Chapter 15: Expansion and Transformation in the Department of Pathology

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Chapter 15: Expansion and Transformation in the Department of Pathology

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In this section, Dr. Bruner first discusses other initiatives she undertook while Chair of Pathology. She notes the new computer system she selected for the Department; she authorized transcriptionists to work from home, a move that greatly improved their productivity and ability to meet the 2-hour deadline to transcribe reports. (She says that sometimes she wants to go back and change a detail in a report, only to find that it has already been transcribed.) Dr. Bruner has been Deputy Head of the Division of Pathology and Laboratory Medicine since 1998, and here she explains that her role is to serve as the Division's second in command, representing Dr. Stanley R. Hamilton, M.D., at meetings with upper administration. She then turns to changes made in the Pathology Department once the Mays Clinic opened. The Clinic spurred huge growth in the Department, since MD Anderson pathologists are very involved in providing information during treatment decisions and surgery. A frozen section room was built in the Mays Ambulatory Clinic. Dr. Bruner explains that it is so critical to locate some pathology services very close to operating rooms, so that information from intraoperative frozen sections (tissue samples frozen and analyzed during surgery) can be quickly communicated to surgeons as they work.

Identifier

BrunerJM_02_20120607_C15

Publication Date

6-7-2012

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; The Administrator; Building/Transforming the Institution; Multi-disciplinary Approaches; Growth and/or Change; Overview; Definitions, Explanations, Translations; Devices, Drugs, Procedures; Institutional Processes; Discovery and Success

Transcript

Tacey Ann Rosolowski, PhD:

What were some of the other initiatives you found really significant to undertake when you became chair?

Janet M. Bruner, MD:

One of them, which I really had less to do with, was putting in a new computer system. We had to do that, and one of the faculty spearheaded that. It took us two or three years. We worked with our IT department and sent out a huge request for proposals and reviewed them, and it was a real detailed process. We finally did choose the computer system that we’re still with today. I think we put that in in 2003, so it’s been almost ten years. That was a huge change and, again, I think much for the better. We chose a computer system that was easier for us to work with. There are some other changes, not so much for the faculty. There was a time where we sent our transcriptionists off site. I don’t know—did I mention this to you?

Tacey Ann Rosolowski, PhD:

You mentioned something about transcription.

Janet M. Bruner, MD:

Yeah.

Tacey Ann Rosolowski, PhD:

I think it was a related issue.

Janet M. Bruner, MD:

They—

Tacey Ann Rosolowski, PhD:

Oh, right.

Janet M. Bruner, MD:

Yeah.

Tacey Ann Rosolowski, PhD:

I’m not sure if that was on record or off, but they were so much happier.

Janet M. Bruner, MD:

Yeah, but the one who—yeah. They really thought that they would like to work off site, and we got a supervisor who was willing to try to take them there. We had some benchmarks that they had to achieve before they were permitted to work off site, and probably our most experienced one was too chatty and could never make these benchmarks. She was just too distractible, and she was a real touchy-feely person who would just talk and couldn’t type and would be off keyboard. So finally we said—everybody else had gone home, and there were two people left, and we said, “You’ve got to do this. Put your nose to the grindstone,” and she did. She managed to make the benchmarks, and she went home—took her computer, went home, and every one of them, their productivity went up so much. I’ll swear we had about eight transcriptionists at one point to transcribe all—and all they transcribed—I won’t say all, but they transcribe only our clinical reports. They don’t transcribe documents. They don’t transcribe publications. It’s only the patient reports. That’s all they do, of which there’s about 60,000 or 70,000 a year, so it was a lot. And there’s a turnover in personnel, and it came to a point where they got so fast at transcribing—I’ll remember—it’s happened to me more than once. We use a dictation system that’s computerized so we can go back and listen to our dictation through the computer, and I would finish dictating a case and think, “Oh, I’d better go back and listen to that,” and it was too late. It was already typed. So that’s good. That’s the best you can hope for. They were typing almost as we were dictating. Now they sometimes—their goal is to be no more than two hours behind us, and at various times the institution has decided that it’s too expensive to have dedicated transcriptionists for Pathology, so they want us to send out a request for proposals for other transcription services. We’ve done that in the past, and no one bids on it because our criteria are that they have to have this two-hour window because it’s important to get the patient reports out. They’re keeping up with it pretty good. If they fall more than the two hours behind, they feel really terrible. They’re guilty. They send us emails. “Oh, we’re more than two hours behind. Please bear with us. We’re going to catch up.” But now I think we’ve only got about four transcriptionists because they got so good that as transcriptionists would leave—would quit—we would look at the situation and say, “I don’t think we really need to replace her at this point.” So we actually are working today with fewer transcriptionists than we had in the mid-2000s.

