Chapter 14: The Pathology Department: Becoming Chair and a Controversial Move to Subspecialize

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Chapter 14: The Pathology Department: Becoming Chair and a Controversial Move to Subspecialize

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Description

Dr. Bruner begins this section with a problem she inherited as Chair of Pathology "more faculty than the workload demanded. She then discusses her controversial initiative to subspecialize the Department, a major departmental transformation and a controversial one at the time, though the aim was to align the knowledge bases of pathologists with the specific subspecialties they served. She notes the influence of an article that documented how Massachusetts General Hospital's pathology department divided into subspecialties. MD Anderson's Pathology Department was successfully subspecialized in September 1999, and Dr. Bruner sketches the process of this "great achievement" that required a lot of communication, planning, and mental preparation. She notes with satisfaction that the Pathology Department had visitors from Memorial Sloan-Kettering Cancer Center to see how MD Anderson managed the change.

Identifier

BrunerJM_02_20120607_C14

Publication Date

6-7-2012

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; The Administrator; The Leader; Building/Transforming the Institution; Multi-disciplinary Approaches; Growth and/or Change; Obstacles, Challenges; Institutional Politics; Controversy; Institutional Processes; Experiences re: Gender, Race, Ethnicity; MD Anderson Culture; MD Anderson History

Transcript

Tacey Ann Rosolowski, PhD:

Interesting. Yeah. Well, shall we talk about when you became chair of the department? Because we sort of had our oral history version of the cliffhanger.

Janet M. Bruner, MD:

Right.

Tacey Ann Rosolowski, PhD:

And you had said you came into this role, and you had so many ideas for things that you wanted to achieve.

Janet M. Bruner, MD:

Right. Right.

Tacey Ann Rosolowski, PhD:

So tell me about getting the news and then actually stepping into the role.

Janet M. Bruner, MD:

There were a lot of problems at the time because we had been without a permanent chair for a couple of years, and we had lost faculty. We had hired a couple of new faculty, but mainly we had lost faculty. I think the department was—unfortunately for pathologists, when faculty members leave, the work doesn’t decrease. It’s still there, so the people who are left behind just have to work harder. It was an awful situation. I had some faculty who were literally working fourteen or fifteen hours a day, seven days a week in order to get their work done—in order to get the clinical work done—and luckily because Dr. Hamilton had just been hired also. He had negotiated a very large recruitment package with a lot of positions because, obviously, he could see that, too. We started close to the same time. He started in July, and then it took him four or five months to get his feet on the ground and decide where he wanted to go. So then he appointed me, and I didn’t go through a formal interview process for the chair because I had just been through the one for the division head. I think the administration was comfortable with the fact that they thought I would be able to do the job. One of the things that I was a little bit afraid of at that time—we had maybe twenty faculty members or twenty-five—we had quite a few older men in the department that were more senior than me, one of whom was the acting chair, and when he became the acting chair, I think he quickly realized that he really didn’t like it very much—didn’t like that job. So I don’t think he was too reluctant to give it up, and I think that I was a little bit concerned—not too much—but I think some other people in the administration were more concerned than I was that I would have a lot of trouble because of that—being the younger woman. It never seemed to materialize. I didn’t feel like I had trouble. Now maybe they just weren’t letting me know. Maybe the faculty who thought I was a problem weren’t letting me know, but things seemed to go fairly smoothly. We knew right away. We had been talking in the department for the last—for the past—oh, I don’t know—maybe three to four years about doing more subspecialization because we had a few things that were specialized. Neuro was one, which was my specialty. Lymphoma and leukemia—lymphoma was subspecialized. Hematopathology was not fully subspecialized but pretty much. There weren’t too many people that knew how to sign that out. We had a gynecologic pathologist who was very anxious to subspecialize, and that had been resisted by other faculty in the department. We also had this cadre of faculty who were very committed to general pathology. “We don’t want to subspecialize because we’ll lose something.”

Tacey Ann Rosolowski, PhD:

Can I interrupt you there? When I was doing some of the background research, it was noted as kind of one of the accomplishments that the Pathology Department here became the first at a cancer center to subspecialize diagnostic pathology—the diagnostic pathology services.

