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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.

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  Chapter 01: An Early Desire to Be a Physician and Focus on Difficult Illnesses

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky begins this chapter by describing his close, 1950s-style family. His father was a chemical engineer who was frequently relocated for his job. Dr. Dmitrovsky explains that he learned to connect with people and make friends quickly through this early experience. Dr. Dmitrovsky also explains that even at a young age, he was interested in becoming a physician and helping people. He aspired to having a life of purpose and meaning, and felt that medicine, particularly with a focus on very difficult illnesses, would provide this.

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  Chapter 02: College Influences: A Research Project, a Book, and Working as an Orderly

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky begins this chapter by explaining how he selected Harvard University for his undergraduate education (AB, MA conferred 1976). He explains that he majored in biochemistry, an honors major, because it afforded him the opportunity for in-depth experience with research and writing an honor's thesis. This was one of three very significant college experiences, and Dr. Dmitrovsky next describes his research project, which focused on the communication junctions between cells. Current theories held that cell communication influenced cell malignancy. Dr. Dmitrovsky also wanted to work with Dr. Goodenough's laboratory because of the state of the art molecular imaging in use. He goes into detail about his research.
  
  Next, Dr. Dmitrovsky explains that he also wanted to have some clinical experiences to confirm that he should pursue a career in medicine, so he worked as an orderly at a geriatric hospital. Being able to see through the eyes of patients and their families provided him with a second significant experience. Dr. Dmitrovsky talks about witnessing the "grace of families" who cared for their elderly loved ones and how that convinced him of the importance of involving families in care. Dr. Dmitrovsky concludes that these experiences convinced him that he wanted to make progress with complex medical problems and have an impact on patients and families. He then talks about a third influence on view of a medical career, the book Stay of Execution: A Sort of Memoir, by Stewart Alsop, who was diagnoses with a rare form of leukemia. Dr. Dmitrovsky says that this book showed him how scientific discovery influenced medicine and patient experience. He also notes that he became intrigued that there could be a hospital that focused specifically on rare and difficult to treat disease.

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  Chapter 03: Medical School and a Life-Changing Experience as a Physician Volunteer Near the Cambodia-Thailand Border

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky begins this chapter by explaining why he chose to attend Cornell University Medical College (MD conferred in 1980). He notes that he did research studies as well as a rotation at the National Cancer Institute. Next Dr. Dmitrovsky talks about volunteering to travel to Cambodia the summer after medical school. For three months he worked with the International Rescue Committee and saw difficult cases in the Khao-I-Dang Holding Center on the Cambodia-Thailand border. He talks about the diseases and conditions he say, many of which American doctors never diagnose. He talks about his triage experience. He also tells an anecdote about being invited back to Cambodia last year to give a graduation speech and meeting a patient who had been treated at the Holding Center. He notes that his experience had a "huge effect" on him, solidifying his desire to have a career of service.

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  Chapter 04: A Fellowship and a Risky and Successful Study of Cell Differentiation

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Dmitrovsky talks about the research project that would set him on the path to discover the effectiveness of retinoids in treating acute promyelocytic leukemia. He begins by noting that at the end of his residency, he had decided to focus on hematology/oncology and took a Research Fellowship ('83 " '86) at the National Cancer Institute, Navy Medical Oncology Branch, in Bethesda, working with Dr. Ilan Kirsch. He explains why he enjoyed working with patients with terminal disease during the initial, clinical, year.
  
  Next, Dr. Dmitrovsky explains that, at the time, he still believed he would enter private clinical practice. This is the reason that he took on a risky research project during his final two years of protected laboratory time. He explains that the study was to use dimethyl sulfoxide (DMSO) to influence the role of the c-Myc oncogene in controlling leukemic differentiation (how undifferentiated cells become differentiated and capable of malignant growth) with the intention of developing treatments. He explains the technical challenges of conducting this study (the primary reason why all the other fellows at the NCI had declined the project). He talks about the success of the study and the discovery, after publishing the results in Nature, that two other groups had reached the same results, a fact that convinced him of the role of serendipity in scientific discovery.

• 

  Chapter 05: A Faculty Position and a New Laboratory to Study the Role of Retinoids in Leukemic Differentiation

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky begins this chapter by noting that his successful study of DMSO and the c-Myk oncogene enabled him to secure his first faculty position at Memorial Sloan-Kettering Cancer Center in the Division of Hematology/Oncology. He then talks about the evolution of his research, beginning by sketching academic medicine's conventional research path. Dr. Dmitrovsky then explains that the next step in his research would build on his work with DMSO and leukemia, so he posed the question, Can you cause cancer cells to mature? He explains why DMSO was not a viable treatment option for this process in humans, and so he built his "nascent lab" around studies of retinoic acid. He cites another example of serendipidity: within a few months, receptors for retinoic acid were discovered, giving credence to his hypothesis. He began to study how retinoids could cause germ cells to mature and become tumors. Dr. Dmitrovsky then says that he heard about a Chinese study of the use of all-transretinoic acid to treat acute promyelocytic leukemia. He embarked on the first American clinical trial that showed success in using retinoids to treat APL, and then collaborated with Dr. Ron Evans to clone the Retin-A receptor. Dr. Dmitrovsky then explains that the APL's molecular and genetic mechanisms became widely studies, and so he decided to change his research focus.

• 

  Chapter 06: Shifting Focus to Lung Cancer

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Dmitrovsky talks about how he built on his studies of retinoids and leukemia treatment and began to investigate treatments for lung cancer. He decided to focus on retinoic acid's role in causing the destruction of a cancer-causing protein. He explains why he selected lung cancer and why it was important to him that lung cancer affects both men and women. Dr. Dmitrovsky says that his initial question was, Can we use retinoic acid to prevent lung cancer? He explains his first experiment, which showed that after treatment with retinoic acid, immortalized cells did not become malignant when exposed to tobacco carcinogens. He talks about studies that revealed the molecular pathways involved in this process, challenges that arose in creating a targeted approach (because of a silencing of β-receptor for Retin-A), and how these obstacles were overcome over a ten year period, enabling him to eventually discover a survival advantage. Dr. Dmitrovsky explains that he found activity in a very resistant form of lung cancer for which survival without treatment is 4 " 6 months and with retinoid treatment, 1 " 4 years. Dr. Dmitrovsky then says that he compared his results with those obtained by colleagues at MD Anderson who were involved in the BATTLE trial. They had similar results. He says he hopes to find an even better retinoid.

• 

  Chapter 07: Coming to MD Anderson to Have a Broader Impact on Health

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Dmitrovsky outlines the factors that led to him leaving Dartmouth and taking a position at MD Anderson. He begins by sketching the faculty positions he held and mentions that he was appointed to the Board of Scientific Counselors at the NCI, serving as Chair of the Board. Next he explains that a family member was diagnosed with cancer and this gave him a different perspective on what cancer could do to an individual and family and opened his mind to what he might next do with his career. When his term as Chair of the Board of Scientific Counselors ended and his five clinical trials came to an end, he decided to do more with his administrative experience. At this point he was approached by MD Anderson as the institution conducted a search for a new Provost and Executive Vice President. He notes that he feels a deep sense of commitment to MD Anderson's mission.
  
  Next, Dr. Dmitrovsky describes his acquaintance with Dr. Ronald DePinho and explains that his conversations about the Provost's position were mainly conducted with executive leadership.

