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  Chapter 08: Developing Multi-Disciplinary Care Within the Department and in the Institution

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  Dr. Burke talks about his work in the early nineties on a planning group to develop multi-disciplinary care and more patient-centered care throughout the institution. (They had patients wear pedometers to see how far they had to walk for appointments.) He notes the speed at which the transition was made and the shock it could create.

  Dr. Burke explains how the move to multi-disciplinary among faculty also created a situation in which all support services were also disease linked with resulting in increases in their specialization and expertise. He notes that this has been a “recipe for MD Anderson success.”

  Dr. Burke notes that Gynecologic Oncology operated in a multi-disciplinary fashion from the start. He notes that MD Anderson was the first cancer center to restructure care around disease sites.

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  Chapter 09: Bringing Experience with Surgery and National Trials to MD Anderson; Research on Endometrial Cancer

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Burke sketches the evolution of his research career and the specific perspective that made him attractive to MD Anderson. He explains that he started this career while he was a Fellow at the Walter Reed Hospital in the late seventies. He notes the strange situation in which the Army was at the forefront of research in ob/gyn cancers. He then notes that, when he came to MD Anderson, there were many unanswered questions and he brought the institution his experience with national trials and his strong surgical background, and broad network of connections. He briefly explains his leadership philosophy with regards to junior faculty and research: allow them to choose different disease area interests so they don’t get in each other’s way.

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  Chapter 10: Research on Gynecologic Cancers; the Impact of Research on How a SPORE is Administered

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  Dr. Burke sketches his study of endometrial cancer that involved a decade-long project of looking at techniques to reduce the radical surgery needed. His model has radically changed the management of the disease. Dr. Burke describes a uterine SPORE he worked on with Dr. George Stancel [oral history interview] and two junior faculty members, resulting in many new discoveries and new investigators attracted to the field.

  He also explains an important outgrowth of this project: inclusion of patient advocates on the research team.

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  Chapter 11: Maintaining MD Anderson Culture Despite Growth and Financial Challenges in Healthcare

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  Dr. Burke begins this Chapter by describing how the culture of MD Anderson has changed since 1988 when faculty easily had face-to-face relationships. He notes that many institutional values have been formalized as the institution shifted to multi-disciplinary care models and translational research.

  He talks about the advantage of the MD Anderson system in which physicians are not compensated per procedure: this has been maintained a “clean way of providing care.”

  He next talks about the “financial clarity” that Dr. Leon Leach [Oral History Interview] brought to the institution under Dr. John Mendelsohn.

  He next talks about what makes MD Anderson unique: keeping the mission areas in balance has been part of institutional strategy.

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  Chapter 12: Medical Director of the Gynecologic Oncology Center: Developing Processes and Faculty Talent

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  Dr. Burke begins by describing how he resolved inefficiencies in the Gynecologic Oncology Center when he took over. He describes a quality control program he set in place and sketches increases in the Clinic’s patient traffic and faculty numbers.

  Dr. Burke next comments on positions that can serve as training ground for mid-career physicians who will rise in the administration. He explains how his leadership skills grew and talks about his roles on the Credentials Committee and the Medical Staff Committee. Dr. Burke notes how important it is that a hospital’s leadership has this broad perspective: he looks for young faculty who will be open to these opportunities and to future leadership. Dr. Burke talks about how he looks for faculty with potential and gives them chances to develop themselves.

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  Chapter 13: Serving as MD Anderson’s Chief Medical Officer and Physician in Chief A: The Administrator;

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  Dr. Burke first explains how he came to serve 50% of his time as Chief Medical Officer in 1998. He notes the scope of this role and how it affected his clinical practice. He next notes that when John Mendelsohn became president, he was asked to come full time into administration. He explains his decision to shift into administrative work.

  Next, he explains the scope of his responsibilities as Physician in Chief and stresses that clinical operations should be led by a physician. He talks about the complexity of MD Anderson search processes.

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  Chapter 14: As Physician in Chief: Addressing Needs in Pharmacy, Nursing, and Quality and Safety

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  Dr. Burke explains the major clinical needs of MD Anderson in 2007.

  He talks about pharmaceutical needs. He next explains how he built his support team by seeking out people.

  He describes the Quality and Safety program focused on patient safety, explaining the related Clinical Safety and Effectiveness Program first developed for industry, duly adapted for MD Anderson and other health care institutions. He talks about the influence of this Quality and Safety program. P

  Dr. Burke explains how changes innovated by the Clinical Safety and Effectiveness Programmed were first received when introduced. He notes resistance and that the Program encouraged individuals to innovate their own improvements to process and gave prizes for the best solutions to process problems. He gives examples of innovations.

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  Chapter 15: Building a Highly Skilled Nursing Service

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  Dr. Burke describes how he addressed the need for an increasingly skilled staff of oncology nurses.

  He talks about partnering with Dr. Barbara Summers [Oral History Interview], Head of Nursing, to create a program to attract young nurses to the field. He explains that oncology nursing is not a “happy area” and has had difficulty attracting students. They also created programs to help nurses develop their skills and expertise with additional training and degree programs.

  Dr. Burke gives an overview of changes in nursing that broadened the scope of nursing to management, administration, and advanced practice nursing. He notes that Advanced Practice Nurses have expertise and serve as preceptors to their teams and those under them, increasing the quality of care.

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  Chapter 16: As Physician in Chief: Building the Survivorship Program and Pharmacy Support

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Burke first explains that he hired Alma Rodriquez to head the Survivorship Program and gave her a mandate to build that program. One of the first projects undertaken was information gathering to discover what issues and needs patients had as they entered survivorship and long-term survivorship. Dr. Burke describes the feedback from patients and how the Program went about addressing those needs. He notes that today the Survivorship Clinics see thousands of patients. He explains his hope that a freestanding survivorship clinic will be built someday (the institution was closed twice).

  Next, Dr. Burke explains the complexity of pharmacy needs at MD Anderson, how these have been addressed, and how his office is currently building a training program in cancer related pharmacy.

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  Chapter 17: Comprehensive Approaches to Faculty Burnout in a Complex, Growing Institution

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Burke talks about the reality and sources of faculty burnout and the support for those who experience it. He explains that faculty who are deeply connected to the institution’s mission create their own mechanisms to cope with stress and burnout and those who cannot, leave MD Anderson.

  Next, Dr. Burke talks about the mechanisms in place to help faculty with stress. He explains that mentoring can help young faculty find balance and a research niche, which will help with their career stress, and gives examples from his department. He mentions MD Anderson’s counseling services.

  Dr. Burke talks about his personal experience with burnout.

  Dr. Burke says that burnout is an ongoing issue that will not go away. He advocates that faculty work in teams and that these teams care for one another. He also mentions efforts in 2010 and after to rid the institution of dysfunctional behavior. The mentoring program and safety and quality programs arose from this effort.

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  Chapter 18: The Institute for Cancer Care and the Challenge of Value-Based Care

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Burke talks about the creation of the Institute for Cancer Care Excellence in 2008 and its role in defining value-based care. He sets this in the context of the current focus on the financial side of healthcare and the huge effort underway to map processes of care, attach cost to those processes, and determine ultimate value. He first gives context, explaining that MD Anderson wanted to be in the forefront of thinking about value-based care and he and others began to make connections with the “quality movement” (e.g. Brent James). One of the first aims was to publish papers on “value propositions in health care.” Dr. Burke gives some context, explaining that quality, safety and cost lead to a notion of value.

  Dr. Burke explains the viewpoint that MD Anderson took on quality --different from the prevailing viewpoint in the nation. The Institute served as the focal point to bring together all information about this ongoing conversation.

  Dr. Burke explains the challenges in assembling data that support the view of quality advocated by MD Anderson.

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  Chapter 19: Financial Realities in Healthcare: The Need for Investment in Healthy Behavior; Treatments Near the End of Life; the Affordable Care Act

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Burke talks about the fiscal realities that MD Anderson is confronting now and in the immediate future. He first observes that there has been no effort at the national level to make an investment in healthy behaviors, though he sees some change in that recently. He mentions where the resistance has been to such investment and observes that MD Anderson has advocated for these changes, but that no single institution can influence national priorities.

  Dr. Burke next talks about the difficult financial decisions tied up with establishing care protocols at the end of a patient’s life. He talks about studies in progress to determine which efforts near the end of life have value (in that they improve a patient’s survival). He then discusses the realities of the conversations that physicians must have with patients, the decisions that patients and families must make.

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  Chapter 20: Financial Realities in Healthcare: The Affordable Care Act

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Burke talks about the Affordable Care Act. Though creating access to care is a critical benefit, Dr. Burke explains via examples that the Act has created challenges because the payment system it relies on will not survive the Value-Based Care movement. He also gives examples of how the current system pays an institution for “doing things wrong.”

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  Chapter 21: The MD Anderson Network: Origins, Mission, and Lessons of MD Anderson Orlando

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Burke talks about becoming Vice President of the MD Anderson Cancer Network, established early in 2014.

  He gives background on how the Network began.

  Next, he explains why he was appointed to the position and his personal reasons for taking the position.

  Dr. Burke sketches why the MD Anderson Cancer Network offers “a huge delivery” on the institution’s mission.

  He comments on the dissolution of MD Anderson’s partnership with Orlando Health and the lessons.

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  Chapter 22: The MD Anderson Network: Building Partnerships Based on Shared Mission

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Burke explains that his current assignment as Vice President of the MD Anderson Network is to establish partnerships with institutions whose missions link with MD Anderson’s.

  He talks about Network goals of increasing MD Anderson trained physicians and researchers. He gives examples of an innovative program to accomplish this. Dr. Burke notes the importance of this program given that the nation is confronting a shortage of oncology professionals.

  Next he mentions the Network’s role in expanding access to MD Anderson’s clinical trials, lists the features of a good partner institution, and talks about how he is going about bringing MD Anderson’s outside connections under one umbrella. He notes that these partnerships represent revenue streams for MD Anderson.

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  Chapter 23: Building the MD Anderson Cancer Network

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  Dr. Burke begins this chapter on his strategies for building the MD Anderson Cancer Network with a discussion of the major challenges that this initiative must face.

