor Board, and I really want you to make this an excellent educational experience when we review the cases, both from an historical point of view as well as how we’re going to treat the patient.” He loved it, and Tumor Board became a desirable conference because it not only was educational, but because it was a forum for people to discuss the tumor, you know, the cancer, and how we’re going to treat the case, whatever. And Pathology was there to talk about the pathology of the findings, and Radiology was there to—so. And the other thing that I did was, so there was one physician, a leukemia physician, and he was clearly burnt out, burnt out and unstable when it came to—and he was doing some transplants with his leukemia patients, and he would fall apart. He clearly just—he’d been in the trenches too long, but he had a lot of knowledge and he was really good at doing procedures. You know, our leukemia patients have to have bone marrows and they have to have spinal taps as part—and so what I saw happening was that the leukemia physician would see the patient in clinic. They needed a bone marrow. Then they’d have to run down to the OR to do the bone marrow, because you have to put the child to sleep. And then the rest of their patients were sitting around, waiting. I said, “This is really not efficient.” So I pulled him in and I said, “You know what? What I really need help in is trying to organize the clinic. Would you be willing to be the procedure doctor? You’d sit there and the children would come in, you do the spinal taps, you do the bone marrows, you would do all the procedures so we could make clinic more efficient.” He loved the idea, because this would make him feel like he was valuable and doing something. Well, the people in the clinic were not real happy, because they said, “That cuts down on my billing.” I said, “Okay, how about if I look at your billing as a section, not individuals, but as a section, so that when he does the procedures, that goes on your billings as a section. As long as your section meets the goals, I’m happy with that.” They said, “Great.” So again, I think they saw me as a problem solver to make things better in treating patients, that I wasn’t just focused on the lab and getting resources for the lab. Now, unfortunately, I can’t do that now because the new structure is they look at each physician and what their billings are or what their productivity is. So it’s going to make it much more difficult. I wanted to treat it as a section. I can’t do that. I think this is not visionary. I think this is not. But this may not be able to be applied to other treatment areas, other multidisciplinary centers, but I say then let the multidisciplinary center govern themselves the way they want to do it. And that’s really—I see that fading. I see that fading.
Recommended Citation
Kleinerman, Eugenie S. MD and Rosolowski, Tacey A. PhD, "Chapter 14: Challenges to the Division of Pediatrics" (2014). Interview Chapters. 1410.
https://openworks.mdanderson.org/mchv_interviewchapters/1410
Conditions Governing Access
Open
