In accordance with oral history best practices, this transcript was intentionally created to preserve the conversational language of the interview sessions. (Language has not been edited to conform to written prose).
The interview subject was given the opportunity to review the transcript. Any requested editorial changes are indicated in brackets [ ], and the audio file has not correspondingly altered.
Redactions to the transcript and audio files may have been made in response to the interview subject’s request or to eliminate personal health information in compliance with HIPAA.
The views expressed in this interview are solely the perspective of the interview subject. They are not to be interpreted as the official view of any other individual or of The University of Texas MD Anderson Cancer Center.
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Chapter 14: Setting Up the New Ambulatory Clinic (Mays Clinic) –And Redesigning It
C. Stratton Hill Jr. MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hill offers a comprehensive view of his work setting up the Ambulatory Care Clinics and serving as Director from 1974 to ’79 (noting that he learned to work with Dr. Clark’s leadership style effectively during this period). A new Clinic was needed to serve the crowds of patients standing around as if “in feedlots.” Dr. Hill discusses several topics: MD Anderson’s acquisition of the land and money to build the new clinic; the challenges of dealing with a new building whose architects had not planned well for specific medical uses and needs; personnel upheavals; evaluating the function of the building and staff once the departments moved in; his work writing educational materials for patients on the procedures they would undergo; change in the policy of allowing patients to handle their records. Dr. Hill also describes his working relationship with Dr. R. Lee Clark, president of the institution at the time. He talks about calling a key meeting held to address design elements of the clinic that resulted in dehumanizing treatment of patients that was “not the way that anyone here wants to practice medicine."
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Chapter 15: Remembering MD Anderson Presidents and Dr. Eleanor MacDonald
C. Stratton Hill Jr. MD and Tacey A. Rosolowski PhD
Dr. Hill begins this chapter by noting that Dr. Clark supported any change that would improve efficiency and positive effects for patients. He then goes on Eleanor MacDonald [Oral History Interview], an epidemiology specialist with a visionary sense of records organization: she established a system of data and records-keeping for MD Anderson that influenced the entire medical system in Texas. Dr. Hill notes that Miss MacDonald’s work guaranteed the quality of MD Anderson research. He then offers additional observations about Dr. Clark, comparing his leadership style to Dr. Charles LeMaistre’s [Oral History Interview] and discussing the transition as Dr. Clark stayed at MD Anderson during the beginning of Dr. LeMaistre’s presidency of the institution. He recalls working with Roman Arnoldy, an engineer who organized the building of Rotary House (built on the model of a hotel attached to the Cleveland Clinic), which provides convenient and medically appropriate accommodations for patients. He also evaluates Dr. Mendelsohn’s [Oral History Interview] leadership style with the previous presidents, praising his science as well as his administrative and fundraising skills.
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Chapter 16: Preserving the MD Anderson Brand Despite Global Growth
C. Stratton Hill Jr. MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hill discusses financial challenges that MD Anderson currently faces: challenges in expanding the MD Anderson culture beyond Houston while preserving the culture of care; competition between service providers. He also speaks about the new president, Dr. Ronald DePinho –what he appears to offer and also his lack of experience in the operation of clinical services.
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Chapter 17: The Texas Cancer Council and the Texas Cancer Pain Initiative
C. Stratton Hill Jr. MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hill talks about his appointment (by Lt. Governor Bill Hobby) to the Texas Cancer Council (President, 1992-94, 1994-6) and sketches his work starting up the Texas Cancer Pain Initiative (which began in the 1980s with an organizational meeting funded by the Hobby Foundation), an organization that lent its name to the attempts Dr. Hill and others were making to revise legislation with an impact on pain management. Reviewing the organization’s educational efforts (in the late 80s or early 90s), he explains the political and financial reasons why it is more difficult to change pain management practices now than in the past.