• 

  Chapter 08: Views on MD Anderson's 10-Year Strategic Plan and the Role of the Provost

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Dmitrovsky speaks about the value of developing a ten-year Strategic Plan for MD Anderson. He first explains that the plan allows the MD Anderson community to come together to take account of the institution's resources, to recognize that MD Anderson can't do everything, and to make decisions about where energy and resources should be focused. He says that MD Anderson has an opportunity to make a full accounting of where it is and where it wants to be. He talks about areas where MD Anderson can improve, such as patient experience, provider experience, administrative systems and support structures. He gives examples of process improvements.

• 

  Chapter 09: Creating a New Way of Conducting Research and Caring for Patients in a Changing Environment

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Dmitrovsky provides an overview of how MD Anderson must operate in the new environment of research and healthcare economics. He begins by explaining that scientific endeavors traditionally rely on decisive discoveries by individual investigators that also reveal opportunities to development treatments. Today, he says, this process moves ahead via team- and interdisciplinary science, and the institution must educate the next generations of researchers in this way of conducting research. At the same time, MD Anderson must operate in a context of a flat NIH budget while responding to the new economics of the Affordable Care Act.
  
  Next, he notes that MD Anderson is supporting the education of the next generation by making investments in junior faculty with the R. Lee Clark Fellowship Program. He explains the award (juried by experts outside of MD Anderson). Next Dr. Dmitrovsky notes that reductions are being made to the length and complexity of informed consent forms so faculty can spend less time on paperwork and more time for their primary activities. He then speaks briefly about faculty recruitment and retention efforts. Then Dr. Dmitrovsky talks about strategies used to encourage interdisciplinary investigation. He speaks in detail about finding ways to provide team members with proper recognition for their contributions (when contribution is traditionally measured by first or last author status) and linking credit to faculty promotion. He also talks about empowering team members to initiate investigations and provides some examples.

• 

  Chapter 10: The Provost's Office: Acting on a Mandate and A Personal Goal

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky begins by sketching the major functions of the Provost's Office and then talks about initiatives he has undertaken to address low faculty morale. He talks about the importance of listening and explains how he set about hearing faculty concerns. He first explains initiatives set in place to address the faculty's impression that the depth and scope of excellence among the current faculty is unrecognized: the R. Lee Clark Fellowship Program; the Clinical Innovator Award Program. He discusses investments made to relieve the monetary burden of running clinical trials and conducting genomic testing. Using examples, he explains the measures taken to relieve many instances of regulatory burden.

• 

  Chapter 11: Making Changes in an Institution: Goals, Following Up, A Philosophy of Communication

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky notes the overall goals of the changes he has made to the institution. He also reflects on the processes by which changes have an impact and are recognized by an organization's community. He discusses the round of meetings he conducted to report back on measure taken to address faculty concerns and reflects on communication within a large organization. Dr. Dmitrovsky notes his observation that faculty have a skepticism about administration and that they were not speaking their minds in meetings. He explains how he addressed this.

• 

  Chapter 12: The Provost's Office: Creating Support for Emerging Leaders

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky explains how he addressed the need to build the leadership of MD Anderson at the department and division levels. He discusses changes to recruiting processes for heads at these levels, stressing that search committees are looking for individuals "who care more about others than themselves" (and notes the challenges involved). Dr. Dmitrovsky explains the leadership support that is provided for new department and division heads, stresses the "huge" commitment of resources that is being made in them.

• 

  Chapter 13: Evolution as a Leader

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  After observing that physicians rarely have specific preparation to serve as leaders, Dr. Dmitrovsky discusses key moments in his own development as a leader. He notes that he became a department chair in his forties, a relatively young age. He says that he had opportunities to learn negative leadership lessons by observing others. He also learned to reach out to individuals with great leadership skills to learn directly from them. He talks about a mentor, James Wright, former president of Dartmouth College.

• 

  Chapter 14: The Provost's Office: Supporting Faculty Promotions

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky discusses issues involved in supporting faculty promotions in a term-tenure system. He explains the overall situation: faculty must prove themselves, but lack tools to move effectively through the tenure process. He observes that faculty with clinical responsibilities experience the most anxiety. Dr. Dmitrovsky describes measures taken: providing department chairs with guidelines for providing support and mentoring; providing financial support to develop publications; holding information sessions to create transparency about tenure requirements and how to create a strong portfolio. Dr. Dmitrovsky addresses recent questions from the faculty about tenure decisions that have been overturned.

• 

  Chapter 15: The Institute for Applied Cancer Science: The Research Model

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky talks about the model of research set in place at the Institute for Applied Cancer Science [IACS]. He begins by stating the mission of developing multi-disciplinary teams, noting that "the future of science is collaboration" and that discoveries will emerge in the lines between disciplines. He gives the example of genomic medicine. Dr. Dmitrovsky sketches the barriers to moving discoveries to the bedside then talks about the model of IACS research, biotech people and processes are imbedded in research design to speed up discovery and facilitate dissemination via regional care centers and sister institutions.

• 

  Chapter 16: Global Academic Programs: the Advantages of Collaboration Part I

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky explains the benefits of international collaborations for MD Anderson and for the institutions overseas. He notes that Global Academic Programs is a unique model of relationships with over thirty institutions. He explains how these connections further MD Anderson's mission and also provides opportunities for clinical trials, research collaborations, and new knowledge. He gives the example of a recent trip to visit Hunan Cancer Hospital in Changsa Province, China. He explains that MD Anderson will provide support with smoking cessation and prevention. He also talks about making rounds of a clinic where traditional Chinese medicine is practiced in concert with Western medicine.

• 

  Chapter 17: Global Academic Programs: the Advantages of Collaboration Part II

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  In response to a question, Dr. Dmitrovsky underscores that Global Academic Programs does not establish relationships with a commercial motive in mind. They are part of the ten-year plan of furthering MD Anderson's mission of assuming social responsibility for the health of populations. Dr. Dmitrovsky explains MD Anderson's link with the biotech company, Ziopharm Oncology as an example a relationship established with a commercial venture in mind. He then underscores the differences between relationships established to further MD Anderson's social responsibility and mission versus explore opportunities to commercialize discoveries. He gives examples of consulting relationships set up through GAP and talks about what makes a desirable partner. He talks about Hunan Cancer Hospital, a potential partner, noting that it is centrally located in China and would enable dissemination of cancer knowledge and care to a vast number of people. [The interview is terminated.]

• 

  Chapter 18: Global Academic Programs: a Review of International Collaboration

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky summarizes the benefits of international collaborations for MD Anderson and international partners by talking about his recent trip to visit the Hunan Cancer Hospital in Changsa Province, China. He explains that MD Anderson will provide support with smoking cessation and prevention. He also talks about making rounds of a clinic where traditional Chinese medicine is practiced in concert with Western medicine. He talks about the possibilities for a smoking cessation/prevention program, including one for schoolchildren. Dr. Dmitrovsky underscores that the future of medicine is about partnership.

• 

  Chapter 19: Cancer is a Problem for All Humanity: A Truth that Inspires Faculty

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  In response to a question about how intercultural experiences can have an impact on faculty, Dr. Dmitrovsky notes that his experience working near the Cambodian border early in his career made him understand that cancer is a problem for all humanity. He talks about how knowing this gives meaning to all faculty and employees who work at MD Anderson. He explains that people are inspired and empowered by meaningful goals and offers the view that faculty experiences with global partners can reinforce these larger goals, which can get lost in the details of daily work.