Janet M. Bruner, MD:

Right.

Tacey Ann Rosolowski, PhD:

I was wondering. What is the significance of that, and what did people see as the pros and cons?

Janet M. Bruner, MD:

Well, the significance of it is that all of our clinics are subspecialized, and if you have a lung tumor, a general surgeon doesn’t come in and take that out. A thoracic surgeon works on you. So why shouldn’t a thoracic pathologist look at your tissue and make that diagnosis? Pathology was expanding so much. Our technology was expanding, and the knowledge in the field was expanding. It’s a matter of how much can you hold in your mind at one time and be good at it. All the—we had always—all the pathologists, with a couple of exceptions, had always signed out a case, made a diagnosis in whatever kind of tissue came across their desk. So if I’m assigned to be on the service today, whatever tumors come in, I’ll look at them and I’ll make a diagnosis—whether it’s a lung tumor, an ovarian tumor, a bladder tumor, a brain tumor. I’m good in everything. I know all this, and I can sign it out because I’m a pathologist. But the workload—the amount of work was increasing. The sophistication within each area—each body system—was increasing, and there were certain nuances within each area that were best known by people who were really interested in that area. So you might know everything about ovarian tumors, and there are a lot of details that you have to put in a report and tell the clinicians. If you’re really, really interested in ovarian cancer and you read about that—you read the literature, you read the books, you write articles, you write the books, you teach it, and you know everything about it—why should you be signing out a lung tumor—making a lung tumor diagnosis when you really don’t even care about it? When there’s another guy over here who loves lung cancer, and he knows everything about lung cancer? What we were doing was just really aligning ourselves and our knowledge base with our specialty clinics that already existed at MD Anderson. In fact, most all of us were doing clinical research, and you don’t do clinical research in everything. You pick an area because you want to delve deeply into it. So the guy who’s interested in ovarian cancer is doing ovarian cancer research. He’s not even interested in lung cancer, and he’s doing that research in collaboration with the ovarian surgeons, the ovarian oncologists, the ovarian radiation therapists, the ovarian radiologists. They, together, form this multidisciplinary program on ovarian cancer.

Tacey Ann Rosolowski, PhD:

It makes so much sense. Why did it take so long?

Janet M. Bruner, MD:

It takes a long time because you have to have a huge volume of cases. A pathologist should be making a diagnosis on maybe 1000 cases or more—usually more than 1000. Ours do 1000 to 1500 a year. Some of them do 2000, but even so, that means you have to be seeing on average—if you are doing research half the time and diagnosis half the time, that means you better have at least ten or eleven cases a day every day that you’re signing out. Every day you’re doing diagnoses, you have to see ten or eleven cases a day in your specialty, so that means there has to be ten gynecologic cancers, ten brain tumors, ten bladder tumors, ten lung tumors, and most places don’t have that much volume, especially if they’re a cancer center. A general hospital may have that much volume, but they’re minor specimens like hernia sacs and bunions and things like that, which don’t take any specialty expertise really. So it was a matter of having sufficient volume to justify having enough pathologists that we could have at least two people in every area, because you can’t have one. If they go on vacation—uh, oh!—what do you do? So you’ve got to have at least two people who are really, really interested in every area that you’ve decided to subspecialize, and you can have overlap. We told people right up front. “The pluses are you see a lot of material in your own specialty, and you get very good at it.” The patient care level has hugely ramped up because the diagnoses are going to be faster, more consistent, better for the patients, more complete. The downside is you’ve got to have a lot of pathologists, because you’ve got to have at least two people who are interested in each area. The other downside for the pathologists themselves is that in the past everybody was a generalist. Am I going to voluntarily give some of that up and say, “I admit that I’m not as good as you are in lung cancer?” “I’m going to limit my practice to ovarian cancer,” or, “I’m going to give up my expertise in bladder cancer because I want to specialize on prostate cancer?” So you have to give something up. You have to admit that you don’t know everything, and these more senior and mostly male pathologists weren’t really ready to do that. They like to beat on their chests figuratively and say, “I can do anything,” so that was an issue for us, and we had to wait until we sort of had a critical mass of younger and midlevel people whose egos weren’t quite so developed. We also had to recruit more people, because at that time we had lost pathologists. We didn’t have enough people to really subspecialize. We told the pathologists, “You don’t have to have just one specialty area,” because some people would say, “Wait. I like kidney cancer, and I like lung cancer equally well. I would like to do both.” So we said, “Okay. You can do both. It’s okay.” We also never said that you have to stick with one thing your whole career because maybe today you like ovarian cancer, you do a lot of it, and you figure you know everything and you get more interested now in colon cancer so you want to move. Now people have not moved, but we’ve never said they can’t move. We said, “You can move if you want, presuming there’s enough space in the other area.” We can’t have everybody doing kidney and that there’s only two kidney tumors a day.