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Chapter 18: The Open-Door Mission for Rehabilitation and Recovery; Awards
C. Stratton Hill Jr. MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hill talks about his involvement with the Open Door Mission for Rehabilitation and Recovery, where volunteers his time now that he is retired. He talks about his various awards, hoping that they bring attention to issues that need further attention and funding. He speculates that his interest in relief of pain came from his upbringing.
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Chapter 19: A Southern Baptist Background Inspires a Life of Service
C. Stratton Hill Jr. MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hill speculates that his commitment to care is rooted in his upbringing. He notes that he was raised Southern Baptist by practicing parents who had basic beliefs in a religion of love and service to others. (Dr. Hill believes all religions share these values; he is studying comparative religion now that he is retired).
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Chapter 20: Hospice and MD Anderson
C. Stratton Hill Jr. MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hill focuses on his work with the Hospice Movement. He describes the beginning of the Hospice movement in the U.S. (Dr. Hill attended the movement’s first meetings; he serves on the Board of Houston Hospice.) He explains why Dr. Clark was anti-Hospice at the time. He describes some basic beliefs of the group he worked with, primary psychologists, and shares a number of stories that show how he helped shape how Hospice in Houston functioned and evolved into a centralized institution. He again notes that Dr. Clark was against Hospice and such efforts as “Reach to Recovery.” He contextualizes Dr. Clark’s attitude in the anti-MD Anderson movement in Texas (fueled by MD Anderson’s fee-for-service policy) and explains why his attitude eventually shifted, though he stresses that MD Anderson “does not exist to preside over anyone’s death.”
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Chapter 21: Expanding MD Anderson’s Reputation
C. Stratton Hill Jr. MD and Tacey A. Rosolowski PhD
Dr. Hill begins this chapter by explaining why so many ENT cancers were referred to MD Anderson to have the successful, less disfiguring surgeries for people “who were supposed to be dead.” (He vividly describes the process of “walking a flap [of skin]” to perform reconstructive surgery.) He recalls that MD Anderson’s reputation was secured via non-surgical interventions of radio- and chemotherapy, and compares it to the more surgical focus of Memorial Sloan-Kettering. He also illustrates Dr. Clark’s “political moxie… that doctors in general don’t have” –a key factor in MD Anderson achieving prominence. Dr. Hill next returns to his own work on thyroid cancer, offering two specific cases in which he and other MD Anderson physicians were better able to diagnose cancer than others. He talks again about how he started up studies of families.
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Chapter 22: An Endowment for Education, More Research, and a Think Tank
C. Stratton Hill Jr. MD and Tacey A. Rosolowski PhD
During this chapter, Dr. Hill talks about the endowment he made (1998) to MD Anderson for education in Pain Management that would show the complexity of pain associated with cancer. He talks about current plans to discuss toxicities from cancer treatment, “the backdoor of treating symptoms from cancer treatment,” and hopes that the money will be used to support a “think tank” about symptom relief tied to individualized therapy.
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Chapter 01: A Family Tradition of Librarianship
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
In this chapter, Ms. Hoffman sketches her family background and talks about the number of people in the family who have become librarians, beginning with her father, who headed the Saint Louis University Library. She tells several anecdotes to shed light on her own choice to enter library science.
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Chapter 02 : Education and Activities Reflect a Broad Perspective
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
In this chapter, Ms. Hoffman talks about the range of strengths and interests that emerged during her youth: a gift for mathematics, a love of reading, interest in music and sewing. She talks about her choice of undergraduate institution, Case Western Reserve University (B.A., 1971). For graduate school, she elected to go to the University of Illinois (M.S.L.S., 1973) because they has a program in biomedical librarianship.
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Chapter 03: The Texas Medical Center Library: Aspirations to Leadership and How Context Affects Library Administration
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
In this chapter, Ms. Hoffman talks taking her first position out of school at the Texas Medical Center library. She notes her early aspirations to rise to leadership positions where she would be “in charge.” She then talks about what library management meant in her experience and briefly discusses several changes in libraries that have presented management challenges.