• 

  Chapter 20: Addressing Perceived Conflict of Interest

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Using hypothetical examples, Dr. Dmitrovsky explains mechanisms for addressing instances of perceived conflict of interest in the new era of research collaborations between academic institutions, pharma and the biotechnology industry. He first stresses MD Anderson's responsibility to adhere to high standards of transparency. He notes that MD Anderson has examined best practices from other institutions. Next he stresses that actual instances of conflict of interest are addressed and resolved via mechanisms already in place. He then talks about the need to develop processes for addressing perceived conflict of interest. He gives two hypothetical examples of perceived institutional conflict of interest. The first involves involvement of an academic institution in developing a drug after it has contributed to the Phase One clinical trial to validate knowledge about the agent. In another example, he talks about how an institution might respond if it has commercialized intellectual property, which then generates revenue: he sketches how those profits could be used to avoid perceived conflict of interest. Dr. Dmitrovsky then notes how valuable research collaborations are to advancing MD Anderson's mission, bringing down the cost of health care, and attracting new biotechology industries to the region.

• 

  Chapter 21: The Next Ten Years: Goals for MD Anderson Research and Faculty

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky sketches his plans for MD Anderson research and faculty in the next ten years. He begins by discussing mechanisms for supporting the institution's research portfolio, given decreasing federal support.

• 

  Chapter 22: The Next Ten Years: Stewardship and Building A Culture of Care For Faculty and Staff

  Ethan Dmitrovsky MD and Tacey A. Rosolowski PhD

  Dr. Dmitrovsky shares his personal view of what he would like to see achieved at MD Anderson in the next ten years. He first discusses the privilege he feels working at MD Anderson and being guided by the institution's mission and core values. He explains that he would like to see the institution develop a culture of care that extends beyond patients and operates among the faculty and staff. He then talks about his goal of recruiting leaders who are servant leaders and emotionally intelligent. He talks about the support he would like to continue to build for faculty. Finally, Dr. Dmitrovsky talks about the importance of the Oral History Project in strategic planning for the future.

• 

  Chapter 01: A Texas Family in a Small Town

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois talks about his family background, early education and key experiences. He first sketches his family roots in France and Ireland, noting that the emigres eventually settled in South Texas in a farming and ranching community. He grew up in a family of modest means, with his father working in the oil fields while also sustaining a ranch. Dr. DuBois next talks about his involvement in the Future Farmers of America while in high school. He decided to raise livestock and eventually one of his steers won a local grand championship and was shown at a livestock fair in Houston. This was a key event in that it allowed him to apply for a scholarship that enabled him to attend college. Dr. DuBois discusses what made that period of time so critical: he talks about the skills, work ethic, and "grit" he developed through that project. He notes he was also very involved in sports during high school.
  
  Next, Dr. DuBois talks about his education in this community where there were only 80 students in the high school and few people attended college. He notes that he was a good but not spectacular student and assumed that he would go into some kind of agricultural education and teach. He talks about applying for his scholarship and some challenges using it for college.

• 

  Chapter 02: A World of Research Opens Up at Texas A & M and UT Southwestern

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois explains that when he began college at Texas A & M University, he soon realized that agricultural education was not challenging enough. This was reinforced when he took the opportunity to become involved in a research project with Dr. Stanley Cohen on epidermal growth factor purified from mouse salivary glands. He talks about transferring to the Biochemistry Department, where he found the faculty very supportive and where he was advised to move forward with a PhD program. He then explains why he ended up staying in Texas for his PhD program at University of Texas at Southwestern Medical Center in Dallas. Dr. DuBois talks about his PhD program at UT Southwestern and his work with Michael Waterman on induction of cytochromes in the liver, leading to his dissertation work on the mechanisms by which pharmaceuticals regulated levels of cytochrome p450 in the liver. He also notes that he had the opportunity to rotate through other laboratories and participate in clinical conferences, all of which led him to decide to go to medical school.

• 

  Chapter 03: Medical School with a View of How the Basic Sciences Might Address Clinical Problems

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  Dr. DuBois begins this chapter by noting that in '79-'80 he had a vision of how basic sciences observations about drugs could be used to address clinical problems. He elected to go into gastroenterology at through his medical program at UT Health Sciences at San Antonio (MD, 1985). During the summers he conducted research in Dr. Raymond Burke's laboratory, characterizing selenoproteins. He explains that he also had the opportunity to work with Thressa Stadtman, who discovered selenoproteins, through a fellowship program at the NIH (1983-1984). During that time he made advances to that work by identifying steps required in purifying the proteins.
  
  Next, Dr. DuBois talks about his internship and residency at the Johns Hopkins Hospital (1985-88), where he worked with Dr. Victor McKusick, who was working on cloning all the genes affected when a cell is stimulated to grow. Dr. DuBois explains that he worked on an RNA binding protein, Nup475, a project he continued working on as a Research Associate to Daniel Nathans at the Howard Hughes Research Institute (July 1988-March 1991).

• 

  Chapter 04: Research and Administration at Vanderbilt University, Focusing on Cancer

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  Dr. DuBois begins this chapter by explaining how he was led to take a faculty position at Vanderbilt University in 1991, and where he would stay for sixteen years.2 He first talks about how he continued his research, leading to the discovery that COX-2 played a role in cancer and that it could be inhibited. This work was published in Cell in 1993, and helped him make his name.
  

• 

  Chapter 05: Thoughts on Healthcare, Academic Medical Centers and the Medical University of South Carolina

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  After a question about education for physician-scientists, Dr. DuBois shares some of his own experiences teaching medical students then explains how the Medical University of South Carolina (where he currently serves as Dean of the Medical College) has moved to create a flexible and integrated curriculum. He notes the institution also offers a MD/PhDs as well as combined degrees in business administration, law and other fields. He explains the "huge need" in healthcare for physicians who are good at business concepts, noting why this will be a "savior for academic medical centers."

• 

  Chapter 06: An Offer from MD Anderson

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  Dr. DuBois begins this chapter by observing that administrators take two to three years to understand the ropes of their new roles, two to three years to set up processes, and another two to three years to reap the benefits of these processes.He next talks about stepping into the role of Director of Vanderbilt University's cancer center in 2005, because the former director was retiring and the institution wanted an internal hire. In 2006, he notes, he got a call from John Mendelsohn to talk about an opportunity to serve as Provost at MD Anderson. He explains what he learned of the situation at MD Anderson and what it might offer him. He also explains his family's reluctance to leave Nashville.

• 

  Chapter 07: Provost and EVP at MD Anderson: an Overview

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois provides an overview of the position he assumed when coming to MD Anderson in 2012. He first shares his impressions of Dr. John Mendelsohn, then president of MD Anderson, then notes that he was involved in assisting Dr. Mendelsohn secure the $150 million gift from the Khalifa Foundation of the United Arab Emirates.
  
  Next he explains that his mandate from Dr. Mendelsohn was to develop the institution's research to higher levels. He describes what had been set in place by the time he arrived, including Dr.Mendelsohn's idea of the "cancer care cycle." He explains that he focused on stimulating collaboration across the institution, getting teams to work well together, and on supporting study of patients who were unusual responders to treatment. Dr. DuBois talks about setting up his own lab on South Campus.
  