  He talks about the importance of “profiling” the patient populations at each partner institution in order to select the right clinical trials for their involvement and gives an example.

  He discusses the financial projections for the Network’s operation (in the 60 – 80 million range) and how that revenue will be used.

  Dr. Burke explains his philosophy and goals. By bringing all partner institutions under a single umbrella, the Network can to touch as large a percentage of the United States population as possible.

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  Chapter 24: Significant Research Initiatives

  Thomas W. Burke MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Burke talks about the significant research he conducted prior to devoting most of his time to administration. He was involved in early projects defining the respective roles of radiation and chemotherapy. He talks about the challenges of large-scale clinical trials, particularly with rare cancers. He sketches his work defining the surgical staging for uterine cancer in the eighties and nineties and his work training individuals in robotic and laproscopic techniques.

  Dr. Burke next explains why vulvar cancers were “a great niche” for him to take on in the sixties and seventies and describes an additional study.

  At the end of this chapter –and the interview—Dr. Burke talks about how satisfied he has been to work at an institution that enabled him to reinvent himself. He is content to know that he has trained many people and put together many teams that have launched all kinds of services.

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  Chapter 01: A Family Tradition in Medicine; Attracted to the Medical Mentality

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  Dr. Buzdar begins this chapter by explaining that his father, who was in banking, wanted all his children to become physicians (and they did enter medicine). He explains that the educational system in Pakistan was based on the British system, and he entered the science track in eighth grade. He recounts inspiring scenes from science classes. He also explains that his college and medical school experiences were unique, as he attended the 200 year old Nishtar Medical College, Multan, Pakistan [MB,BS, 1967], where he received a high quality education. Dr. Buzdar notes his own qualities of curiosity, his intellectual interest in medicine, and his interest in "looking for things for tomorrow."

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  Chapter 02: The Advantages of Moving to Texas and to MD Anderson

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  Dr. Buzdar begins by talking about how he came to leave New England (where his wife, Barbara, was very happy) and come to Houston. He explains that there was an unexpected opening at MD Anderson, and called Dr. Schullenberger to follow up. Dr. Buzdar then sketches his evolving research focus within the Breast Cancer Section. He explains that, at the time, there was little that could be done for breast cancer patients as oncology was in its infancy. He talks about the dramatic results achieved when he and Dr. Gabriel Hortobagyi [oral history interview] developed the 3-drug combination of 5-flourouracil, Adriamycin and cyclophosphamide for use in patients with metastatic breast cancer, resulting in cancers shrinking in 75% of patients. The combination was then used for adjuvant therapy. Dr. Buzdar talks about controversy over using aggressive chemo therapy with severe side effects, noting that the study was blocked by other disciplines when it came up for review in the IRB.

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  Chapter 03: Undertaking Breast Cancer Research When the Field was Young

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Buzdar sketches his evolving research focus within the Breast Cancer Section. He explains that, at the time, there was little that could be done for breast cancer patients as oncology was in its infancy. He talks about the dramatic results achieved when he and Dr. Gabriel Hortobagyi [oral history interview] developed the 3-drug combination of 5-flourouracil, Adriamycin and cyclophosphamide for use in patients with metastatic breast cancer, resulting in cancers shrinking in 75% of patients. The combination was then used for adjuvant therapy. Dr. Buzdar talks about controversy over using aggressive chemo therapy with severe side effects, noting that the study was blocked by other disciplines when it came up for review in the IRB.

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  Chapter 04: A Philosophy of Clinical Research (and Its Early Controversies)

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  Dr. Buzdar first sets his philosophy of clinical research in the context of his early work on aggressive chemotherapies. He says that a principle investigator should always be honest with the patient. [The recorder is paused.] The "gold standard," he says, is full information. [The recorder is paused.] Dr. Buzdar notes that there was almost a "cult" attitude at the time that the best procedure was to push more drugs at higher doses, without evidence that this had an impact on outcomes. He notes that he was chair of the institutional review board at the time. He then notes that MD Anderson was the first institution to add taxanes to the FAC regimen, a combination that is still standard of care.

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  Chapter 05: IRBs and a Few Words about the Growth of Multi-disciplinary Care

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  Dr. Buzdar begins this chapter with an explanation of why ethical review boards (the first IRBs) were established after the Second World War. MD Anderson was in the forefront of the movement, and established the first ethics committee in 1966. Dr. Buzdar served on the IRB for a decade. Dr. Buzdar then talks about the power of the IRB, which operates as an independent and final authority in determining whether a protocol can proceed. He gives an example of immunotherapy trials using CAR T cells [chimeric antigen receptor T cells], a treatment that has very serious side effects, leading in some cases to death. Dr. Buzdar describes the unique (in the nation) initiative that MD Anderson has undertaken to monitor and treat these patients for side effects. He notes the value of immunotherapy for patients who are resistant to every other known treatment. Dr. Buzdar also explains that the immunotherapy protocols represent efforts in multidisciplinary care and research. This, he says, is MD Anderson's unique system. He describes how multidisciplinary care works and how it gives rise to research. This has also necessitated a move away from the traditional axiom, "do no harm," he states.

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  Chapter 06: Research on Hormone-Dependent Breast Cancers

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Buzdar talks about his work on the effectiveness of anti-estrogens in shrinking cancers. He led the research, he explains, on aromatase inhibitors that block estrogen production. After skepticism, this work led to new therapies that became standard of care. Dr. Buzdar talks about his collaboration with Dr. Gabriel Hortobagyi. He notes that accepting the challenge of collaboration is an important first step in doing multidisciplinary research.

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  Chapter 07: VP of Clinical Research

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Buzdar talks about his role as Vice President of Clinical Research, an office that oversees five IRBs. He notes that in the mid-eighties, there was one IRB with a tiny office and one secretary; now he has three hundred people working under him. [The recorder is paused.] He explains that the office has a dual role, to oversee clinical research and ensure compliance with federal regulations, and to educate faculty and personnel about regulations. [The recorder is paused.] Dr. Buzdar stresses that patients come to MD Anderson because of the innovative research conducted and to have access to clinical trials, and research remains a primary part of the institution's mission. He then offers examples of his Office's role in preserving transparency in the process protocol approval process. He notes that investigators are impatient to get their protocols underway, and the Office is involved in educating them about the complex processes that have to unfold in order for this to happen prior to and after approval (which involves many legal documents).

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  Chapter 08: The Clinical Effectiveness Committee and the MD Anderson Algorithms of Care

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  Dr. Buzdar chaired the Clinical Effectiveness Committee from 2007 to 2014, and in this chapter he talks about the committee's role in "spelling out patient care." [The recorder is paused.] The purpose of the Committee's activities was and is to develop the MD Anderson approach for disease management from start to finish, for every disease site, based on evidence. A primary downstream use of this information is to define the rationale behind care to insurance companies. Dr. Buzdar explains that the algorithms were developed by disease center experts, who present their findings to the committee. They are then approved as the institutional standard of care. Dr. Buzdar notes that Medicare has used the MD Anderson model as a national standard. There is also a series of publications based on the algorithms. He explains that the Committee is still in existence and continues to develop and refine the algorithms in real time. There are yearly reviews of all algorithms and there may be immediate reviews in response to a new study or treatment innovation.

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  Chapter 09: Early Research: Changing the Natural History of Breast Cancer

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Buzdar talks about his first studies of combination chemotherapy that he conducted with Dr. Gabriel Hortobagyi and that successfully "changed the natural history of breast cancer." He discusses a first study of patients with recurring breast cancer in one or two places, noting that 25%-30% of the patients treated in the seventies are still alive today. He explains that the success of the treatment meant that the research team never conducted a randomized trial. He discusses the next study of combination chemotherapy given to patients with inflammatory carcinoma of the breast. He explains how skeptical individuals were of the success of the trail, both within and outside the institution. He talks about the controversy surrounding aggressive chemotherapeutic treatments.

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  Chapter 10: Research in Breast Medical Oncology: Pushing Against Medical Conservatism

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  Dr. Buzdar begins this chapter by describing the overall culture of medical conservatism he and others faced as they conducted studies with chemotherapy. He talks about the innovations led by J Freireich and Emil Frei in the Department of Developmental Therapeutics, and that it took a while to convince others in the institution about the value of combination treatments and aggressive treatments.
  
  Next, Dr. Buzdar sketches a picture of how small Breast Medical Oncology was when it began, occupying only a hallway with pull-down desks to write on. Despite such small beginnings, he points out, MD Anderson research had great impact on the natural history of breast cancer; he cites the publication of a recent book on MD Anderson treatments for the disease. Dr. Buzdar also cites the influence of R. Lee Clark on this research, noting that he instituted the policy of keeping comprehensive data on patients (following a patient to the end of his/her life, if possible). He describes Dr. Clark as "down to earth" and tells a story about sleeping in Dr. Clark's office.

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  Chapter 11: Endocrine Treatments for Breast Cancer

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Buzdar talks about research that developed in the aftermath of the discovery of Tamoxifen and hormone dependent cancers. He was the principle investigator on a national blinded study of the effectiveness of the aromatase inhibitor, anastrozole, which was eventually approved by the FDA and approved globally based on his work.
  
  Next, Dr. Buzdar talks about the origin of research into the link between hormones and cancer. He notes his collaboration with endocrinologist Dr. Najib Saaman. He explains the impact that advancing technology has had on the study of tissues.

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  Chapter 12: The Evolution of Tumor Registries at MD Anderson

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Buzdar explains how tumor registries have evolved at the institution. Originally there were many registries associated with departments, but now there are two. Dr. Buzdar participated in a group to advocate for an institutional bank which was activated on 31 January 2017. He explains that all patients are now asked if they will donate tissue to the bank. He talks about the "clear environment" conditions maintained at the registry and why this is important. Another bank, in existence for two or three years, preserves samples of metastatic disease collected sequentially from a patient as the disease evolves. Dr. Buzdar sketches the controversy around creating these institutional banks. He also talks about the evolution of the methods for analyzing tissues and how they are subject to government regulations when used in research studies. He also stresses that the primary purpose of the banks is patient care: to preserve tissue for use in treating the patient who donated the sample. Dr. Buzdar gives some examples to illustrate how the tissue resources are used. He also talks about the size of tumors and the size of samples preserved.