Next, Ms. Hoffman talks about the administrative environment at the TMC library, noting that resources dried up in 1986 with the drop in oil prices.
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Chapter 04: The Texas Health Science Library Consortium: Building Collaborations and Connections around the TMC Library
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
Here Ms. Hoffman talks about her role and the challenges involved in setting up a the Texas Health Science Library Consortium, a system of shared services at the Texas Medical Center.
Next, she talks about her involvement in professional associations and explains why they are important to the progress of a librarian’s career.
She then talks about leadership lessons she learned through experiences at the TMC library and recounts an anecdote about her work on a credentialing committee.
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Chapter 05: Stepping into Leadership at UT Southwestern Medical School
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
Ms. Hoffman begins this chapter by explaining why she chose to leave the Texas Medical Center Library and take a position as Executive Director of the Library and UT Southwestern Medical School in Dallas.
She talks about the situation she inherited at UT Southwestern, digresses briefly on her role as Executive Director at MD Anderson’s Research Medical Library, then returns to talk about how her goal in Dallas was to take the library into the 21st century. Ms. Hoffman lists some differences in working at a public versus a private institution and comments on what she was able to achieve at UT Southwestern.
Next she talks about her particular strengths in strategic planning. She notes, “I was a visionary,” and describes her vision for the UT Southwestern Library and how she set about making that a reality.
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Chapter 06 : A New Opportunity at the Research Medical Library
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
Here Ms. Hoffman tells the story of being recruited to MD Anderson to become Executive Director of the Research Medical Library. She explains the situation she stepped into, commenting on limitations of staff at that time. She also talks about the pressing need to develop the Library’s technological base.
She shares a story from her on site interview: an interaction with a faculty member very committed to the Library’s technology.
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Chapter 07: First Steps to Develop the Research Medical Library
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
In this chapter, Ms. Hoffman explains the situation she inherited from the previous director, Marie Harvin. She discusses two challenges that she first addressed: first, helping the staff address difficulties stemming from a staff members alcohol problems and, second, limitations places on the Library due to physical space in its location at that time in the Bates Freeman Building. She notes that originally library use was restricted to physicians and researchers only.
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Chapter 08: Developing Areas of Staff Expertise in the Library
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
Ms. Hoffman begins by explaining that she strengthened RML services by recruiting individuals to perform high level online searches. Next, she discusses the creation of the Historical Resources Center, an action that was associated with the Library’s acquisition of the papers from the Office of the President. This acquisition brought awareness to the need for a formal mechanism to preserve the institution’s history. (Ms. Hoffman notes that her interactions with Beth White at the TMC Library underscored the importance of such archives). She explains that a task force was created to address the issue of preserving MD Anderson history, also resulting in the creation of the oral history project.
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Chapter 09: Working on Leadership Structure and Developing Services to Align with Institution Mission
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
Ms. Hoffman begins this chapter by explaining how she changed the reporting structure in the Library for greater efficiency. She refers to an article she published in the Journal of Hospital Librarianship (document available). She discusses where the RML fits within the institution.
Next, Ms. Hoffman explains the Library’s different service areas and how they align with the institution’s mission areas: research, education, patient care, prevention. She explains her role in establishing The Learning Center for patients, an initiative led by Louise Villejo [oral history interview].
Next, she discusses funding for the Library, noting that it always has had good support from the institution.
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Chapter 10 : The Creation of the Historical Resources Center
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
In this chapter, Ms. Hoffman talks about the creation of the institution’s Historical Resources Center. A task force submitted a white paper to elaborate on the importance of this new center. She then talks about the three projects undertaken once the Center was established: creating a physical place to safely house documents and artifacts; writing the institution’s history; creating the oral history project.
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Chapter 11: The Library’s New Location on the Penthouse Floor of Pickens Academic Tower
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
In this chapter, Ms. Hoffman explains how, against standard corporate practice, the Library came to be located on the top floor of the newly build Pickens Academic Tower (with the presidential and other c-suite offices underneath). She talks about the process of designing the new library for that space and some of its special features.