  
  
  Next, he mentions that, when asked what MD Anderson could do to move to the cutting edge of research, he responded that immunotherapy would be a fruitful research path. He explains that he already knew Jim Allison and his work and began speaking with Dr. Allison about coming to MD Anderson. 3
  
  Dr. DuBois then explains that he was hired into a role of Provost when the position had previously been titled, Chief Academic Officer, to send more of an academic message. He explains what the former CAO had set in place before he arrived.
  
  

• 

  Chapter 08: On Growing as a Leader, First Impressions of MD Anderson, and a First Day on the Job

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  Dr. DuBois begins this chapter with a few additional comments about his decision to leave his position at Vanderbilt University and take on the role of Provost at MD Anderson.
  
  Next he reflects on how the role of Provost allowed him to "up his game" as a leader and notes how the sheer size of the institution as well as the varied research interests of faculty presented a challenge. He also notes that his own experience with high-impact publishing allowed him gave him insight into the research environment.
  
  
  
  Next, Dr. DuBois explains that on coming to MD Anderson he saw how dedicated employees were to their jobs and to patient-centered care. HIPAA - he also explains his personal connection with the institution through an aunt who was diagnosed with breast cancer and whose quality of life was greatly improved with MD Anderson treatment.
  
  Dr. DuBois then explains how a family emergency interrupted his first day on the job.
  
  

• 

  Chapter 09: Building Research from the Provost's Office

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois summarizes several of his first activities as Provost. He notes that he set up with staff then talks about how he addressed some issues in leadership of the UT Graduate School of Biomedical Sciences. He explains why he undertook to increase the amount of faculty salaries covered by grants. He then discusses how he improved reduced the time needed for IRB approval of research protocols, hiring a process engineer to evaluate the process and reduce the number of days from 250 to 80/90.
  
  Next, he explains why he wanted to develop a mentoring plan. Next he discusses some attempts to address physician burnout and also mentions some of the Medical University of South Carolina's programs.

• 

  Chapter 10: Strategic Planning, Budgets, Physical Space, and Industry Partnerships

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois summarizes several areas of activity with broad institutional impact. First he talks about the members of the Executive Committee who met with John Mendelsohn every week and describes the strategic plan that committee had worked out prior to his arrival.
  
  Next he talks about the committee's relationship with the Board of Visitors in addressing the "assumptions we are making about the future of the institution." As an example he notes Dr. Thomas Burke's role managing the clinical burden and the $250 million margin that created a low margin in context of other businesses. Dr. DuBois next notes that he was surprised at the degree to which the institution's financial team wanted to ensure a return on any investment. He gives an example of the improvements that Dr. Ronald DePinho proposed to make on South Campus to foster research, and also talks about the Proton Therapy Center and the Center for Biomedical Imaging. He mentions a discussion of indoor walkways to connect the south and north campuses, which leads to a discussion of the importance of designing physical space.
  
  
  
  Next, Dr. DuBois speaks about efforts to build partnerships with industry, also explaining how Texas laws about intellectual property hamper development of these collaborations.

• 

  Chapter 11: Financial Processes, Challenges, and a Crisis;

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois focuses on financial matters. He notes that as Provost he was required to manage a much larger budget than he had in previous roles. He also explains that Leon Leach [oral history interview], hired by John Mendelsohn, brought a heightened awareness of finances to the institution.He next focuses on the economic downturn of 2008/2009, which required the institution to cut costs dramatically and reduce the workforce by 500. He explains how the Executive Committee worked to anticipate how to weather this challenge and talks about the parameters they used to identify employees to cut. He talks about the stresses of executive leadership.
  
  
  
  Next, Dr. DuBois talks about building the Division of Academic Affairs. He notes that CPRIT funds were key for this growth and discusses working with CPRIT leadership to keep the MD Anderson community informed of their grant application processes. He talks about the connection between Academic Affairs and the research institutes and how key the former was in recruiting faculty for the institutes.
  
  
  
  Next, Dr. DuBois discusses issues related to the faculty. He talks about the "Wall of Science and Medicine" he created to bring awareness to the faculty's high profile publications and to stimulate pride and competition among the faculty. He then covers work with the Faculty Senate and the themes of concern.
  
  Next, Dr. DuBois talks about the problem of rewarding investigators for their team science efforts, then notes that the Provost's Office was able to set a good tenure process in place.

• 

  Chapter 12: Executive Teamwork and a Long-Range Vision for the Institution

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  Dr. DuBois begins this session by observing that the evolution of his leadership at MD Anderson was tied to the close working relationship of the executive team, who may have had differences at times, but who all agreed on where the institution should be headed. As an example, Dr. DuBois talks about the economic crisis of 2008/09. He talks about the very rapid and measured response of the executive team and the success of averting a serious institutional crisis. In addition to the reduction in workforce, Dr. DuBois notes that clinicians were asked to see one additional patient per session. He explains that there was general agreement that the long-term vision of the institution focused on keeping patient care first and talks about what is involved in keeping the institution abreast of the highest standards of care, including recruiting the best faculty.

• 

  Chapter 13: A Candidate for the Presidency of MD Anderson;

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois talks about undertaking the process of applying to be MD Anderson's fourth president. In response to the interviewer's observation that many people in the institution felt he was viewed as Dr. John Mendelsohn's heir apparent, Dr. DuBois confirms that Dr. Mendelsohn raised the issue of his retirement from the presidency during their first recruiting conversations. He felt he was "groomed for the role." He then describes the search process and the steps he underwent to apply and interview for the position of president. He notes that he had a lot of support within the institution, but that the Board of Regents makes their own, independent choice, and internal candidates have challenges. (Dr. DuBois explains that he was really focused on the administration of the institution, on making incremental changes within the reality of the institution as opposed to bringing broad visions of institutional transformation, an allusion to the perspective brought by outside candidates. Dr. DuBois sketches the areas of growth he included in the vision he presented to the Board of Regents. Dr. DuBois then talks about going through the final interview process and then getting the news that the Board had made another choice. He explains why he had wanted to job. He talks about his disappointment and initial feeling that he wanted to move on to another institution, but that people within MD Anderson asked him to stay on to help with the transition under Dr. Ronald DePinho.

• 

  Chapter 14: An Institution Transitions Under a New President

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  Dr. DuBois begins this chapter by explaining how his role as Provost and Executive Vice President expanded his administrative experience.
  

• 

  Chapter 15: Institutional Changes and the Decision to Leave MD Anderson

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois identifies the institutional changes that prompted him to leave MD Anderson. He first notes that he tried to advise Dr. DePinho about problems emerging among the faculty. He observes that he had been approached by other institutions, but had wanted for professional and personal reasons to finish his career in Texas.
  
  Dr. DuBois lists how he and Dr. DePinho differed in their view of leadership and administration. He notes changes in the leadership structure, and how the individuals from industry that Dr. DePinho had established on South Campus reported directly to Dr. DePinho and Dr. Lynda Chin, rather than following the usual communication chain through the EVPs. He observes how unusual it is to have both a president and his wife in prominent positions in the institution.
  
  Dr. DuBois then discusses explains the controversies around the application that Dr. Lynda Chin made for CPRIT funds, skirting the usual process. Dr. DuBois explains why the application process existed and why not following it was such a problem. He explains the impact of the Chin/DePinho actions on the CPRIT process and MD Anderson.
  