Tacey Ann Rosolowski, PhD:

That’s amazing.

Janet M. Bruner, MD:

Yeah.

Tacey Ann Rosolowski, PhD:

That’s incredible.

Janet M. Bruner, MD:

And they don’t have to drive. They don’t have to park. They get computer support from our computer guys.

Tacey Ann Rosolowski, PhD:

Yeah. Works out well.

Janet M. Bruner, MD:

It does work out very well. We had a lot of other—there were some other significant changes in faculty and in processes that we’ve done. We talked about the bar coding.

Tacey Ann Rosolowski, PhD:

Right.

Janet M. Bruner, MD:

That was a more recent initiative that was huge for us as far as patient safety and quality of care.

Tacey Ann Rosolowski, PhD:

Is there anything else you’d like to say before we to turn toward your next move to Deputy Head of Pathology and Laboratory Medicine?

Janet M. Bruner, MD:

No, although that came kind of at the same time.

Tacey Ann Rosolowski, PhD:

Okay. Well, maybe you can talk about how it was related and that—

Janet M. Bruner, MD:

I think that really is the—Dr. Hamilton also asked me to do that. It’s the second in command to him, and I back him up when he’s gone and do some functions that he just doesn’t have time to do. It’s not really a huge thing, but it does mean that I feel responsible for supporting him and making sure that we are in alignment in all things administrative. I think that’s—he travels quite a bit, so it’s important for him to have somebody left behind that he can trust that’s going to go to a meeting and really represent our interests—his interests—at the highest levels of the administration.

Tacey Ann Rosolowski, PhD:

Just so I understand, you essentially became deputy head at the same time you became chair? Was that—?

Janet M. Bruner, MD:

Yeah, I think it was right about that time.

Tacey Ann Rosolowski, PhD:

Interesting. Okay. What are some of the situations in which Pathology has had a particular interest that needed to be represented to the upper level of the administration?

Janet M. Bruner, MD:

I think he—as one of the division heads they—the division heads meet as a group, and it’s the highest administrative structural body. They talk about more global issues for the institution like information systems for the electronic medical record—how that’s going to affect things. They consider issues such as the global issues for the budget. You know—next budget year is coming. We need to add some faculty, but how are we going to manage that? And depending—you know—we want to add these surgeons. What is that going to mean for Pathology? What’s it going to mean for Oncology? What’s it going to mean for Radiology? So it’s those kinds of discussions at the table. A lot of discussions about the outreach—the regional care centers, outreach programs, and some of those—you know—how are we going to manage that and what does it mean for each segment—for Pediatrics, for Radiology, for Radiation Oncology?

Tacey Ann Rosolowski, PhD:

Sounds like a pretty broad palette of—

Janet M. Bruner, MD:

It is. It’s much more working with the—all of the other areas in the hospital.

Tacey Ann Rosolowski, PhD:

We kind of talked about the growth of the Department of Pathology since you joined in 1984. I was wondering if there was anything you wanted to add about that, particularly given the conversation we just had about the perspective you get as being deputy head when you see how Pathology dovetails at a higher level with all of the other divisions and subsections within the institution.

Janet M. Bruner, MD:

Just that I think—one of the things we—we grew tremendously, from about twenty or twenty-five faculty when I took over. When I stepped down I think I had a little over sixty faculty.

Tacey Ann Rosolowski, PhD:

Wow!