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Chapter 12: The 2008 Layoffs
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
In this chapter, Ms. Hoffman discusses the “most difficult thing she had to do as a manager”: cut 10% of the library’s budget. She describes the instructions she received from the institution on how to make her decisions. She talks about the support the institution provided for you to go about notifying employees of layoffs. She provides advice to other managers facing this challenge.
Next, Ms. Hoffman talks about the areas she targeted for cuts and why. She discusses the impact of this financial crisis on the staff.
She segues to another management challenge: dealing with an incident of violence against a staff member, then returns to final comments on the reduction in force.
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Chapter 13: An Interest in Teaching and Work with Professional Associations
Kathryn Jones Hoffman MSLS and Tacey A. Rosolowski PhD
In this chapter, Ms. Hoffman talks about the pleasure she took in teaching and describes the intensive courses she taught all around the world on MeSH and the NLMC classification systems. She also discusses the importance of her work with associations and talks about some of her ongoing, post-retirement activity with them.
She then talks about retirement, noting why many people are afraid to retire. She discusses her involvement in the MD Anderson Retirees Association and comments on the continuing relevance of libraries and librarians.
After closing the interview, she adds a story of working with Dr. Peter Pisters on a research project. Dr. Pisters was selected to be MD Anderson’s new president after Dr. Ronald DePinho’s resignation.
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Chapter 01: The Importance of Addressing Faculty Health
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman sketches the range of reasons why it is important for institutions to address faculty health. He mentions the economic reasons as well as moral reasons. He sketches the sources of stress for clinicians and notes that physicians have conducted studies to understand how institutional pressures exert stress. He sketches the stressors for research faculty, noting that this population has not been significantly studied.
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Chapter 02: Growing Up in a Small Town in North Carolina
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman describes the working class, racially diverse community of Apex, North Carolina, where he grew up.
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Chapter 03: A Strong Mother Tells Stories with Impact
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman talks about his mother, a strong woman with a strong impact on him. He notes that her very difficult background formed her into a very strong woman who would speak her mind and stand up for what is right. She would also tell Dr. Holleman and his brother stories that captured lessons as they were growing up. He offers three stories that influenced him and that he says had an impact on the work on faculty health that he is doing at MD Anderson.
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Chapter 04: Developing an Ability to Deal with Psychological Turbulence
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman talks about graduating from Apex High School [1973] and attending Harvard University. Dr. Holleman explains how he made that choice, unusual for his community. Next, Dr. Holleman explains more about the dynamics in his family. Growing up in this environment, he says, enabled him as a counselor to treat people with personality disorders and depression.
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Chapter 05: A History Major at Harvard and a Desire to Make a Positive Difference
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman provides background for his desire to study history and possibly enter politics. He explains that he has skills much like his father, whom he admired. He recounts formative experiences with desegregation and political action that shaped his desire to address inequality and suffering and make a positive difference for people. He gives more insight into his family’s progressive values.
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Chapter 06: A PhD Program and a Professional Focus on Ethics
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
Dr. Holleman begins this chapter by explaining that his educational path took a turn because of his fiancée, Marsha Cline, who wanted to go to medical school: he explains how they made the choice to come to Houston. Next, he explains that while looking for work and a course to take, he was offered the opportunity to begin a doctoral program in the Department of Religious Studies at Rice University [Ph.D., 1986, Religious Studies]. This program led to his focus on medical ethics, a specialization he pursued with a Fellowship in Ethics at Baylor College of Medicine [1987-1988]. He developed expertise in primary care medical ethics. He gives examples of ethical issues that can arise and explains that his work changed practice at Baylor.
Completing his fellowship, Dr. Holleman explains, he advanced to faculty status as an Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine [1988-1998]. He describes the theoretical and philosophical focus of the department, whereas his strength centered in communication with patients. He was tasked with starting the Medical Humanities program at and founded the Compassion and the Art of Medicine lecture series/course [in 1989] that is now in its 27th year.