  
  
  Next, Dr. DuBois talks about changing attitudes among long-term employees and faculty as well as the Executive Committee as the DePinho presidency evolved. He also notes that in Dr. DePinho was not entirely to blame for the worsening situation at the institution, as he came into his role with no experience running a large, clinically-focused institution.
  
  

• 

  Chapter 16: New Roles at Arizona State University and the Medical University of South Carolina

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois talks about the roles he took on after leaving MD Anderson, first discussing his work as Executive Director of the Biodesign Institute at Arizona State University (December 2012-Feb 2016).4 He describes the change it made after MD Anderson, the scope of his work linking the physical and biomedical sciences and developing collaborations with clinicians. He explains why he enjoyed the job (and why it was, effectively, a 4-year sabbatical), as well as why he needed to leave that role.
  

• 

  Chapter 17: Advances in Cancer Interruption

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois talks about the latest evolution of his research into cancer interruption. He begins by talking about the process of moving his laboratory from MD Anderson to Arizona, then his rationale of looking at targets of research opportunity in pre-malignant disease. He reviews his previous work on COX-2, then talks about his current work, which uses the approach to target processes around pre-malignant lesions, "making prevention molecular. Dr. DuBois gives some examples and discusses the implications of this approach for prevention.

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  Chapter 18: Final Comments on Leadership and Retirement

  Raymond N. DuBois Jr., MD, PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. DuBois shares general views of leadership. He notes that, in his view, a seven to ten year tenure is sufficient and he envisions himself working for a foundation or as a chief scientific officer after he reaches that limit. He offers his advice to individuals who aspire to executive leadership, again stressing the need for physician leaders to train for administration and in finance.
  
  Next, Dr. DuBois underscores the need to develop a pipeline of leaders in healthcare who have emotional intelligence and can truly lead. He notes that the traditional criteria of research success is not sufficient for picking leaders for institutions today. He uses the example of the Mayo Clinic to demonstrate a very effective institution culture that builds good internal leadership.
  

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  Chapter 01: Memories and Details about Family

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung sketches her early family experiences. She notes that she was from an “Air Force family” and lived overseas for a time, arriving eventually in San Antonio, where both her father and mother worked on planes at the Lackland Air Force Base. She shares memories of her father, who committed suicide when she was ten years old. She notes that her father named her “Wenonah” for her Shawnee grandmother and because the name means “morning star”, alluding to the fact that she was her father’s first born.

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  Chapter 02 : Finding the Way to Nursing

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  Dr. Ecung begins this chapter by noting that when she began college (San Antonio College, transferring to Texas Woman’s University, BS in Nursing conferred in 1977) she believed she would focus on business. She talks about how ambitiously she approached her first jobs in high school and her success as a young employee. She then explains how a guidance counselor limited her sights for study in college to teaching and nursing because of her gender, though she notes that “he didn’t know he was doing me a favor.”

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  Chapter 03: An Education that Stressed Nursing Leadership; Experiences of Bias

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  Dr. Ecung talks about her nursing education at Texas Women’s University in this chapter. She talks about the value of the Socratic method employed and shares anecdotes about racial bias she observed and experienced.

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  Chapter 04: Making a Commitment to Oncology Nursing

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung explains how she decided to focus her career on oncology nursing despite her first reservations. She explains how she first took a job (after graduating in 1977) as a floor nurse at MD Anderson, caring for patients with testicular and breast cancer. She shares stories of working with patients and describes why she found it so difficult that she left after a year and a half.

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  Chapter 05: Nursing in the Department of Developmental Therapeutics

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung provides a portrait of her work in the Department of Developmental Therapeutics when she returned to MD Anderson in 1978. She explains the physical organization of the clinic (Station 16). She discusses how she reorganized patients by disease type and assigned specific nurses to each disease type to deepen their knowledge so they might be more effective working with faculty and teaching patients about their diseases. She talks about the impact –notably in the retention of nurses.
  
  Next, Dr. Ecung talks about the working relationships between research nurses and clinical nurses in Developmental Therapeutics.

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  Chapter 06 : Developing Nursing Care in the New Clark Clinic

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung talks about her shift to a new position as Nurse Manager of Station 55 (in 1987), which was moved to the newly constructed Clark Clinic. She talks about the physical organization of the new clinic space and how it functioned more effectively. She outlines changes that she helped make to nursing care between 1987 and 1993, including combining the roles of research nurses and clinical nurses into the Primary Attending Nurse designation. She talks about the challenges of effecting this change and the increase in patient satisfaction it created. She notes that she “had a list of nurses waiting to get into Station 55,” and she was extremely careful to bring in new nurses who fit with the culture of the group. She also recalls that other clinics were asking for information on how Station 55 had been so well reorganized.

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  Chapter 07: Reorganizing Station 65 [now the Breast Center], the Preceptorship Program, and Multi-Disciplinary Care

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung discusses the period when she was managing Station 55 and was also tapped to reorganize Station 65, now known as The Breast Center. She explains that this was the first of a number of situations in which she would serve as a “turnaround agent.” She describes some of the skills she brought to that role and then sketches the situation in Station 65 when she took over. Dr. Ecung explains that she wanted to bring a new view of nursing and nursing culture through a rapid team transformation. She explains that she was successful in establishing a core group of people who supported her vision of empowering nurses as decision makers working in concert with physicians.

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  Chapter 08: A New Role as Clinical Administrative Director: Instituting Multi-Disciplinary Care

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung tells the story of taking on the role of Clinical Administrative Director (in 1996). She begins by talking about the interview process, which took place during a difficult period of her life. She then talks about her responsibility to build multi-disciplinary care teams as the institution went to a “one stop shopping” model. She also talks about the effects of this “huge change” on faculty, nurses, and on patients. She also notes that at the time other cancer centers were discussing this change, but MD Anderson took the step of instituting it and “became the way” of organizing care.

  Next she notes that she has always had “great nurses” who wanted to “do more than put a patient in a room.” She talks about the interview process she used to select nurses. She also recalls her Master’s program, where she began to understand her administrative philosophy.

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  Chapter 09: Period of Transition for a Leader

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung talks about a period of transition she went through in her focus on leadership. She begins talking about an MD Anderson-sponsored leadership development program she attended, then shifts gears and explains how Dr. Charles LeMaistre invited her to chair a group of classified employees tasked with interviewing candidates for the new presidency of the institution. She notes that this role gave her visibility among staff outside of medicine; she also recalls lessons learned, illustrating with an anecdote about how she had to handle an awkward moment during an interview with Dr. John Mendelsohn. She notes that these experiences prepared her for leading larger interdisciplinary teams.

  Dr. Ecung then returns to her original story about her leadership training, telling a story about how she intervened as a bridge builder when Dr. Mendelsohn and Dr. Todd Pritchard got into an argument about mentoring.

  This set the stage in which Dr. David Callendar asked her to interview for the role of Associate Vice President for Clinical Programs. She explains that Dr. Barbara Summers (oral history interview) was chosen for the position. She tells a story of how she demonstrated her support for Dr. Summers in her new role: Dr. Summers eventually asked her to lead the Clark Clinic Renovation project, her second major opportunity for exposure to executive leadership. [Dr. Ecung’s husband, Ramone, comes in briefly at the end of this chapter.]