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  Chapter 13: Additional Research Studies: HER2/neu Breast Cancer; Taxanes

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  Dr. Buzdar begins this chapter by talking about MD Anderson's contributions in the 1990s to therapy for HER2/neu breast cancer. He describes a trial with women with intact breast cancer, half of whom were given the best standard chemotherapy before surgery and half who were given the new anti-HER2/neu therapy. He describes the dramatic result when surgeons discovered that the tumors had disappeared, even microscopic tumors, resulting in this drug's approval as standard of care. Dr. Buzdar notes that the MD Anderson breast group has been on the forefront of research. He gives the example of Dr. David Hohn, who conducted the first studies of taxames in humans. He describes the randomized trial that resulted in Taxol becoming standard of care. He notes that now the challenge is to determine which patients will respond to which treatments.

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  Chapter 14: Research Nurses at MD Anderson

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  Dr. Buzdar begins this chapter by noting how important transparency is when asking a patient to participate in clinical trials. He then discusses a new, four-month training program for research nurses that was launched eight months previously (the first structured program for training research nurses). He explains the special features of training for research nurses and their role in educating patients about clinical trials. He sketches the history of research nurses at MD Anderson and notes that the new training program was created on the recommendation of a group of investigators.

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  Chapter 15: Electronic Medical Records at MD Anderson, Yesterday and Today

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  Dr. Buzdar begins this chapter by noting that, though MD Anderson was slow to update its electronic medical records system, it was an early adopter of the technology, developing a home-grown system, ClinicStation. He sketches come of the issues involved with the new system, Epic, that was adopted to integrate all patient records and provide some additional features. Dr. Buzdar gives the example of patient consent forms to participate in clinical trials: this is now fully electronic and to date fifty thousand patient consents for trials have been processed electronically. He also explains that key elements of all the protocols in which a patient is involved is accessible through Epic. Dr. Buzdar also explains that, at MD Anderson, each patient has always only had one medical record, not a separate set of records for ambulatory and inpatient care, as is the norm elsewhere.

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  Chapter 16: The New Committee on Drug Side Effects

  Aman U. Buzdar MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Buzdar explains the function of the Committee on Drug Side Effect, created six months previously, as a response to the serious [rapid and life-threatening] side effects possible with immunotherapy such as CAR T-cell therapy. He explains the special procedures used to deliver care to these patients and the training that the teams receive to watch appropriately for signs of side effects. He also explains that he and others are working with Informational Technology and Epic to put a red banner on these patients' electronic medical records to alert all teams that they require special monitoring. Dr. Buzdar notes that all unexpected events are reported to his Office [Clinical Research]. The first immunotherapy side effect was "alarming" and he met with division heads to talk about how to manage and prevent these side effects. They responded quickly to set up a system to manage these patients. In the final minutes of the interview, Dr. Buzdar talks about retirement and the contributions he is pleased to have made to the institution.

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  Chapter 01: A Family Experience Rich in Influences

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Cohen talks about the rich array of influences his family life offered. He talks about his multicultural upbringing by an American father and Florentine mother. He recalls his summers spent in Italy, notes that he speaks fluent Italian, and observes that Italy feels like home to him. He begins to talk about the maternal line of his family and particularly his grandmother, Vanda Scaravelli, whom the family would visit each summer and who became one of his most important mentors. He recalls early influences that raised his awareness of the pleasures and health benefits of food: in the early 1980s, his parents did research for their first cookbook (he was their "number one taster") and that his uncle, Alberto, was a vegetarian and macrobiotic gardener. He recalls their garden in Italy and the "gourmet vegetarian" foods that would be prepared.

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  Chapter 02: A Path to the Emerging Field of Health Psychology

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Cohen talks about his educational path and the evolution of his interests. Because of his interest in marine biology, he attended Reed College (Portland, Oregon, BA conferred, 1987), but was uncomfortable with the institution's policy about early specialization. He explains how he gravitated toward courses in psychology, pharmacology, and physiology, eventually becoming a psychology major. He talks about the professors he worked with and animal experiments he helped conduct on drugs and behavior. He notes that his thesis on the role of alcohol in disrupting complex behavior was published in APA.

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  Chapter 03: Professional Goals Coalesce During a Post-Graduation Gap

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Cohen tells the story of his experiences during a two-year gap period after his graduation from Reed College. He begins with the influence of mentor, Arthur Patton, whom he had met at the age of fifteen and who encouraged him to take time off after graduation to spend time with his grandmother, Vanda Scaravelli, and take music and yoga lessons from her. Dr. Cohen describes the impact of this time, particularly on his sense of discipline, noting that his grandmother was his "main mentor." Dr. Cohen then talks about his uncle Alberto, who had a dream of going to India and inspired him to go to India for three months.

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  Chapter 04: Identifying a Purpose and a Graduate Focus in Health Psychology

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  Dr. Cohen begins this chapter with an anecdote about an experience he had while traveling in India that convinced him he needed to find a purpose. This motivated him to think about graduate study, and he again gravitated toward the field of health psychology, selecting a program in Medical Psychology at the Uniformed Services University of the Health Sciences, Bethesda, Maryland (MS conferred, 1993; PHD, 1994). Dr. Cohen stresses that his aim was to go into research. He describes research he conducted during his fellowship years [1/1994-11/1995 National Cancer Institute of Canada and The Toronto Hospital, Toronto, Canada, Paul Ritvo; 1/1995-12/1997 Postdoctoral Research Fellowship, National Cancer Institute of Canada, Division of Behavioral Medicine and Oncology, University of Pittsburgh, Pittsburgh, PA, Andrew Baum]. He goes into detail about his work with mentor, Andrew Baum and the value of medical school courses he took in Bethesda. He then narrates how he came to focus his research on cancer. He observes that the field of health psychology was just forming and framing research questions to explore how psychological processes have an impact on health. He recalls his excitement when reading an influential study published in 1990 that showed that HIV patients who took part in stress management had improved immune markers. He was also influenced by John Kabat-Zinn's work applying eastern based philosophy to medical problems. He talks briefly about his dissertation research on the effects of surgical stress on the immune system. He recalls that the research pathways available when he left graduate school were "HIV or cancer." He discusses why cancer was a good choice for him. He mentions meeting his wife, Alison Jeffries, in graduate school. He explains how he ended up working with Andrew Baum at the University of Pittsburgh, noting that he learned to collaborate with a surgeon and run a small clinical trial.

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  Chapter 05 A Graduate Focus in Health Psychology

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

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  Chapter 06: Early Research and the Art of Grantsmanship

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  Dr. Cohen begins this chapter by explaining that he transferred his fellowship work to the University of Pittsburgh because he was unable to do the research he wanted at Toronto Hospital: he was approved to transfer his grant money from NCI Canada to do this work. Dr. Cohen explains that his study originally focused on how group support post-surgery influenced outcomes for men with prostate cancer. This next turned into a study of pre-surgical stress management. He then talks about the art of writing grants to "market" research to a "reluctant buyer." He talks about how he adjusted to the medical center environment at the University of Pittsburg and discusses the importance of the support of surgeons for his work.

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  Chapter 07: Building Psycho-Oncology at MD Anderson; Setting Up Research

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  Dr. Cohen first tells the story of applying for a position at MD Anderson, noting that he wanted to leave the University of Pittsburg in order to become more of a leader in his field. He notes that no one was focusing on psycho-oncology at MD Anderson when he came in 1997; he explains why he was hired, noting that it was rare for a new faculty member to "walk in with an RO1." He then talks about the first studies he set up in collaboration with other faculty members. He also talks about learning to work with temperamental researchers and explains that the environment at MD Anderson was very drug focused with little focus on patient experience.

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  Chapter 08: Opening the Place of Wellness [The Evolution of Integrative Medicine, Part 1]

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Cohen talks about how the development of integrative medicine services at MD Anderson began with a survivorship conference in 1997, where patients became enthusiastic about yoga, massage and other complementary offerings and asked, Why don't we have this at MD Anderson? Dr. Cohen then describes how the Place of Wellness began as a very small, very patient-driven initiative with very little budget, but nonetheless the first integrative medicine center in a free standing cancer hospital. He notes studies indicating that the majority of cancer patients favored using complementary medicine to supplement standard of care treatments. Then around 2000, Dr. Cohen explains, the Physician in Chief and John Mendelsohn directed more support to formalize Integrative Medicine as an initiative to improve patient quality of life and conduct research. Dr. Cohen was approached to design the program and sketch a 5-year budget for a center and a department. The program was approved, and the Place of Wellness became a center incorporative research.

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  Chapter 09: A Vision for the Integrative Medicine Center; Building Support among Faculty [The Evolution of Integrative Medicine, Part 2]

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  Dr. Cohen begins by explaining that he had the vision of turning the Integrative Medicine Center into a Department, but this would take time. He talks about the administrative homes the IMC had over time. Next he talks about the process of promoting the new array of treatments and services and building support for prescribing these treatments in the medical consultation process. He notes that the Center originally offered more than 200 programs but eventually streamlined in order to offer what could impact cancer outcomes based on evidence. Dr. Cohen talks about the aggressive promotions he and others did to build awareness of the Center's offerings and tells several anecdotes to illustrate the process, including how physicians often need to directly experience benefits of complementary techniques in order to support them.

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  Chapter 10: Integrative Medicine at MD Anderson: Challenges and the Future

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  Dr. Cohen talks about the impact that executive leadership had on Integrative Medicine at the institution by insisting that the program "start small," but nonetheless has supported recruitments. Dr. Cohen talks about how John Mendelsohn has served as a mentor for him. He also talks about his shift in perspective, accepting that serving patients is more of a goal for him than transforming the Center into a department. He offers observations about the hierarchical organization at MD Anderson and how this influences getting things done. Next he talks about obstacles to building integrative medicine into the standard of care.