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Chapter 07: Discovering Work with Underserved Populations
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman talks about a third formative experience that shaped his professional focus. He explains that he decided to volunteer at Ben Taub Hospital, a hospital for the underserved where Baylor medical students and residents were trained, in order to understand what his students in the humanities program were experiencing. He tells some anecdotes to show how his time there opened his eyes to the suffering of both patients and young doctors and led to his conviction that this was the population he should be working with.
Based on this, he explains, he started a home visit training program for residents and eventually added a program for conducting health visits for the homeless. He talks about the evolution of these programs and how they led to his decision to go back to school, as he was effectively running a community health center [the Search Center] and functioning as a coordinator and counselor.
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Chapter 08: An MA in Counseling to Develop Expertise
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
Dr. Holleman explains that he “found himself” when he began his master’s program [M.A., 1996, Marriage and Family Therapy] in counseling at the University of Houston -Clear Lake. He explains how earning credentials in counseling altered his roles at Baylor Collect of Medicine, where he became an Associate Professor in Family and Community Medicine [1998] and founded the Baylor-Star of Hope Center for Counseling [1998] in addition to fulfilling his previous roles.
He notes that the Department of Family and Community Medicine developed an expertise in psychosocial medicine because of the vision of the chair at the time, Robert Rakle.
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Chapter 09: Time for a Change in Work Scene
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman explains decisions that led to him taking the job of Director of the Faculty and Health and Wellness Program at MD Anderson. He first summarizes the roles he was serving at Baylor College of Medicine in the 2000s, then explains why he quit that job in 2007.
Next he explains how he had become acquainted with staff in MD Anderson’s faculty health program through collaborations with the “Compassion and the Art of Medicine” series he established. He talks about his reasons for taking the position at MD Anderson, including his interest in seeing the differences between working with homeless individuals and physicians. He explains how he discovered it was actually easier to work with the homeless.
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Chapter 10: Discovering the Severity of Burnout at MD Anderson
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
Dr. Holleman notes that he started at MD Anderson in January 2010, then discusses the severity of the burnout he discovered among the physicians and researchers (also a national problem). He details the sources of burnout among physicians that stem from turbulence in the healthcare environment and at MD Anderson: increased time spent on paperwork, sense of losing autonomy in the clinic, the need for child care, loss of a sense of meaning in the workplace. He notes that no formal studies have been done of faculty scientists, but summarizes findings from an informal survey: increased grant paperwork, shrinking grant funding, drop in morale, conflict with institutional leadership.
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Chapter 11: The Faculty Health and Wellness Program: History and Evolution
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman sketches the history of the Faculty Health and Wellness Program and briefly describes the initiatives he set in place, including the Stressbusters Program designed to address physician burnout. He first notes that when he arrived at MD Anderson he saw the effects of faculty burnout, but has also never worked at an institution with more employee commitment to the institutional mission.
Next he talks about how he did a needs assessment through informal focus groups and began to hear about the serious morale issue among faculty, a problem that intensified when Dr. Ronald DePinho [oral history interview] assumed the presidency.
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Chapter 12: Learning about MD Anderson Culture Inspires a Different Perspective on Burnout
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
Dr. Holleman begins this chapter by explaining that he was effectively offering the faculty resiliency training. He then devotes the rest of this chapter to explaining the “epiphany” he had as his experience of MD Anderson culture evolved.
Dr. Holleman recounts that, during training sessions, faculty would be “boiling” and would state that offering resiliency training was effectively “blaming the victims”: defining burnout as a personal problem and individual responsibility, when in fact it had been created by systems within the institution. On realizing this, Dr. Holleman explains, he began to research burnout and mentally redefined his role as being an advocate for faculty to the administration. He confesses that he didn’t feel comfortable in this role. He gives examples to demonstrate that burnout is a systemic rather than a personal problem.