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  Chapter 10: Professional and Personal Values and Changes in Institution Culture

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  Dr. Ecung begins this chapter with some brief comments about mentoring: she notes that “I am a product of mentoring” and talks about her own strategies of mentoring. She tells an anecdote about mentoring staffmembers who are already fairly highly placed but looking to rise higher in the institution. She notes that by virtue of her mentoring, she began to serve as “the doorway” to the Physician in Chief’s office. She explains that honest and integrity are key concepts in her personal and professional philosophy and these values served as motives for her decision to retire.

  Next Dr. Ecung offers her observations on changes that she has seen in MD Anderson’s culture over the past five years, noting that the institution does not feel “as wholesome” as it did during her years of service and that the place is “reshaping” in ways that do not match who she is. As an example, she explains that for 37 of her 39 years at the institution she never felt that she was looked at as black, but now feels invisible in meeting with the president [Dr. Ronald DePinho; oral history interview]. She also explains that she has observed Dr. DePinho’s wife, Dr. Lynda Chin, behave in ways that were damaging to moral.

  She notes that in the past, she observed situations arise where the faculty might not like an institutional policy or decision, but nevertheless supported the president. Today, she explains, the faculty does not feel heard and this support is not as strongly expressed.

  She also notes changes in the Physician in Chief’s office. The atmosphere was very close and trusting in the past, but now sees a kind of class system in place.

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  Chapter 11: The Decision to Retire and Reflections on Working Under Two Physicians in Chief

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung explains the factors that led her to retire at the end of 2016, setting her decision in the context of her work with two physicians in chief, Thomas A. Burke, MD [oral history interview] and Robert Brigham.

  She begins by noting that she was serving as Associate Vice President of Clinical Operations when Dr. Burke came in as physician in chief, and he made the conscious decision to keep her in that role. This gave her to opportunity to observe the process by which he was removed from that position and notes that she felt it was “not done with integrity.” She talks about Dr. Burke’s accomplishments in his role and explains that he had the habit of “speaking truth to power” while also being a “citizen of power.” She explains the process of removing him (2013) and why integrity is so important in executive levels of an institution.

  
  
  Next, she talks about her expanded role as Vice President of Clinical Operations under Dr. Thomas Buchholz because another key individual had left the institution and Robert Brigham had come in as new Senior Vice President for Hospital and Clinics, working closely with Dr. Buchholz. She describes the new perspective that Mr. Brigham brought from his years at Mayo Clinic and the changes that he and Dr. Buchholz instituted.

  Dr. Ecung explains how her role changed and was ultimately diminished in this new administrative context. She talks about her decision to retire and cut off from all contact with MD Anderson for one year, explaining her reasoning. She also talks about how people who remained in the office of the Executive Vice President felt they had lost an advocate when she left.

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  Chapter 12: Associate Vice President of Clinical Operations, an Evolving Role

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung talks about her role as Associate Vice President of Clinical Operations (2003 – 2014). She explains how she was selected for this position then talks about the steep learning curve she had during her first two years: it was a few years before a task crossed her desk that she had performed previously. She gives examples of the tasks she took on during Hurricane Katrina and during the Joint Commission Survey to accredit the institution.

  She observes that after five years, she was familiar with the role. She gives examples of how she instituted processes that could be repeated: evaluating faculty salaries; the holiday letter program; advisory board contracts. She compares her view of the role to Dr. Barbara Summers, who had held it previously.

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  Chapter 13: Key Projects

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  Dr. Ecung begins this chapter by identifying her role as Chair of the Clark Clinic Renovations Project Team as one of her most significant (2005 – 2008). She ran the first interdisciplinary committee comprised of forty-three individuals from all over the institution to have input. She notes that it was extremely successful. She talks about the impact of her decision to have committee members present to the Dr. Buchholz, rather than presenting their conclusions herself.

  Next she talks about addressing long wait times (sometimes twelve hours) in the Emergency Center (though the recommendations were not implemented). She speaks on more detail about the survey conducted to gather information for the American College of Surgeons’ accreditation process, noting that MD Anderson most often received a “commendation” level evaluation.

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  Chapter 14: Vice President of Clinical Operations, and a New Working Environment

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  Dr. Ecung begins this chapter by narrating the story of how she was promoted in 2014 to Vice President of Clinical Operations (along with others in the Office of the Executive Vice President). She notes that her official role didn’t change, as its scope was already “huge” and she was required to have a great deal of agility to take on new projects.

  The role did shift, however, along with circumstances over the next two years, she explains, because Dr. Buchholz had taken over as Physician in Chief in 2013. Once Robert Brigham came in as Vice President of Hospital and Clinic, she explains that she was expected to do more, but also serve a more restricted and diminished role.

  She notes that projects effectively stopped when Dr. Buchholz came in as he adjusted to the new role.

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  Chapter 15: Instituting Multi-disciplinary Care and Electronic Medical Records

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung sketches some of the major changes she saw during her years working for the Physician in Chief.

  First she talks about the process of adopting electronic medical records. She explains that under David Callender, the institution looked at a variety of vendors and determined that the MD Anderson-developed system, ClinicStation, exceeded what was on the market. In 2014, she explains, leadership decided to adopt the EPIC EMR system. She talks about the pros and cons of ClinicStation and notes that the administration planned on a $250 million loss when instituting EPIC.

  
  
  Next, she talks about the process of supporting the evolution of multidisciplinary care at MD Anderson, a process that involved helping faculty and staff understand what it was about and then managing the transition of practice to a team approach. She talks about the difference between physically bringing the different specialties together versus creating a culture of collaboration. She talks about some of the strategies used to foster collaboration, including the importance of cross-training nurses and holding planning conferences with faculty across specialities. She talks about the importance of spatial support in design of clinics, developing teams, holding formal conferences, and including multidisciplinary teams in patient visits, the latter resulting in a “show of force for a patient.”

  Dr. Ecung talks about working on the Clinical Effectiveness Committee that formalized multidisciplinary approaches in the MD Anderson algorithms of care. She points out that the Sarcoma center did a costing of each algorithm.

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  Chapter 16: A PhD and Teaching Leadership Theory and Policy after Retirement

  Wenonah B. Ecung PhD and Tacey A. Rosolowski PhD

  In this chapter, Dr. Ecung first explains her decision (in 2010) to get a PhD and then talks about teaching Leadership Theory after her retirement in 2016.

  First she explains how she came to earn a PhD at Our Lady of the Lake University at San Antonio after that institution established a cohort in Houston in 2010. She talks about her husband, Ramone’s support of her work and the challenges of doing a PhD (conferred 2013) while involved in a demanding position. She recalls her graduation.

  Dr. Ecung then discusses the impact of her program of study as she served as Associate VP and VP of Clinical Operations.

  
  
  Next, she explains how she was invited to teach leadership theory and policy after her retirement. She explains that she wants to give back to the University and this is her contribution of community service.

  Finally, she notes that her heroine is her mother.

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  Chapter 01: An Early Interest in Writing Serves a Career in Science

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter, Dr. Elting briefly talks about her parents then sketches her early educational experiences. She explains that though she took science and math courses, she loved to write and planned on focusing on writing and literature when she attended Lindenwood University in Saint Charles, Missouri. She explains how her skill in writing has served her career in the sciences. Dr. Elting talks about the learning environment and then explains why she returned to Houston to attend the University of Houston.