Tacey Ann Rosolowski, PhD:

Right.

Janet M. Bruner, MD:

That’s not going to work. It just—so we started—we had been thinking about this for about three or four years at that time, but the generalists had won out. They said, “No, we don’t want to subspecialize.” Okay. So we gave up. Then Mass General published an article around 1996, I think it was—‘95 or ‘96—that they subspecialized. They’re not a cancer hospital. They do everything—with some information about how they did it, how they organized their specialty, how they organized their educational program in with that. The other issue with subspecialization is—we said, “Okay, we’ve got these clinical fellows in the department who are here to learn as much as they can,” and when they learn is when they’re sitting with the pathologists as they’re making diagnosis. It’s a very individualized teaching. So we had some pathologists who loved breast cancer, and we had other pathologists who hated breast cancer and loved prostate cancer. Why should the clinical fellows be sitting with the person who loves breast cancer, looking at prostate cancer, and learning from them about prostate cancer? That just didn’t make any sense, so we thought it’s also going to improve our education programs. After Dr. Hamilton came and after I took over, we knew we were going to hire a number of additional pathologists, so we sort of looked for people who were interested in different particular things. So we didn’t hire all colon pathologists. We hired one person who was interested in colon, another one for skin. What else did we do at that time? Some people were interested in breast pathology. We added these people on with the understanding that we would subspecialize, but we used essentially the year 1999—from the beginning of the year 1999 through the rest of that fiscal year, which is through August—to get used to the idea. And this is sort of—my managing change courses kind of helped me through this, because I told the pathologists early in the year, “We are going to subspecialize. We’re going to do it on September 1,” because that’s the beginning of our fiscal year, “so we know what we’re aiming at. Between the first of 1999 and that September 1, we need to poke holes in this, and you guys need to tell me every problem that we’re going to run into because we need to be ready. We’re not going to turn it back. Once we go, we’re gone, and we need to have everything. We need to have thought of everything. What’s going to make it? What’s going to crash? What’s going to fail? What are we up against here?” Dr. Hamilton wanted to do it sooner. He really wanted to do it right away. I said, “No. This is a huge change.” It was a huge change! We were the only ones, and there were people even in this department who thought, “It isn’t going to work. She’s going to have to go back. We’re not going to be able to do this.” It took a lot of just talking. What’s going to go wrong? What’s right? How should we do this? How should we divide the cases up? How should we structure our fellowship program? Because it was totally different. We had to worry about those guys. There was just a lot of mental preparation before we finally made the move, and it worked out fine. I didn’t hear about any issues, so I was never tempted to go back. There’s still the older, more senior faculty who were the generalists—and actually there are even some younger faculty who are still here today—who in their heart of hearts wish they were generalists. I’m sorry for that, but I don’t regret it. They’re here. They stayed here, and I think that some of the senior faculty were pretty uncomfortable with it. I didn’t hear any overt rebellion because they knew—I guess they knew me well enough by that time to know that there was no use in talking to me about it. But one thing that I do try to deal with change, and that is I try to think of what’s going to go wrong, and I try to get that out and get it on the table, because there’s no point in failing. A lot of times you can say, “We’re going to do a trial. We’re going to try this for three months and reevaluate,” but in this case it was too big a change. We weren’t going to be able. We had to change our computer systems and other processes and systems that were much more far-reaching in the department, so we couldn’t change and go back. It just so happened that we had the right number of people who liked each different specialty. It just worked out. I guess we were just fortunate, but it seemed to work out fine.