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  Chapter 11: Research Projects at MD Anderson, the First Focus on Integrative Methods

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  Dr. Cohen notes that the first phase of his research conducted when he arrived at MD Anderson in 1997, focused on "conventional psychodynamic studies" such as his study of management of presurgical stress in breast and prostate cancer patients. He notes that a turning point came when he met Alejandro Chaoul, a graduate student at Rice University who was volunteering at MD Anderson, and initiated a study of the effects of yoga on post-surgical lymphoma patients (published in Cancer). He explains the focus of the study, the results, and how it evolved.
  
  Next, Dr. Cohen talks about the life quality issues of primary concern to cancer patients, including fatigue, pain, peripheral neuropathy, and sleep disturbances.

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  Chapter 12: Consolidating the Focus on Mind/Body Research

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  Dr. Cohen explains how his focus on mind/body research intensified once he met Dr. Raghuram Nagaranthna from the VYASSA Institute. He talks about the mission of the institute and explains the organization of the pilot study they ran studying the impact of yoga on the quality of life of breast cancer patients undergoing radiation therapy. He talks about the publicity that this study attracted then tells an anecdote to illustrate how a radiologist became convinced of the value of yoga and became a supporter of the study. Next he talks about a study of the treatment of "chemo-brain" with Tibetan sound meditation. He then describes new work on the use of hypnosis in combination with local (as opposed to general) anesthesia for breast cancer procedures. He explains the risks of general anaesthesia.

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  Chapter 13: Research with Chinese Partners at Fudan University Shanghai Cancer Center

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Cohen talks about the turn his research took when he began to build a research partnership with Fudan University Shanghai Cancer Center [now a Global Academic Partners sister institution]. He first explains that he was interested in partnering with institutions that offered a combination of western and traditional treatments and details why Fudan was a good choice.
  
  Next, Dr. Cohen talks about three clinical trials set up at Fudan, looking at natural products, acupuncture and chi quong. He talks about the results of the studies and the impact on Fudan University.

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  Chapter 14: A New Holistic Focus on Quality of Life and Transformation

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Cohen talks about his shift in focus away from "reductionist research" to a whole-life view of health and transformation. He explains that perspective goes back to experiences he had as a child and young adult in Italy, when he learned the benefits of being mindful about everything in his life. Next he tells the story of a turning point in 2009, when John Mendelsohn was interested in bringing author David Servan-Schreiber to MD Anderson to talk about his book, Anti-Cancer Way of Life. [NOTE: health info discussed, but Servan Schrieber is on record about it.] He tells the story of how Dr. Servan-Schrieber was able to inspire philanthropists to contribute several millions for a pilot Comprehensive Life Study in Stage 2 and 3 breast cancer patients. Dr. Cohen talks about how the design of the study and its transformational effect on patients.

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  Chapter 15: A New Book on the How-To of Quality of Life

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Cohen explains his approach to a new book that is intended to be a practical follow up to Dr. Servan-Schrieber's more theoretical, Anti-Cancer Living, with Dr. Cohen's wife, Alison Jeffries serving as the "how to" voice. He explains the approach taken in the book and how he and Ms. Jeffries approached Penguin/Random House to secure a contract. He also talks about working with agent Doug Abrams. Dr. Cohen also explains the complexities of basing the book on the in-progess comprehensive life study at MD Anderson. He talks about anticipated criticisms from colleagues.

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  Chapter 16: The Future of Integrative Medicine

  Lorenzo Cohen PhD and Tacey A. Rosolowski PhD

  Dr. Cohen shares observations about where he is in his career and the support that MD Anderson is currently providing to Integrative Medicine now that John Mendelsohn is no longer president. He also observes that the timing might be right for a change, as growing evidence about the value of IM approaches may support insurance reimbursement. He talks about the health trends in China and India, both of which are now in the "Reagan Era Good Life" period, with threats to quality of life and health. He expresses his hope that colleagues at Fudan University will become involved in quality of life studies.

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  Chapter 01: The Path to Radiation Oncology

  James D. Cox MD and Lesley W. Brunet

  In this chapter, Dr. Cox talks about his educational background, his training in radiation oncology, and his interest in cancer. He also discusses his further training in several European hospitals and the development of the field that used to be called “radiotherapy.”

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  Chapter 02: Appreciation for Surgeons and Surgery in Collaboration with Radiology

  James D. Cox MD and Lesley W. Brunet

  Dr. Cox talks about the people who were major influences on him, his reflections on leading physicians at MD Anderson, and how surgeons often interacted with radiation oncologists.

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  Chapter 03: Military Experience

  James D. Cox MD and Lesley W. Brunet

  In this chapter, Dr. Cox talks about his military service during the Vietnam War, his work being stationed stateside at Walter Reed Army Medical Center, and his treatment of patients with cancer. “We saw very large numbers of young men with Hodgkin’s disease and testicular cancer,” he said, “and women who were dependents of active-duty army personnel, with cancer of the cervix, breast, and so on.”

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  Chapter 04: Responsibilities at MD Anderson, the Limits of Leadership Roles, and Working with Other Leaders at MD Anderson

  James D. Cox MD and Lesley W. Brunet

  Dr. Cox talks about his decision to come to MD Anderson, his position as Vice President for Patient Care and Physician-in-Chief, and why that “title was a great title and it was a bad job, for me.” He also discusses being glad to return to being a practicing radiation oncologist, is reflections on MD Anderson President Dr. Charles LeMaistre, and the main differences between being a physician and being an administrator.

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  Chapter 05: Inside Institutional Structures: Personalities and Remaking the Division System

  James D. Cox MD and Lesley W. Brunet

  In this chapter, Dr. Cox talks about various personalities at MD Anderson and difficulties regarding its organizational structure, specifically related to its departments and divisions. He also shares what he considers his biggest mistake: his efforts to restructure the institution.

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  Chapter 06: On Executive Leadership Styles within the Division System

  James D. Cox MD and Lesley W. Brunet

  Dr. Cox talks about the varied leadership styles of people in the MD Anderson division system. Many, he said, “were considered kind of wild and crazy and off in their own world, and although they were enormously creative … they were always a little suspect.”

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  Chapter 01: Early Memories and a Visual Mind

  James D. Cox MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Cox talks about childhood memories of West Virginia and Dayton, Ohio, where he recalls blackouts during WWII and his parent’s Victory Garden. He recalls his early inclination for the sciences and talks about the strongly visual field he ultimately selected as well as some of the visual qualities of his own thinking. In addition to appreciating Early Renaissance art and Gothic architecture, he admits that he loves women’s fashion, particularly enjoying features of design and proportion. His visual sensibilities focus on structure, he notes.

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  Chapter 02: Clinical Research in MD Anderson Culture; The Radiation Therapy Oncology Group; and Specific Clinical Trials

  James D. Cox MD and Tacey A. Rosolowski PhD

  In this segment, Dr. Cox talks about his focus on clinical research. He begins by explaining why clinical research has been less appreciated at MD Anderson than laboratory or translational research. (As an instance of how clinical research can transform a field, he cites studies comparing the effectiveness radiation therapy vs. chemotherapy plus radiation.) Most clinical studies of radiation therapies were started by the Radiation Therapy Oncology Group (RTOG), and MD Anderson faculty was an important participant in these studies. Dr. Cox sketches the history of the RTOG, explaining its central role in organizing studies and gathering research statistics for twenty institutions. Dr. Cox explains that he viewed the RTOG as his laboratory, during his years of administrative service, and he served as senior investigator, though others were more hands-on participants.

  Dr. Cox reflects on his skills in research design, offering as an example these skills, ideas he summarized in “Design and Implementation of Ion Beam Therapy,” a chapter in the book, Ion Beam Therapy: Fundamental Technology, Clinical Applications (Springer, 2011). He explains what is meant by good research design and lists several factors that contribute to a successful clinical trial.

  Dr. Cox then compares laboratory to clinical studies and notes that, in general, laboratory researchers are more directive in trials, while clinical researchers tend to be more cooperative. He says that there is a give and take in clinical research that would not be comfortable for most senior laboratory investigators

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  Chapter 03: An Education Leading to Clinical Study

  James D. Cox MD and Tacey A. Rosolowski PhD

  Here Dr. Cox explains the path that led him to clinical work in radiology. Dr. Cox became interested in cancer during his second year in medical school, while taking pathology, and he describes his first autopsy of an individual who had died from stomach cancer. He was fascinated by the cellular destruction and compares it to being “fascinated with a fire.”

  Dr. Cox next talks about the curriculum he followed at the University of Rochester School of Medicine and Dentistry (Rochester, NY) and his year at the Penrose Cancer Hospital in Colorado Springs, where he saw how helpful radiation therapy could be in combination with surgery. This convinced him to return to U of R to train with Dr. Juan del Regato in radiation oncology. He talks about his shift to the residency program at Penrose, where he became involved in a B-04 trial on breast cancer run by Dr. Bernie Fisher.

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  Chapter 04: Challenges of Clinical Trials: Informed Consent

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox explains that, while in his residency at Penrose, he became interested in the issues involved when obtaining the collaboration of patients in a study. He then discusses informed consent at length, describing the issues involved and making reference to the Tuskegee syphilis case as a summary of the ethical issues at play. To demonstrate his ideas about informed consent, Dr. Cox describes a trial on cancer of the esophagus. While patients treated with radiation or surgery had some results, pairing chemotherapy with radiation therapy has such profound results that they “couldn’t ethically continue the trial.”

  Dr. Cox explains that the Data Safety Monitoring Committee makes recommendations to stop any trial that is not ethically sound. Dr. Cox talks about several cases in which trials were conducted without any informed consent, and talks about the ethical and philosophical issues involved. He notes that informed consent was not a prominent issue until the 1970s, though now Institutional Review Boards are “out of hand.”

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  Chapter 05: The Radiation Therapy Oncology Group

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox begins this segment with a brief history of the ROTG, founded in the late sixties, after several individuals running clinical trials created centers to gather statistics and manage trial operations. In the late sixties, the NCI gave instructions and funds to draws the disparate centers together. Dr. Cox became involved in 1978 or ’79 and soon became vice chair for research strategy. He lists the areas of research the ROTG followed: hypoxic desensitizers and hypothermia; chemotherapy; and fractionization. He explains that he evaluated the results of studies. He speaks about an MD Anderson study treating cancer of the cervix with a combination of radiation and chemo.