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Chapter 13: Advocating for Faculty with a Blog under Ronald DePinho
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman describes how he started the first faculty happy hours to create time for faculty to build connections. He then tells the story of the blog he started to give voice to faculty concerns, The Faculty Voice. A primary reason, he explains, was the strong fear among faculty of expressing their critical views of the institution and its leadership. He explains why this sentiment took root among the faculty.
Next he explains the reasons why the administration under Ronald DePinho demanded that the blog be taken down after he published an anonymous post on nepotism focused on Dr. DePinho’s wife, Lynda Chin, MD. He explains his editorial standards in writing and publishing posts. He explains the reasons that the Legal Department gave for demanding that the blog be removed. He also talks about conversations he had with colleagues in the Department of Behavioral Science, in which they expressed concerns that his blog would have repercussions for his department. Dr. Holleman conferred with the Faculty Senate and a plan was made that it would be taken over and renamed, The Sentinel, but the publication foundered after a few months.
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Chapter 14: Changes to MD Anderson’s Culture and Ronald DePinho’s Resignation
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
Dr. Holleman sketches the faculty’s concerns about Dr. DePinho and Dr. Chin. He also sketches changes in MD Anderson culture that were created after Dr. DePinho assumed leadership of the institution.
He then notes that Drs. Emil J Freireich and Emil Frei are “veteran physician-scientists” who represent the old culture of MD Anderson. He talks about the first impressions of Ronald DePinho and then explains how Dr. DePinho’s decisions shifted the culture.
Next, Dr. Holleman talks about Dr. DePinho’s resignation and what appears to have led up to it. He notes that he is hearing a lot of optimism from the faculty now that Dr. Marshall Hicks has been named interim president. He also notes that the selection of the interim team represents a return to the old values of MD Anderson: a focus on patient care and clinical research under the stewardship of servant leaders.
Dr. Holleman and the interviewer discuss how, during this interim period, the institution will be rediscovering its core values. Dr. Holleman then sketches the positives as well as the negatives that Dr. DePinho brought to the institution.
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Chapter 15: A Role as “Toxin Handler”
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman reflects on the role he has served vis a vis the faculty during the last five and a half years. He notes that his job has been to listen to the faculty and reflect back what they are saying. He also tells an anecdote about learning the phrase, “toxin handler” to describe what his real job is. He defines this role more fully.
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Chapter 16: Faculty Health and Wellness: Programs and the Anti-Bullying Task Force
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman begins to sketch the range of traditional and non-traditional programs that Faculty Health and Wellness offers, then turns to one initiative in particular, the Anti-Bully Task Force. He defines what shapes bullying can take in the workplace and stresses the “emotional immediacy” that victims of bullying experience. He then clarifies that the Task Force was created in 2013 in response to the way Dr. Ronald DePinho handled his policy of raising the standards for promotion and tenure.
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Chapter 17: Faculty Senate and Changes to the Shared Governance System
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman observes that representatives of the University of Texas System intervened in Dr. DePinho’s style of addressing the promotions and tenure system. He explains that Dr. DePinho had diminished the role of the Faculty Senate, and UT System’s Chancellor McCrave expanded its original powers under the reorganized shared governance system. Dr. Holleman notes that the Faculty Senate continues to discuss and refine how this system should work. He praises Faculty Senate and observes that this new system has allowed new faculty leaders to emerge. He cites studies that have found that the effectiveness of leaders is dependent on burnout, and that empowering faculty leaders is key to reducing burnout at the institution.
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Chapter 18: Faculty Health and Well Being: Programs and the Faculty Health and Well Being Committee
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman returns to the topic of the Program’s offerings, then focuses on the Faculty Health and Well Being Committee, which he chairs. Formed in 2010, this committee is designed to “multiply the effect” of the Program by bringing together faculty who are interested in providing additional programs to faculty and to conducting research on topics related to health and well-being. He talks about the activities of several committee members. He then talks about the areas that he and the committee would like to see expanded, notably social events for young faculty and for young faculty and spouses/families. He tells stories to demonstrate how successful and needed social events have been in the past.