Janet M. Bruner, MD:

Yeah. It was unbelievable. There were some years—one of the times when we grew the fastest was when we opened the Mays Clinic, because it’s an outpatient surgery center, and they also require support for intraoperative diagnoses—this frozen section—so all of a sudden I had to have a pathologist over there every day because it’s not physically close enough that you can manage from the same lab. So that year that they opened, we recruited I think eight pathologists that year.

Tacey Ann Rosolowski, PhD:

Can I ask you a really—it seems like a silly question, but to me the doesn’t seem all that far away. What’s the ideal distance, and why does that physical distance make so much of a difference?

Janet M. Bruner, MD:

Because the intraoperative frozen sections require us to receive the specimen, process it, and look at it and make a diagnosis all within twenty minutes, and we never know when it’s coming, so someone has to be physically sitting there outside of their surgery suites ready to do that at all times. We do a lot of frozen sections here at MD Anderson because the surgeries that are being done are really definitive surgeries for oncology. We look at—a surgeon cuts out a tumor, and he says, “ I need to know if that tumor is touching my surgical margin at any point,” so we have to actually do a microscope slide and look at the margins of that tumor all around, because he doesn’t want to have to go back in. It doesn’t do him any good to find out two days later, oh, yeah, the tumor was at the margin, because he could take a little more tissue right now, but if he sews the patient up, they’re partly healed. To have to go back in and find that exact same spot to make that margin what we call “clean”—no tumor there—it’s just too much.

Tacey Ann Rosolowski, PhD:

So I think you had said it’s “intraoperative frozen sections?”

Janet M. Bruner, MD:

Right.

Tacey Ann Rosolowski, PhD:

So “intraoperative” means during the operation?

Janet M. Bruner, MD:

During the operation.

Tacey Ann Rosolowski, PhD:

Okay.

Janet M. Bruner, MD:

Right.

Tacey Ann Rosolowski, PhD:

I was going to ask you about that. Okay.

Janet M. Bruner, MD:

Right.

Tacey Ann Rosolowski, PhD:

(laughing) Things are becoming clear now.

Janet M. Bruner, MD:

Yeah. So the problem is those are stat. Those are the status kind of stat that we get and the timing is such that by the time—if the specimen reaches the point at which he needs to know the diagnosis somebody—if at that point he called me and said, “Walk over here, process the specimen, give me a diagnosis”—it takes me seven minutes or ten minutes to walk there. We just had to set up a whole separate frozen section operation in the Mays Clinic, and we had to staff it. So we had to hire more technicians who support us, more pathologists, because it’s more work. Somebody has to be there every day, and it’s caused problems for us because here at Alkek, we’re four floors removed from our surgery suites, so if somebody has a problem with a case and needs another pathologist to help them look at it, they can call. We run up the stairs, we take the elevator—it’s two minutes, and we’re there. If somebody at Mays Clinic has a problem and needs another pathologist to help them look at the case, it’s a ten-minute walk, so that’s the kind of problem it causes for us. It’s just very, very inefficient, a time delay, and no one’s ever said this, but I wonder how many times the pathologist over there thinks to themselves, “Gee, I wish I had somebody else to look at this with me. Oh, that’s going to take fifteen minutes. Never mind,” and just makes the diagnosis, which is not good. So it’s not a good situation to have physically separate surgeries—surgery suites. Other hospitals have it. I hear that’s the way it is in New York at—it’s not that way at Sloan-Kettering. They’re right there. But it’s that way at Columbia, I think. It really does enhance the quality and immediacy of the surgical patient care to have pathologists immediately available for frozen sections. We probably do too many frozen sections because we’re there. The surgeons know that, so they say, “Let me just send this out and get a diagnosis,” but we try to convince them that in most cases it’s a preliminary diagnosis because the quality is not quite as good as our permanent section is a couple of days later. But it’s something we do a lot of. We’re used to it, the surgeons are used to it and it’s just something that sort of—I guess it’s kind of a hallmark of MD Anderson. We do a lot of frozen section diagnoses.

Tacey Ann Rosolowski, PhD:

Interesting. Well, I’m also hearing that recurring theme of speed.

Janet M. Bruner, MD:

Yeah. Yeah.

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Chapter 15: Expansion and Transformation in the Department of Pathology

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