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  Chapter 02 : Inspired by J Freireich and Doing Support Work for MD Anderson Researchers

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter, Dr. Elting explains that after a friend suggested she work at MD Anderson to make money for college, she got a job as a clerk-typist in the Tumor Registry, where she learned about diagnoses, anatomy, and treatment. She tells an anecdote about how she came to attend rounds one day in Developmental Therapeutics. The outcomes for patients that day were particularly bad, she recalls, and Dr. Emil J Freireich [Oral History Interview] talked the faculty to remind that that a cure could be discovered at any moment. She says, “I was a goner,” she was so inspired.

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  Chapter 03: Finding a Way to Have a Research Career at MD Anderson

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter, Dr. Elting explains why she rethought her career path so she could come to MD Anderson and conduct research. She was interested in her work in the Coding Department, where she was recognized, and rewarded. She decided to switch her studies to medicine and thought of applying to medical school, however, ultimately attended Houston Baptist University for a degree in Nursing (BS conferred in 1974). In 1976 she began working at MD Anderson working for Dr. Gerald Bodey [Oral History Interview]. She explains the pharmacological studies she worked on and notes the status of research nurses.

  Dr. Elting describes the unstructured environment in Developmental Therapeutics, where it was possible to be innovative. Dr. Elting tells a story of taking such an opportunity to aggregate data on one study when Dr. Bodey was away. She observes that some people thought it was presumptuous to take over a task usually performed by a physician, a fact that led to a divide between floor nurses and research nurses, but that didn’t stop many people from simply taking over a task. Dr. Elting notes that in an unstructured environment, mentoring is unstructured as well.

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  Chapter 04: Earning a Master’s in Public Health and a Landmark Study of Infections

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter, Dr. Elting explains the work she did under Dr. Gerald Bodey while also attending the UT School of Public Health to work on her Master’s and supplement the information she knew she lacked. She talks about the open environment that provided her with a good learning experience. She notes that she was interested in infections caused by multiple organisms. Dr. Elting explains that she did a large study of polymicrobial septicemia, which still may be the largest study ever conducted.

  Next Dr. Elting explains the main lessons she learned during her Master’s program: that she could offer clinicians a view of entire populations (rather than a focus on individual patients); that she could strengthen studies by insisting that the basic research question be articulated. She also explains that she learned to communicate effectively with clinicians and non-biostatisticians by using graphic charts and pictures, rather than tables of numbers.

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  Chapter 05: A Doctorate in Public Health and Appointment to the Faculty

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting begins this chapter by explaining that her Master’s program gave her confidence in the quality of her own research questions and helped spur her to pursue doctoral work.

  Dr. Elting explains why she never considered leaving MD Anderson.

  Next she sketches the skills her doctoral program helped build, particularly computer skills. She observes that computers were not much in use in research at MD Anderson during the eighties.

  Next Dr. Elting explains MD Anderson rules that made it difficult for her to be promoted to the faculty. She also notes that it was difficult to get some physicians to see her as a colleague when they had known her for years as a nurse/technician. She describes her duties once she was promoted to the faculty.

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  Chapter 06 : Early Research Studies

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter, Dr. Elting talks about research studies she conducted just after receiving her DrPH. She worked on two emerging types of infections (alpha streptococcal infection and pseudomonas maltophilia) and explains how here research was constructed to enable her to draw solid conclusions about infection risk factors.

  Dr. Elting notes that she conducted this research with Dr. Gerald Bodey’s research money, then explains that she was able to get an independent grant to study how to effectively present data from clinical trials so clinicians would understand and use it. She designed a study using comparing the use of numbers versus pictures in communicating information about drug toxicities and patient responses. It was clear that pictures worked best, and Dr. Elting’s conclusions were adopted at many other institutions. Dr. Elting notes that MD Anderson has always been “behind the curve” in adopting medical records systems.

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  Chapter 07: Research Focus Expands to Risks and Outcomes of Care

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting begins this chapter by explaining that the threat of infections was decreasing and so she expanded her research focus to supportive care. She transferred to the Department of General Internal Medicine (GIM) and worked with the Ambulatory Treatment Center.

  Dr. Elting notes that she was advised to begin working independently of Dr. Gerald Bodey, as many professionals attributed her research to him because of their long working relationship.

  Dr. Elting explains that in GIM she conducted research on nausea and vomiting. She also developed an interest in effectiveness, efficiency, and cost and conducted time/motion studies and studies to demonstrate the effectiveness of expensive drugs that insurance companies were unwilling to cover. She began to study economics.

  She then makes observations about her own learning and mentoring styles.

  Dr. Elting discusses the first study she conducted independently of Dr. Gerald Bodey: a study of the frequency and outcomes of thrombocytopenia (low platelet count) and the cost/benefits of transfusion versus drugs to treat the condition. This study brought her recognition and established her as the primary researcher in the field of risk and the outcome of care.

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  Chapter 08: A Study of Thrombosis Opens New Research Niche in Side Effects

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting explains how her study of thrombosis in cancer patients enabled her to establish a new research niche.

  She explains how her study of thrombocytopenia led to her interest in thrombosis and helped shape her approach: looking at individual patients at MD Anderson and carefully describing symptoms in this large population in a way that had relevance to current practice. This was the beginning of her focus on side effects, she notes.

  
  
  Next, Dr. Elting compares her approach to the typical retrospective study often conducted by fellows. She notes that the most frequent question she received from reviewers was, Are these symptoms as bad outside of MD Anderson, in ordinary practice? She explains why MD Anderson has a different patient population, but notes that it was possible to generalize this information to the general population and she began to look at expanding studies accordingly.

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  Chapter 09: Departing from Epidemiology and Conducting Cost-Effectiveness Studies

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting talks about how her interest in value of care evolved.

  She sets context by noting that in the 2000s many states began requiring that hospitals report the quality of results, making available data about procedures and surgical outcomes. Dr. Elting was able to look at toxicities that caused death and fees for procedures. She explains that expensive and effective new drugs were available to treat toxicities, but insurance companies were unwilling to cover the cost. She says that she initiated cost effectiveness studies to demonstrate that the more expensive drugs ultimately saved money. Her studies were very successful at convincing payers to change their policies. She then talks about the reactions of her colleagues to her change in research direction.

  Dr. Elting explains that this research took her away from traditional epidemiology and allowed her to differentiate herself, a fact that was critical to her success.

  Dr. Elting tells a story about a period when General Internal Medicine didn’t have enough beds because they were filled with patients made too sleepy to function by their anti-toxicity medications.

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  Chapter 10: Research on Health Effects of Policy Decisions and a Study of Childhood ALL

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter Dr. Elting talks about her current research focus on the health effects of policy decisions made by state and local governments.

  She begins by noting that there is no federal health policy in the United States, so policy decisions made at a “semi-macro level” have an effect locally on subpopulations. Dr. Elting gives an example from Texas health care.

  Dr. Elting explains that to study these effects, she began to study outcomes by volume of cancer procedures. She then gives an example of a study she conducted on the availability of mammogram machines across Texas, showing that in areas with no machine, patients suffered more late-stage breast cancer. She notes she is currently working with a pediatric surgeon looking at pediatric cancer in Texas.