Next, Dr. Holleman notes that the Committee has recently included a new dimension in its mission: supporting the Faculty Senate and the Shared Governance System. He explains that such processes can address the problem of faculty health from the institutional level. He explains that the Committee wants to work more closely with Faculty Senate and that the Faculty Health and Well Being Program in general needs to develop its role in advocating for the faculty to leadership.
Finally, he talks about the current environment of change, created when Dr. DePinho tendered his resignation. He observes that interim leaders are focusing on “what the institution’s calling is really about.”
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Chapter 19: Looking Ahead to Writing
Warren L. Holleman PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Holleman talks about his long love of playwriting. He talks about the plays that have been performed and his plans to work on others. He also talks about his plans to continue his academic study of physician burnout and he would like to write a book on life balance.
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Chapter 01: Experiences of War and Emigration
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
In this Chapter, Dr. Hong talks about key experiences in his homeland of South Korea. He explains that in his family of seven children, his oldest brother became a prominent bio-scientist and served as his mentor and “a second father,” who went to the United States for his Ph.D. training, returning to inspire the young Waun Ki Hong.
[The recorder is paused for approximately 10 minutes.]
Dr. Hong next talks about the impact of living in a country where here experienced three wars: the Second World War, the Korean War, and the Vietnam War, during which he served in the Korean Air force as a flight surgeon. Seeing the devastation of war, he explains, instilled in him the spirit of service and collaboration. His military experience helped him establish his own sense of discipline and accountability, the capacity for team effort and respect for chains of command.
Dr. Hong explains that when his military service ended (in 1970), he came to the United States for an internship. He says that arriving as an immigrant was a challenge, but he is “an eccentric and doesn’t play it safe. He then explains why he was only able get an internship at a community hospital.
[The recorder is paused for about 11 minutes.]
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Chapter 02: Choosing to Specialize in Cancer Research and Treatment
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
After explaining why his internship at Lebanon Hospital in New York was disappointing, Dr. Hong describes his move to the Veterans Affairs Hospital in Boston, Massachusetts. He talks about cross-cultural adjustments. He also explains that he saw many cancer patients in Boston and decided to work on smoking related cancer. He was, at the time, thinking about cancer treatment from a new perspective (which would create an entirely new field), as he was not approaching head and neck cancer as a surgeon. He describes his next move to Memorial Sloan-Kettering in New York, where he was part of a top fellowship program and met “good people,” among them Dr. Irwin Krakoff, who would later come to MD Anderson and serve a role in recruiting Dr. Hong for that institution. Dr. Hong next traces his move back to Boston, where he joined the faculty of the Veterans Affairs Hospital as an assistant professor (1975-1984). Dr. Hong was the only medical oncologist on staff, and he describes how he was able to prove himself able to build a medical oncology program. Dr. Hong also states that he was “lucky” because the drug Cisplatin had become available, and he was able to obtain and test the drug on head and neck patients –he was one of the first individuals to treat head and neck patients with chemotherapy and the first to demonstrate its effectiveness in preserving the larynx. He explains that the human motive of preserving patients’ ability to speak and swallow motivated him. Dr. Hong tells a story about his connection to George H.W. Bush.
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Chapter 03: New Fields and the Discovery of Vitamin A’s Role in Chemoprevention
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
Dr. Hong first describes the trial that demonstrated chemo’s effectiveness for patients of head and neck cancer. (One group was given the standard treatment of surgery and radio therapy and the second treated with chemotherapy and radiation therapy.) Dr. Hong then explains the process by which academic medicine came to recognize medical oncology as a subspecialty. He then explains that many head and neck patients develop second cancers. He defines leukoplakias, the white patches or pre-cancerous lesions that appear in smokers. He explains that he learned about leukoplakias from head and neck surgeons and that these lesions are also associated with Vitamin A deficiencies, a connection that led him to use Vitamin A and its derivatives as chemoprevention agents. Dr. Hong describes the first trials in which patients with leukoplakias were treated with high dose retinoic acid (synthetic Vitamin A) vs. a placebo, yielding a sixty percent response in the former group. This demonstrated for the first time that a chemical treatment could reverse a cancer process. Dr. Hong explains the implications of this discovery as well as how retinoic acid works with cell mechanisms. He also notes that toxicity effects associated with high doses of retinoic acid.