  Dr. Cox describes how technologies of radiation therapy have evolved and how this evolution has been influenced by the NCI’s interest. (Dr. Cox feels the NCI has a prejudice in favor of chemotherapy, thus making less money available for radiation and surgery, even today.)

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  Chapter 06: Radiation Oncology at MD Anderson

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox briefly describes how radiation is used to kill cancer cells and mentions a few of the first studies to investigate its effects.

  Dr. Cox then talks about the Dr. Gilbert Fletcher’s role in developing radiation therapy and its use at MD Anderson. He discusses the challenges Dr. Fletcher faced during this time when surgeons believed that the best treatment was to surgically remove cancer. Dr. Fletcher eventually convinced the MD Anderson community that radiation therapy could be successfully combined with surgery for positive patient outcomes. Dr. Cox talks about the attitudes of several surgeons: Dr. William MacComb, Dr. Richard Jesse, and Dr. J. Ballantyne.

  Dr. Cox describes Dr. Fletcher’s strong will, his unique form of genius, and his honesty even about toxicities of radiation levels. He notes that MD Anderson people “had great affection for him.”

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  Chapter 07: Leadership Experience

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox reviews the experiences that led to the many leadership roles he has held during his career. He begins by noting that when he entered the military under the Berry Plan, there was a shortage of career people in radiation oncology and, at the age of thirty two, he became Head of the Radiation Oncology Service at Walter Reed Hospital, though he had served in administrative roles in smaller arenas.

  Dr. Cox offers comments on the qualities of MD Anderson and why he has stayed at the institution so many years, noting that it offers “the best cancer care anybody can get.”

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  Chapter 08: Early Clinical Studies

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox begins the discussion of his research career with his residency. He explains that hypotheses in clinical research derive from the care of patients. Survival is the “immutable endpoint” that determines whether a treatment is successful, but survival does not tell you why a treatment is successful. Early in his career, Dr. Cox developed an approach to determine why treatments succeed, though he observes that many of the questions he asks about patterns of failure are irrelevant from other perspectives (e.g. medical oncology).

  Dr. Cox describes studies done in the 70s with lung cancer to determine why treatments failed. When he became involved in the Radiation Therapy Oncology Group (RTOG) his style of designing studies influenced the group. All of the ROTG studies during his ten years with the group used survival as the endpoint. Returning to his residency years, Dr. Cox talks about his studies of cancer of the breast and cervix. Dr. Cox notes that his view of clinical trials was strongly influenced by his mentor, Dr. Juan del Regato.

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  Chapter 09: Research Focused on a Range of Body Areas

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox summarizes the range of research he administered on fractionation while involved with the RTOG: lung cancer, head and neck cancers, cervix and brain. He also discusses the key importance of adding chemotherapy to patients’ treatment regimens to get the best results.

  Dr. Cox next explains that while he was Chair of the RTOG he was able to move combined treatments forward in the NCI and other organizations. He explains why the NCI is biased toward chemotherapy. He also comments on NCI politics is influencing how gynecologic cancers will be investigated.

  Dr. Cox next comments on other cancer studies he oversaw during the period when he was Vice President for Patient Care under Dr. Charles LeMaistre [Oral History Interview].

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  Chapter 10: Lung Cancer and Uncommon Lymphomas

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox describes the research he undertook when left the position of Vice President for Patient Care and returned to his full-time faculty position, beginning with his new role as “the lymphoma person.” He explains the lymphoma trials that combined radiation and chemotherapy and that resulted in a successful response as well as a genetic translocation that will give rise to a genetic marker. He notes studies of radiation and chemotherapy in uncommon lymphomas.

  Dr. Cox next explains how he was involved in teasing out the natural history of unusual lymphomas to understand them as distinct cancers. He uses testicular lymphoma as an example, describing how this cancer is treated with both radiation and chemotherapy. Patients with this cancer were rarely cured before this approach was developed: with this treatment, the cancer is eliminated in 50% of cases. Dr. Cox conducted this work between 1992 and 2000.

  Dr. Cox then explains that he always saw cancer as more than one disease: he explains what it means to understand this at the molecular and cytogenetic level, eventually resulting in diagnoses being rendered by biochemical, molecular or genetic findings. He notes that his work at MD Anderson was tightly linked to his work with the RTOG. He continues, explaining that he returned to work with lung cancer in the late nineties. He mentions that lung cancer still has the highest death rate among all cancers, though mortality from lymphoma is increasing and Dr. Cox explains this is largely attributed to environmental chemicals. He explains the “modest progress” that he and the lung group at MD Anderson have made combining drugs, radiation, and surgery. Dr. Cox explains his work using prophylactic cranial irradiation to decrease the risk of brain metastasis from small cell carcinoma and notes that studies were also done to determine if this irradiation increased the risk for neuropsychological complications.

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  Chapter 11: Documenting the Benefits of Proton Therapy

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox explains a difficulty with proton therapy: the advantages can be seen on paper and modeled by computer, but “we don’t yet have the evidence that people want.” He describes the kinds of treatment advantages that proton therapy provides, particularly the reduction of toxicity.

  Dr. Cox explains a study showing that proton therapy avoided toxicity in treatment of 15 patients with cancer of the tongue, then describes the next step of this research: to demonstrate the differences between two dimensional and three dimensional, conformational therapy. He explains that proton therapy offers these advantages because the beam can be targeted to hit very isolated structures.

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  Chapter 12: Multidisciplinary Conferences at MD Anderson Lead to More Effective Treatment Plans

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox notes that proton therapy treatment focuses heavily on lung cancer and lists other cancers being studied, explaining that the study of esophageal cancer puts all the modalities together. This leads Dr. Cox to talk about the Tumor Board and Thoracic Conference –weekly multi-disciplinary meetings where specialists from different disciplines discuss cases and treatment options for patients. He explains that surgical techniques have improved so much that surgery is now also being integrated into the treatment modalities. He then describes the history of the conferences, which go back to the earliest years of MD Anderson and have proliferated through the entire institution. Dr. Cox describes how these meetings educated everyone, e.g. by having specialists from a wide range of fields talk to a radiologist, a pathologist, or someone conducting research on molecular markers. (He acknowledges that attendees are self-selected).

  Dr. Cox affirms that the multi-disciplinary meetings have affected the culture of MD Anderson: Multi-disciplinary care is a hallmark of MD Anderson care. He explains that that the salary pool on which compensation is based at the institution insures that there is no economic incentive behind treatment decisions. “We function as a team” for all patients.

  Dr. Cox explains that not everyone embraces multi-disciplinarity and that, in the past, MD Anderson faculty who worked on the disease sites tended to talk only to one another. When he brought in the RTOG, the multi-disciplinary focus has a definite impact on the institution. Dr. Cox closes this section by noting some other multi-disciplinary organizations and by explaining that MD Anderson may not be helped by some of the NCI’s recent decisions on how to restructure cooperative groups.

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  Chapter 13: The Regional Care Centers and Sister Institutions

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox gives an overview of issues involved in setting up regional care centers and sister institutions. He begins by noting that Radiation Oncology backed away from involvement in MD Anderson-Banner because of concerns that MD Anderson would have no hand in quality control for patient care. He next talks about setting up the first regional care center in Bellaire (1998/99): the regional care centers were originally established to provide radiation therapy.

  Dr. Cox explains that for thirty years the treatment plans for all MD Anderson patients are created by way of a peer-review process that insures high quality care and results.

  Dr. Cox next lists some other satellite centers and describes the lessons learned about recruitment and competition from within the communities. He concludes that, in general, the quality of the care centers has stood the test of time and paved the way for medical oncology and laboratory services to be offered at the sites as well. He summarizes the convenience that the care centers offer to patients. Next he describes the financial and administrative relationships between the care centers and MD Anderson. Dr. Cox then comments on the sister institutions in Orlando, Florida and Madrid, Spain, noting the importance of quality control and oversight of faculty for the success of such initiatives.

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  Chapter 14: Head of the Department and Division of Radiation Oncology

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox explains his dual role as Head of the Department and Division of Radiation Oncology, first discussion his Departmental goals of expanding the faculty and creating a strong and highly specialized department. He also notes that the department was technologically out of date when he took over, and he explains the upgrades he introduced: a modern system for treatment planning, a CT simulator, and the transition from 2-D to 3-D treatments. The department next combined 3-D treatment planning with computer assisted treatment planning to refine patient protocols. Dr. Cox explains how the Department established a dosimetry school as the program grew. The Department next developed intensity modulated radiation therapy.

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  Chapter 15: The Division of Radiation Oncology

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox describes challenges that he faced in developing the Division of Radiation Oncology. a change in attitude toward buying new equipment greatly helped move the Division forward. He describes a communication gap that existed with Ken Hogstrum, Chair of the Department of Radiation Physics (who focused on education over patient care and research), a problem resolved when Dr. Cox removed him. Dr. Cox describes some of the changes that took place as Dr. Hogstrum and a number of his supporters left, emphasizing that the individuals recruited to replace them shared his goals of developing the technological base of the Division as well as the ‘research portfolio,’ which went from effectively no research to over a million dollars of research funding. Dr. Cox ends this segment with comments on his administrative approach.

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  Chapter 16: The Division of Radiation Oncology"”Strategic Planning and Growth

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox summarizes the growth of the division between ’97 and 2007, when he retired: from seventeen to fifty full-time faculty and from 240 to 600 patients seen per day. He notes that the Division made a lot of money for the institution and achieved a high level of credibility from good planning. He sketches the yearly strategic planning meetings the Division held each year, noting that the main goal of all planning was to ensure that the Division was the best in all areas. He explains that a second goal was to create a supportive environment for everyone, and believes that they were successful in achieving that. At the end of this segment, Dr. Cox offers reasons for the separation of Departments within the Division of Radiation Oncology.