Tacey Ann Rosolowski, PhD:

How—?

Janet M. Bruner, MD:

Go ahead.

Tacey Ann Rosolowski, PhD:

Oh, no. I was going to ask how it changed the way you worked with other departments.

Janet M. Bruner, MD:

It changed the way—I think it changed the closeness that we felt to our other collaborative departments. The other thing that I’ll never forget—one of the pathologists—obviously we had the same number of people working on August 31 and September 1. We didn’t add a bunch of people that same day. The cases were about the same—the number of cases—so the workload was about the same, and one of the pathologists came to me a couple of months later, and she said, “You know? I just love this specialization! It’s so much easier! I get my work done so much faster! I can go home earlier. The cases are easier. It’s just great!” And I realized it’s because she loved what she was doing now. She didn’t have to do those cases that she didn’t like, and it was just so gratifying to me that here the workload hadn’t changed, but people mentally and emotionally felt so much better about the work they were doing because they loved it. We still have one general rotation, and that is our frozen section rotation, which is the immediate diagnosis during surgery. It keeps people in touch with the general systems so you didn’t have to leave it behind totally, and it also lets the pathologists interact with all of the surgeons in that one area. Otherwise, we’re pretty much limited to interacting with our own surgeons. And I also would hear comments like, “Oh, man. I am so glad we subspecialized,” from a thoracic pathologist—a lung guy—“I am so glad we subspecialized, because you know the thoracic surgeons are so great here. We get along so well, and they’re so wonderful, and now I don’t have to deal with those GU surgeons. They’re awful!” Meanwhile, the GU—genitourinary people—are saying, “You know, we love those GU surgeons. They are so great! We get along so well, and they’re so easy to work with, and now we don’t have to deal with those egotistical thoracic surgeons because they’re just awful!” So it was all so wonderful to hear that.

Tacey Ann Rosolowski, PhD:

You’re getting people together that speak the same language.

Janet M. Bruner, MD:

Right. Right. And they respect each other. And each of the surgeons, I think, is much more comfortable with a pathologist who’s interested and knows more about his specialty, and that’s the effect it’s had. There’s a lot more communication between—more directly between the surgeons and the pathologists in each area.

Tacey Ann Rosolowski, PhD:

That’s an exciting change.

Janet M. Bruner, MD:

It is. And that was probably the major change we made. It was also very gratifying that within five years of when we specialized I had some visitors here—maybe six years or seven years—from who called. Now there is the place. That is the general place. They are generalists. They didn’t want to subspecialize. They laughed at us. They said, “You’re going to fail. You guys are going back. Nobody can do this and really carry it off. It’s not going to work. This isn’t going to work.” About five or six years later—I happen to know the chairman at Sloan-Kettering, and he called me up and he said, “Can I come down there with my vice chair? We really want to see what you’re doing. We’re thinking maybe doing this—maybe—and we just want to see how you did it.” So that was very gratifying, and I was very generous. They looked at everything. I also heard around that time Cleveland Clinic—one of their pathology—I don’t know if it was the chair or the vice chair—called and wanted to know some information, and we sent him some statistics and information on how we did it. They have since subspecialized, and I think more places have. Again, what holds people back is you’ve got to have a lot of pathologists. It’s not the most cost-effective system, especially in a smaller place, so the big places can afford to do it. The other reason that we can afford to do it is because clinical diagnosis is not all we do. We do research also so we’re only talking about—already we have more pathologists than a hospital who doesn’t have any research, because some of our time is protected for research. We have maybe forty percent more or maybe fifty percent more pathologists than a place who just does clinical diagnostic stuff.

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Chapter 14: The Pathology Department: Becoming Chair and a Controversial Move to Subspecialize

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