  Dr. Elting notes that few families can afford care for childhood cancer. She explains the funding of the study and its impact. She gives an example of partnering with the University of Texas Medical Branch to produce video talks and other educational materials for communities and primary caregivers. She mentions some other efforts to disseminate information beyond academia.

  Dr. Elting talks about why Texas is an interesting state to study and why it allows conclusions about how barriers to care operate and affect outcomes. She talks about interventions her office has helped to create.

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  Chapter 11: Providing Data to Inform Policy Makers

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting begins this chapter by talking about how the Affordable Care Act has had an impact on the study of health outcomes. She also notes that the ACA has provided an opportunity for her to provide information to the state legislature in Austin and influence the conversation about healthcare. As an example of the issues she might take on, she explains her work on Medicaid has shown that people who have gaps in insurance coverage have worse outcomes than those with continuous coverage. The latter is ultimately more cost effective.

  Next Dr. Elting talks about the mechanisms her office uses to deliver information to Austin. She explains that, as a public institution, MD Anderson can only educate, not lobby. A report goes to every legislator. Individuals specifically interested in public health receive an email and those who interact with legislators on behalf of health issues also receive information.

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  Chapter 12: Training Laboratory and Clinical Researchers in a Populations Perspective

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter, Dr. Elting talks about Project 4, a training initiative run by Dr. Carlos Barcenos to inform junior faculty about health policy issues and encourage them to integrate a population-focus into their thinking and research. She gives examples of how they encourage this integration and how the training changes the faculty’s thinking about resource allocation, the cost of care, and what insurance can and cannot accomplish. Dr. Elting explains that the participants will become leaders in their fields and educators of the next generation of oncologists, so this training is key to shift their practice and contributions to how the healthcare system works.

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  Chapter 13: Developing the Ambulatory and Supportive Care Oncology Research Program

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter, Dr. Elting talks about her roles as Director of Clinical Epidemiology and Informatics within the evolving Ambulatory and Supportive Care Oncology Research Program (1992 – 1998), housed in the Department of General Internal Medicine.

  She explains the vision and goals of this new research program, designed to provide data to guide initiatives to de-hospitalize chemotherapy patients to outpatient status and she brought quantitative methods to this clinical department.

  Dr. Elting talks about research conducted when a new group of antibiotics became available, making it easier to treat infections and fevers in chemo patients. She explains that the research conducted in the new program shifted the standard of care from inpatient to outpatient treatment. She notes that this was considered “a wild and crazy thing to do,” very risky and dangerous.

  Dr. Elting talks about how the study offered a leadership opportunity. She reflects on the success of the program.

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  Chapter 14: Training Clinicians to Think Analytically about Research Problems

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter, Dr. Elting talks about how expanding General Internal Medicine’s research program allowed her to train clinicians in analytical thinking. She explains how physician’s generally think about clinical problems, defines what analytical and quantitative thinking are, and the effect that training in these methods has on clinicians.

  Dr. Elting ends this chapter by explaining what she learned from working with clinicians in this way. She notes that her role as Director of Research (1998-1999) in the Section of General Internal Medicine was simply an expansion of her role as Director of Clinical Epidemiology and Informatics.

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  Chapter 15: Developing Health Services Research in the Division of Cancer Prevention

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting talks about her role as Chief of the Section of Health Services Research (2001 – 2013) and explains the department affiliation.

  She sketches the research focus on the outcomes (including economic and business outcomes) of treatments, not the treatments themselves.

  Dr. Elting explains why she was selected to take on this role and how she was asked to head the section and “go find a department to be in and make us famous.” She explains why she identified the Department of Biostatistics and Applied Mathematics as the most likely home.

  Dr. Elting then sketches this administrative history of the Departments of Biostatistics and Applied Mathematics. She describes the challenges of finding a way to work with other department members whose perspectives were different and notes a landmark moment of finding common ground for collaboration.

  Dr. Elting notes that her appointment to the role of Vice Chair of the Institutional Review Board raised the profile of Health Services Research and further credentialed her and her Section.

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  Chapter 16 : Institutional Review Boards at MD Anderson

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting sketching her role in MD Anderson’s Institutional Review Boards, including establishing a new IRB when the board overseeing clinical research didn’t serve the needs of non-clinical researchers. She talks about the role of the research review committee (PBHSRC) that also looks at protocols.

  
  
  Next, she sketches a history of IRBs at MD Anderson, first established in 1966, before the federal requirement to establish such review processes. She explains how attempts were made to create effective processes that would not slow research.

  
  
  Next, Dr. Elting explains the value of IRBs and traces how their role has changed as more resources have been provided to support monitoring.

  Dr. Elting explains that the computer system that enables efficient entry and management of data has lagged behind the development of IRB processes and causes problems with the system. She also notes that when HIPPA requirements

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  Chapter 17: A Brief History of Office Space Occupied

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting begins this funny chapter by announcing that she has “done some homework.” She goes on to explain that she has had twenty-four different offices at MD Anderson, two of them in buildings that were ultimately imploded. She notes that the fact that she was asked to relocate before the implosion, and jokingly adds that she sees this as proof that the institution values her work.

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  Chapter 18: A Brief History of Institutional Review Boards at MD Anderson

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  Dr. Elting begins this chapter by reviewing the proliferation of IRBs at MD Anderson. She discusses the reasons why they were necessary and how they have emerged as pressures on researchers were changing. She explains why the mid-nineties were a key time for rising resources to fund IRB oversight. She explains that when HIPPA went into effect, MD Anderson’s Compliance office became more concerned about adherence to proper policy.

  Next Dr. Elting talks about the need for IRB oversight given ethical issues that have arisen with the increase in genetic/genomic research and increases in projects involving ‘big data’ requiring that personal health information moves from institution to institution.

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  Chapter 19: Researchers in Relationship to Institutional Review Boards: A Perspective from an IRB Chair

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter, Dr. Elting responds to the observation that many researchers have an adversarial view of IRBs. She underscores the importance of training in IRB issues and then explains that she was responsible for formalizing MD Anderson’s IRB training program for new faculty members and research nurses.

  She explains her strategy of addressing IBR mistakes while she served as Chair (Institutional Review Board IV, 2003-2005). She gives examples of the kinds of issues that would arise and explains why they appear, particularly in the social sciences departments.

  Dr. Elting notes that the IRB she chaired was formed to handle issues arising from research projects, such as hers, conducted in the community with non-MD Anderson patients. She explains the issues that would arise and gives examples of creative solutions to these unexpected situations.

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  Chapter 20: Adding Biostatistician to Research Protocols Raises the Bar of MD Anderson Research

  Linda E. Elting DPh and Tacey A. Rosolowski PhD

  In this chapter, Dr. Elting explains how it became a requirement to include a biostatistician to all MD Anderson research protocols. When Dr. Don Berry was recruited to head the Department of Biostatistics, this new requirement was a condition for accepting the position.

  Dr. Elting agreed with his requirement and talks about its significance. She explains how important a biostatistician’s view can be in designing and protocol as well as interpreting data. (She comments on the design of research conducted by pharmaceutical companies.) She talks about the positive effect on MD Anderson research.

  Dr. Elting observes that PIs were at first skeptical, because they didn’t know how they would pay for biostatistics services, but Don Berry secured substantial funds from MD Anderson to provide this support free of charge and most people were happy to have the help.