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  Chapter 17: The Proton Therapy Center

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox notes that the use of intensity-modulated radiation therapy was a starting point for thinking about how advanced technology could be used to concentrate radiation beams on a tumor. The idea to construct a Proton Therapy Center began in 1998, when Dr. Cox spoke to John Mendelsohn about the possibility, and Dr. Mendelsohn then went to the UT System. Though the University of Texas System would not fund it, Leon Leach [Oral History Interview, Dan Fontaine and others were enthusiastic and looked for other funding sources. Dr. Cox explains what created the enthusiasm for proton therapy, given the absence of any studies to confirm its benefits or advantages over other types of therapy. Dr. Cox believes that his credibility in the institution spurred the administration to embrace the idea.

  Dr. Cox next sketches the partnership between public and private sources created to fund the initiative, with Hitachi as the vendor. He notes that his wife, Dr. Ritsuko Komaki, served as a mediator to help MD Anderson people deal with cross-cultural issues that arose during negotiations with Hitachi. He then explains what they requested in the design of the proton source and the challenges that arose as Hitachi dealt with their specifications, noting in particular how difficult it was to get three computer systems to work together.

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  Chapter 18: Research at the Proton Therapy Center; the Future

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox notes that the Proton Therapy Center project was started in May 2003. Since 2006, when the first patient was treated, 4400 patients have been seen, with virtually all patients involved in research studies. Dr. Cox explains that there is a master protocol for studying increasing dosages and the degree to which normal tissue is spared. Specific protocols have been created to compare proton therapy and intensity-modulated radiation therapy on non-small cell lung cancer and for cancer of the esophagus. Next Dr. Cos explains the reasons why individuals question the value of proton therapy. Some are anti-technology. Some admit that it looks valuable on paper, but question whether the effects are real; some say that, in principle, there is value, but there are too many technical uncertainties to warrant going ahead with it. Others accurately state that no randomized trials have been conducted to definitely prove that proton therapy is superior to x-rays. These studies are underway now. Dr. Cox says that the main benefits are fewer side effects for the patient. In some cases physicians are able to deliver higher doses of radiation, which may result in better tumor control. Dr. Cox says that all of these objections make it difficult to get papers accepted in journals so good results can be demonstrated.

  Dr. Cox affirms that the Proton Therapy Center has been very successful. The Center is also in the process of expanding uses for patients, so proton therapy will be part of treatment for many diseases and stages of disease. He anticipates that eventually 20% of MD Anderson patients will be treated with proton therapy. He explains how patients are identified for proton therapy (curative uses, rather than palliative). The Proton Therapy Center will be upgrading certain functions, taking advantages of developments Hitachi has recently made.

  Dr. Cox observes that the regional care centers have not referred as many patients for proton therapy as he would have expected and that they would like to treat even more patients. As the segment closes, explains that the original investors pulled out of the project and MD Anderson owns 51% of the interest in the Center.

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  Chapter 19: The MD Anderson Presidents

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox begins with observations about Charles LeMaistre, who recruited him to serve as Vice President of Patient Care, “a good title, bad job,” as he says. Cr. Cox explains that he and Dr. LeMaistre had very different orientations toward MD Anderson administration. Dr. LeMaistre was interested in issues related to the UT System, Dr. Cox says, then explains why he believes that Dr. LeMaistre didn’t fully understand what was going on at the institution. Dr. Cox says that during Dr. LeMaistre’s tenure, the institution was on the verge of greatness, but couldn’t take the next step because many faculty were “living in silos.”

  Dr. Cox next talks about John Mendelsohn, who was very aware of what was going on in the institution (at least during the first years). He then turns to Ronald DePinho, whom he admires for his grand aims and desire to change the institution in a major way. He offers his view of the Moon Shots Program, which he sees advancing team science, though he has no expectation that is will eliminate the cancers at which the various sub-programs are aimed.

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  Chapter 20: Contributions to MD Anderson

  James D. Cox MD and Tacey A. Rosolowski PhD

  Dr. Cox talks about his contributions to MD Anderson: he spurred clinical research and therefore contributed to the care of patients. Administratively he believes he helped foster collegiality across departments and division, making faculty comfortable with multi-disciplinary work styles. Dr. Cox recalls that Gilbert Fletcher set a very high standard for radiation oncology at MD Anderson. Dr. Cox says that he has contributed to maintaining that stature, one that differs from any other cancer center in the world.

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  Chapter 01: Always a Builder

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau begins this segment with a brief view of his family experience growing up in Cleveland. He explains his interest early in life in the sciences and engineering. He notes his fascination with "how things went together: he built a layout of trains in the basement and worked with old gas model airplanes. He notes that we has a Boy Scout and received an Eagle Scout award.
  

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  Chapter 02: Early Job Experiences Inspire an Interest in Management

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau talks about the on-site experience he acquired during his first job at Chicago Bridge and Iron (CBI; hired 1968), where he worked on projects that involved assembling nuclear vessels. He also notes that his interest in managing people evolved while he was assigned to the Plymouth Station Nuclear Power Plant. He describes developing a scheduling system for a shop and expecting to be praised, however people didn't appreciate it. He also describes how his report on the situation at Plymouth created some political problems and resulted in his transfer. Mr. Daigneau then assessed his options and decided to apply for MBA programs. He took a job in the Public Works Department in Peoria ('70) so he could attend Bradley University. The Director of Public Works mentored him and made him Chair of the Utilities Commission.

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  Chapter 03: An Evolving Perspective on People Management

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau explains how his work experience in Peoria and his study for his MBA led to his interest in motivation theory and thoughts of studying for a PhD. He took a job as a construction manager at the University of Iowa in Iowa City and was also accepted in the PhD program. Mr. Daigneau comments on the challenges of working at an academic institution and notes that he became a "hero" for his work. He was mentored by key people, but still wasn't managing people successfully. He describes what he enjoyed about working in a university environment and also the limits of this particular position. Mr. Daigneau decided to leave the University of Iowa (and his PhD program) because he wanted "to manage things." Mr. Daigneau next talks about his job as Manager of Physical Plan at University of Wisconsin-Superior (1976). He notes that he followed prevailing management theory at that time '"managing by objectives." Nevertheless he did not see the management results he expected, though this job was a big confidence booster and he "thrived under people how would give a long leash."

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  Chapter 04: A Theory of People Management and Another Career Move

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau describes lessons he learned about management and his own management style, giving examples. He says that was "inquisitive about how things work, and if it doesn't work, then abandon it." At this point his ideas about management by objectives changed and he saw the importance of creating an environment where the objectives of individual employees matched those of the company. Mr. Daigneau then talks about the lack opportunity for promotion in academia, a fact that led him to next take a job as Assistant Vice President at Greeley College, where he stayed for eight years. He lists his achievements: he developed a master plan that is still being followed and developed the co-generation plant to produce heat and electricity very efficiently.

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  Chapter 05: University of Rochester and a First Experience with Health Care Institutions

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau explains that he found himself at a crossroads at Greeley College when he realized that he did not want to advance to Vice President of Administration. He was approached by the University of Rochester to become Director of University Facilities, though the medical school and Strong Memorial Hospital were at the time administratively divorced from the rest of the University. He comments on how organizations can create silos, with negative consequences for efficiency. He recalls receiving an invitation from Strong Memorial to evaluate its facilities. Within six months of submitting his report, he was given true responsibility for directing all university facilities and merged all systems to create an integrated system with good efficiency.

  [The recorder is paused for about 7 minutes]

  Next Mr. Daigneau notes that executive management wants a physical plant manager to deliver results and solve problems, and over the course of his career he was successful in making problems disappear. He also observes that the main mission of a university is "not to build buildings, but to create and transfer knowledge." Facilities management can dovetail with administration and create opportunities for people and for income generation that can serve other purposes.

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  Chapter 06: Lured to MD Anderson: A New Position and The Three-Building Plan

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau explains that around 1992 he was working with others to conduct Facilities Management Evaluations at the request of institutions. David Bachrach initiated an invitation that he serve as a team leader of a peer review of the newly begun Three-Building Plan. Mr. Daigneau explains that he conducted the review and sent the report and later received a call from an executive recruiter on behalf of MD Anderson. He turned down the job and explains his ethical reservation about taking job as Assistant Vice President for a building plan that arose from service on a peer review team. Mr. Daigneau next explains that two years later MD Anderson was looking to fill the new role of Chief Facilities Officer (the scope of responsibility for this position was based on one of the recommendations in his report). Mr. Daigneau explains why he took the position.

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  Chapter 07: Background: The Three-Building Plan

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau provides an overview of MD Anderson's scope when he arrived in 1994: the Main Campus, Bastrop, and Smithville, with buildings totaling about 3.5 million square feet. David Bachrach had just launched the Three-Building Plan (also referred to as the "major building project") which would add another million square feet. Mr. Daigneau talks about the management team responsible for the building project and how it fit into the current Master Plan. He also describes the silos created in the current system and describes Dr. Charles LeMaistre's management style. He also explains that translational research was emerging at the time and MD Anderson needed to connect research and clinical activity. The Three-Building Plan included: a new research building with animal and other laboratory space; Alkek Hospital to replace the old hospital, expand operating room space and provide new technology; and the LeMaistre Clinic. Mr. Daigneau notes that the latter was an "add on" to spend a great deal of cash that MD Anderson had accumulated. Mr. Daigneau notes that there was no real Master Plan at the time in that there was no vision of how the organization would evolve. When he arrived, the funding and design of the Three-Building Project was completed and construction on the Alkek had begun.

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  Chapter 08: The Three-Building Plan: Building Relationships, Facing Challenges, Creating the Project Core Team and the Design-Build System

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau discusses the first steps he took on the Three-Building Project. He began by building direct relationships with those who would be using the buildings. He explains that he didn't want users to call executive management; he wanted to hear from them directly. He notes that when he arrived, there was a Department of Design and Engineering that users did not trust; the management level of Physical Plant was also perceived as non-responsive. His goal was to shorten communication channels so that there were no more than three levels between him and the customer. Mr. Daigneau explains that he pulled together a Facilities Management Design Group comprised of all supervisors who would plan design for the future. He also met with every section chief at his/her office to say, "Call me directly if you have a problem."

  Mr. Daigneau next explains some structural problems that he addressed. Construction management was very bureaucratically structured, with all building contracts held by a management company out of Austin, Texas. This led to a near "train wreck" in the Three-Building Project. He addressed this by developing a new team and working out a new system for bidding contracts. He created the Project Core Team (a system that existed until he left MD Anderson) that would include plant operations, planning, design, construction, and executive management.

  Mr. Daigneau next talks about the problems created by the "hard bid" contract system and how it could create problems with delays on the part of the architect or other contractors. He also explains how worked successfully to modernize the construction contracting rules in Texas, changing legislation to allow a 2-contract system, "hard bid" and "design-build." He explains the old and new systems and also tells an anecdote: MD Anderson successfully filed an errors and omissions claim against an architect (the problem was fallout from the contract system) and won the case 'the first win of its kind in Texas. MD Anderson uses hard bid contracts on small projects and a design-build system with a construction manager for large scale projects.

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  Chapter 09: Weather is Part of the Job: A Near Disaster and Developing Emergency Plans for Floods, Wind, and Hurricanes

  William Daigneau and Tacey A. Rosolowski PhD

  In this segment, Mr. Daigneau explains that serious flooding during the construction of the Alkek Hospital and the Clinical Research Building "was my introduction to rainfall in Houston." He notes that all of the linear accelerators for radiation oncology were in the flood area with only two construction doors holding water back from the equipment. He addressed the deficiency of MD Anderson's emergency plan, creating Hurricane Manager. (In learning about hurricanes he thought, "I need to find another job!) Mr. Daigneau describes the dimensions of this comprehensive emergency plan, how it was drilled, and what it was designed to achieve.

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  Chapter 10: The Alkek Hospital and the MD Anderson Way of Constructing Buildings

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau begins this segment with two examples of lessons learned from the Three-Building Plan. The first came from Alkek Hospital. The third floor was to house all the diagnostic imaging equipment, but by the time construction reached the third floor, the technology had changed and the most up-to-date equipment would not fit in the rooms. They had to tear out everything and redesign the rooms. The second example involves problems with moving users into new buildings. Mr. Daigneau summarizes the goal that he set for MD Anderson building projects: three years from the statement "I want a building" to moving in. Because "time is your enemy," his strategy was to reduce construction time as much as possible and to delay building out shells to the last moment (providing opportunities for needed design changes). He describes how this works and also sketches other strategies that preserve options in building projects: how to work with architects, how to use the design-build system to an advantage, types of designs to focus on. He notes that he and others studied how malls are built to exploit ideas about preserving flexibility. Mr. Daigneau notes that he took pride in the fact that MD Anderson could build faster than anyone in the Texas Medical Center, including private institutions. He describes the MD Anderson way of building: build fast, don't make mistakes, and engage everyone who will occupy the building all the way through the process.

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  Chapter 11: John Mendelsohn's Plan for MD Anderson and the First Building Projects" The Mays Clinic and the Faculty Center

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau first reviews the challenge that managed care presented to MD Anderson. He recalls that Dr. Charles LeMaistre put all expansion plans on hold in reaction to the report on managed care submitted by the Sharp Group (the Sharp Report). Mr. Daigneau notes that the Archives contain plans he created to close facilities. In contrast, as Mr. Daigneau explains, Dr. John Mendelsohn arrived and announced the plan to expand the institution by fifty percent. He lists the key people involved in developing the expansion plan and describes how the Master Plan was redrawn to improve space utilization and address the four years of compression created under Dr. LeMaistre.

  Mr. Daigneau then talks about two new buildings planned 'the Faculty Center and the Ambulatory Clinic Building (also called The Mays Clinic)"” and Dr. Andy von Eschenbach's role in moving this project forward. He then explains how the new Ambulatory Clinic Building (the Mays Clinic) was designed to maximize clinic capacity. He tells a story demonstrating Dr. Andrew von Eschenbach's role in motivating faculty to move their offices out of the clinics and into the Faculty Center.

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  Chapter 12: The New Master Plan: Expanding the Main Campus

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau describes challenges he confronted in studying how to add buildings to the main campus and offer patients easy wayfinding. As there were no easy additions possible for patients, he began to look at the land occupied at the time by Garage 5 (owned by the Texas Medical Center) as well as land occupied by the Psychiatric Hospital, a surface parking lot, and the Dental School. Mr. Daigneau notes that future expansion, given MD Anderson's current land holdings, were limited. However research could be expanded by building to the north of Main Campus. These possibilities led to the plan of using all existing space for clinical activities while moving administrative offices, building across Holcombe Boulevard in order to expand the latter.

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  Chapter 13: The Master Plan Brings Special Challenges: Successes with the Faculty Center and the Mays Clinic (Ambulatory Clinic Building)

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau explains that the new Faculty Center is located on a site of a privately owned parking lot. Mr. Daigneau tells a story about threatening to use MD Anderson's power of eminent domain in order to bring the developer that owned the lot to come to the negotiating table. Mr. Daigneau next explains that he used the design-build system to construct the Faculty Center: this was the first time the system had been used by the UT system for any complex building. The Faculty Center was completed in record time, fourteen months for thirty-five million dollars. Moving the faculty offices out of the clinic buildings allowed them see more patients, earning enough money to renovate existing buildings.

  Mr. Daigneau next talks about backfill and redevelopment projects totaling nearly 100 million dollars. He describes the changes required in the Alkek Hospital and LeMaistre Clinics. Speaking about the Faculty Center, Mr. Daigneau notes that he was able to get the administration to promise that if he would complete the building in the short time frame for the 35 million cost, if it was never used for clinical purposes. To construct the Faculty Center, he studied office tower buildings. At the same time, Mr. Daigneau explains, MD Anderson was looking to expand clinical services. He describes the Houston Main Building (also called The Prudential Building) the institution had acquired in the seventies, a twenty-acre property located at the corner of Fannin Street and Holcombe Boulevard. He and Kevin Wardell (to whom he reported) decided to locate the ambulatory clinic at this site: a 250,000 square foot clinic to be constructed in 36 months. Mr. Daigneau explains how the project was eventually expanded to 6000,000+ square feet, though there was no clear determination of who would occupy the building.

  Mr. Daigneau next describes the hurdles overcome to insure a rapid building process for the Ambulatory Clinic: creation of the site master plan (to include 4 buildings); sorting out transportation and traffic circulation issues within and around the site 'a process that involved negotiations with the Texas Medical Center to construct new roadways. He notes that building went ahead though the occupants had not yet been determined, despite discussions that involved all section heads: Dr. David Callendar eventually decided who would occupy the building. Mr. Daigneau explains that the design-build process was used 'a controversial move on such a complex building and the largest ever constructed in the Texas Medical Center. Mr. Daigneau explains the construction approach used by adopting a mall-type strategy of determining anchors. He describes the unique features of the Mays Clinic, decisions made that were critical for the future, some political issues that had to be resolved. He describes the radiation oncology suites that had windows for the first time (instead of being sunk in the ground) and the way circulation was planned to help with wayfinding.

  
  
  Next, Mr. Daigneau explains how Dr. Callendar found two volunteers to occupy the site and also outlines why the Mays Clinic is one of the best-planned, comprehensive facilities from the perspective of patient experiences.

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  Chapter 14: Developing the Wayfinding System

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau notes that the Ambulatory (Mays) Clinic building project created the wayfinding project and also opened discussions about how to construct an efficient bridge system between buildings. He explains that he hired a wayfinding consultant that had worked for Disney and developed a system based on visual cues and sequencing of information. He instructed the consultants to use basic transportation engineering principles to develop signs. He notes that the signs with Gateway Numbers were borrowed from Disney (and were adopted by the Texas Medical Center after MD Anderson erected them). Mr. Daigneau explains how the wayfinding system evolved through the use of focus groups and testing of solutions with patient groups. He also notes that patients were asked to evaluate furniture choices. "We were not building for ourselves," Mr. Daigneau says. Mr. Daigneau next talks about how focus was shifted to the bridge system between buildings when there were some near accidents with physicians crossing Holcombe Boulevard.

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  Chapter 15: The Mitchell Basic Sciences Building; Vulnerable Systems, Tropical Storm Allison, and the Flood-Protection System

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau explains that with construction on the Mays Clinic initiated, they were "in the throes of master planning" and two other issues emerged: 1) the need for a building to house Cancer Prevention and 2) a new research building. Mr. Daigneau explains the complex process of securing the land from the Texas Medical Center to plan a new research site with six buildings owned by MD Anderson, Baylor, and the Health Science Center. He describes how he was able to secure the site of Parking Lot K from the Texas Medical Center to build the Mitchell Basic Sciences Building. He tells a story about constructing the vivarium. Mr. Daigneau also describes how the Mitchell Basic Sciences Building was designed with a foundation "like a bathtub" that would be absolutely flood proof. Tropical Storm Alison hit during construction, with a 5-foot wall of water sweeping the Texas Medical Center and dropping into the hole for the Mitchell Building, though damage was minimal because "smart people put up the flood locks." Mr. Daigneau explains that they quickly learned that 1) they had to relocate electrical switches from the basement and 2) MD Anderson needed a flood wall that is almost automatic. Mr. Daigneau explains how MD Anderson secured a FEMA grant to build a flood wall and he describes the wall and other features installed.

  [The recorder is paused briefly.]

  Mr. Daigneau completes the story of the Mitchell Building, noting that it was the first "fully interstitial" research building constructed by the University of Texas. He defines interstitial, a concept developed by the NIH. This is an expensive process, but it maximizes flexibility and is worth it. Mr. Daigneau notes that because Dr. John Mendelsohn believed in growth, they built two extra floors to accommodate expansion: before construction was completed, they were preparing those two floors for occupancy. Mr. Daigneau explains why the project went over budget (the only time he had to approach the Regents for more money on a project).

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  Chapter 16: Pickens Tower, The Research Medical Library, and Rotary House

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau talks about Pickens Tower, which was the next phase of development designed to provide space for faculty outside of clinical areas on the Main Campus. He explains the decision making behind the faculty fitness center, the food center, and the management of older spaces not suited for research. Mr. Daigneau explains that for symbolic reasons, he did not want MD Anderson's president to occupy the top floor of Pickens Tower. He wanted the Tower to communicate the philosophy that all State and philanthropic money is used wisely. He explains that he went to John Mendelsohn with the idea to put the Research Medical Library on the top floor because of the inspiring message it would send about MD Anderson priorities. The idea "immediately gained traction." [The recorder is paused briefly.] Mr. Daigneau completes the story of the Pickens Tower with a discussion about how parking was created and for the first time offered to employees through a tiered rate system linked to income. He then briefly discusses the expansion to Rotary House, including an addition to the bridge system to improve safety for anyone who would otherwise have to cross busy streets

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  Chapter 17: Overview: A Plan for South Campus [Research Park]

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau sketches the plan to develop a research park (referred to as Research Park or South Campus) on 100 acres of land along Old Spanish Trail south of Main Campus, beginning with a research building. He first explains conversations with the Texas Medical Center and with the National Guard to acquire the land and explains how he used a model of a research park at University of Massachusetts at Amherst to develop the MD Anderson model. This involved finding other institutions to collaborate on developing the site. He also describes his concept of a 20-year building, which was the model he selected for Research Building 1, the first to be constructed on the site.

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  Chapter 18: The Story of Research Park: Strategies to Acquire Land and Collaborators

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau goes into detail about the development of Research Park (and refinement of the Master Plan), beginning with Dr. John Mendelsohn's invitation to the Health Science Center to embark on a joint development project. He explains how the 100 acres was subdivided into lots to support buildings of thirty five to fifty thousand square feet. Mr. Daigneau tells the story of negotiating with the Health Science Center for use of land that currently housed an ecological park used for environmental studies, a process that took a year, with the Regents eventually intervening in MD Anderson's favor. He then explains the negotiation process required to develop the roadways and infrastructure and explains how he worked with Governmental Affairs to secure start-up money from the Governor's office to develop infrastructure. Mr. Daigneau also explains why MD Anderson has never been successful in attracting a third collaborator to develop the property. He then goes on to describe the

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  Chapter 19: Moving Occupants Into Buildings: Commissioning Buildings and Factors that Drive the Move-In Schedule

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau explains that the "Move Team" for any building project includes the project director and representatives of users and facilities operators who develop a move schedule and contract moving services. Mr. Daigneau lists some of the many details that have to be readied prior to a move: telephone and computer systems, key systems, the signage system. He notes that occupants were moved into Alkek Hospital one floor at a time. He also explains that the Mays Clinic, the Mitchell Clinical Research Building, and the Cancer Prevention Building were all opening at the same time, creating a drain on facilities staff. Mr. Daigneau next talks about the "commissioning process" required before any building opens. This is a series of tests performed to confirm that all systems are in working order. He notes that research buildings with laboratories and vivariums are the most difficult to commission, with clinical spaces and office space coming next. He describes the year-long proc

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  Chapter 20: Determining Building Efficiency; Pros and Cons of Leasing Space; Mid Campus; Unique Features of the Institute for Personalized Care

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau defines "building efficiency" as the percentage of space occupied by people and notes that MD Anderson his goal was an occupancy of sixty-nine percent or better. (Patient care areas are always less efficient.) He explains how efficiency drives operating costs and notes some efficiency thresholds set by the State of Texas.

  Next Mr. Daigneau explains that he advocated to get rid of the Houston Main Building because it was very inefficient and expensive to operate. He also explains the "post-commissioning" process that takes place during the first year of use, where he would fine-tune a building's mechanical systems to save on costs. Mr. Daigneau describes the post-occupancy reviews routinely conducted at MD Anderson to provide information used in later building projects. He gives the example of the Mays Clinic, where extensive reviews were conducted and then compared with other clinics. The Mays Clinic became a new standard for patients and staff in terms of productivity and satisfaction. Mr. Daigneau notes that there is a minimal amount of guesswork in his facilities planning processes. He next talks about how the Mid-Campus Building came about to reduce the amount of space that MD Anderson was obliged to lease. He notes that MD Anderson was once one of the biggest lessors in the Texas Medical Center (leasing at twenty-five locations) and he lists the pros and cons of leasing space. He concludes that "you want to own [space] and you want to be able to sell it [when you are done with it]." This enables MD Anderson to anticipate selling unneeded space, part of what Mr. Daigneau refers to as an "exit strategy." He analyzes why the Mid-Campus Building was designed to consolidate functions and reduce costs. The building paid back its costs in seven years.

  Next Mr. Daigneau explains how the planning process for the Mid-Campus Building evolved, expanding the plan from an original 750,000 square feet to 1.3 million square feet, with the top third constructed as a shell to accommodate future uses. He notes that this structure houses the second data system and separate utility systems. He also explains how the unusual, bow-shape came about because of Dr. John Mendelsohn's preference. He then describes the process of acquiring the land and constructing some of the infrastructure for the building.

  Mr. Daigneau next briefly describes the design of the Zayed Institute for Personalized Care (the last building approved while he was at MD Anderson): four towers, two to house offices and two to house laboratories, with external corridors. He explains that they derived the "cloverleaf" design by taking the best practices from a CDC model and outlines some of the challenges it presented. He also discusses the benefits of the external corridors.

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  Chapter 21: The Houston Main Building (The Prudential Building): Its Drawbacks and Implosion

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau tells the story of his controversial plans to demolish the Houston Main Building (also called The Prudential Building). He lists the problems with the building, among them the fact that there was no sprinkler system 'a fact that "kept him up nights." He also describes how he engaged three groups to study the building in preparation for tear-down. He explains why the building had no particular historical or architectural significance. He then talks about the decision to demolish the building once the State Fire Inspector issued instructions to install a sprinkler system. Mr. Daigneau advocated for demolishing the building, and MD Anderson executives all agreed this would be most cost effective. He then explains why demolition was held up until 2012. Mr. Daigneau then describes how he had planned the Mays Clinic and the Duncan Cancer Prevention Building with the demolition of Houston Main in mind. He explains how the decision was made to implode rather than demolish the building and explains the careful process of selecting the demolition contractor. He explains the safety processes they observed and the care taken not to disrupt patient activities at MD Anderson and surrounding Texas Medical Center institutions. He describes the implosion (video available at the website noted ) and notes that the site clearing took only six months.

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  Chapter 22: Transforming Facilities Management

  William Daigneau and Tacey A. Rosolowski PhD

  In this segment, Mr. Daigneau discusses changes he brought to Facilities Management during his eighteen years at MD Anderson. He begins with an overview of his goal when he arrived: to combine all facilities management services into one management group. Mr. Daigneau explains that he created the Facilities Management Design Group to come up with a new plan for integrating Facilities Management services. The Group's first goal was to define the products that Facilities Management offers. They identified three core products: the creation of space (capital); the operation and management of that space; and management of all logistical details that make the campuses work. Mr. Daigneau next explains that the identification of products served as the basis to reorganize Facilities Management. He talks about how Facilities Management services were organized into two operational groups, Research and Education and Patient Care, to serve the unique needs of researchers and physicians. H

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  Chapter 23: Gratified to Serve the Institution's Growth

  William Daigneau and Tacey A. Rosolowski PhD

  In this segment, Mr. Daigneau looks back on his years at MD Anderson and then talks about his plans for retirement. He expresses his satisfaction that he was able to be personally involved in all aspects of organizing and planning the institution's growth as well as planning for continued improvement. Mr. Daigneau explains how he always attempted to move MD Anderson beyond a standard approach to square feet in the institution. He uses the model of Facilities Management 101, 201, and 301 to explain how he pushed MD Anderson to shift from looking at square feet as simple space, to a set of perspectives about use held by a number of different users. This is needed to meet his goal: making 80% of patients happy. When he arrived, he says, everyone at MD Anderson was in 101. By the time he left he had moved everyone to seeing space in more complicated ways. Mr. Daigneau next reflects on some lost opportunities, on challenges that came with the growth of the Division, and the need to cultivate leadership among younger people in the Division. He explains how he attempted to do this by working with Human Resources to create an aptitude test that would identify possible managers, however budget issues made it necessary to suspend this project. Mr. Daigneau explains that with the growth of the institution, it is more important than ever that MD Anderson achieve economies of scale. He notes that Dr. John Mendelsohn was able to achieve growth of the institution's infrastructure for advanced research as well as the numbers of lives saved. The reality of modern research is possible because of growth, and MD Anderson states how pleased he is to have been part of that.

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  Chapter 24: Consulting; A Book-In-Progress; and Outdoor Activities

  William Daigneau and Tacey A. Rosolowski PhD

  Mr. Daigneau sketches his activities since he retired. He owns 3P Management Consulting, dedicated to shifting the focus of management away from outcomes to Product, Processes, and People. He also talks about the book he is writing, The Three Ps of Management. He explains that book evolved when he realized that in his last two years at MD Anderson, many functions ran very well without him. He asked himself, "What did I do right?" His book that draws heavily on the experiences he gained at MD Anderson. Mr. Daigneau also notes that he has always balanced his work with other dimensions of life. He has taken up fly fishing, travels, continues to ski and run marathons.

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  Chapter 25: The Alkek Hospital Addition: A Very Difficult Project

  William Daigneau and Tacey A. Rosolowski PhD

  To close off the interview, Mr. Daigneau shares an anecdote he notes is "the closest I can come to a funny story." He describes touring the Alkek Hospital construction site with Gary Campbell just after arriving at MD Anderson. The columns were just being poured and Mr. Daigneau asked why they were so large. Campbell replied that the building was designed to take an additional ten floors. Mr. Daigneau notes that all diagnostic imaging was on the third floor and all the main operating rooms were located on the fifth floor" these functions would be very sensitive to vibration caused by such a construction project. He said at the time, "I pity the poor son of a gun given the task of building the ten stories." Mr. Daigneau then tells the story of how it was decided to add the ten stories. He explains how a vibration specialist determined it could be done and then gives details of the construction and its challenges. The process took three years 'one year of sorting out details and two for construction.