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Chapter 04: Recruited by Irwin Krakoff; Building Research Teams
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
Dr. Hong begins by describing how he became acquainted with Dr. Irwin Krakoff while he was in Boston. When Dr. Krakoff became head of the Division of Medicine at MD Anderson, he saw the institution’s need for head and neck medical oncology and recruited Dr. Hong. Dr. Hong explains that he had reached the limit of what he could do at the Boston Veterans Affairs Hospital, and that MD Anderson was the right place to advance the field by involving more basic and translational research. Dr. Hong describes MD Anderson in 1984 when he arrived: collaborative and committed to patient care, with many resources and good faculty. He saw the need, however, to integrate biology and the basic sciences more fully into clinical care.
Dr. Hong next reflects on how he was able to build sophisticated research teams by reaching out to people. He notes that he was very effective at winning peer reviewed grants, and states that he advocates scientific research that asks bold questions.
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Chapter 05: A Chemoprevention Study and Reflections on Research, Team Science, and Clinical Trials
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
Dr. Hong begins by discussing the first project he undertook after coming to MD Anderson –a study of the biology and chemoprevention of head and neck cancer funded by an NCI Program Project R01 grant. This was a fifteen-year project of almost twenty million dollars that clarified the genetic processes of head and neck pre-cancers and cancers.
Dr. Hong summarizes the personal qualities he has drawn on to create his research projects: talent, passion, and curiosity. He notes that his research areas –organ preservation, chemoprevention, and personalized, targeted therapy—are all difficult areas that present obstacles. He stresses the importance of supportive collaborators, funds, and posing “bold, impactful questions.” He notes that complex studies take time to unfold and require patience, stubborness, and the ability to encourage and sustain the energy of collaborators.
Dr. Hong notes that to open up a field, a researcher must do something new. He recalls a joke: If you are too smart, you can’t do research, and notes the importance of knowing how to articulate good questions. He touches on the challenge of clinical trials and gives an example of the time frames involved in getting clinical results.
Dr. Hong explains that collaborations with talented colleagues are only successful if one shares common goals and recognizes individual contributions. He also stresses the importance of sharing resources and credit to build trust with collaborators. Dr. Hong then makes a few comments on the increase in team science since the 1980s.
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Chapter 06: Early Larynx Preservation and Current Work on Targeted Therapy
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
Dr. Hong begins with a story of his uphill battle to initiate a pilot study of larynx preservation in the 1980s. The project was eventually funded by the VA Cooperative Studies Program [certificate mentioned]. The results of the landmark study were published in the New England Journal of Medicine in 1998. Next, he talks about the BATTLE Project (Biomarker Based Approaches of Targeted Therapy for Lung Cancer Elimination Project (BATTLE –funded by Defense Dept.). With this study he has moved into personalized treatments based on genetic studies that address multiple pathways leading to many different molecular subtypes of cancer. He talks about the challenges this landmark study presents. [There is a brief interruption near the end of this session.]
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Chapter 07: Bold Research: Opening the Field of Personalized Therapy
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
[Note: At the beginning of this Chapter Dr. Hong refers to “my file”: this is a PowerPoint presentation that is available as a supplement to this interview.]
In response to a question about his strategy of asking “bold” research questions, Dr. Hong speaks in detail about his third area of bold research –personalized, targeted therapy. He defines personalized therapy and returns to a discussion of the BATTLE trials discussed in Chapter 7 (Biomarker Based Approaches of Targeted Therapy for Lung Cancer Elimination Project). Dr. Hong describes the trials’ central hypothesis: by acquiring genetic information about a tumor, one can identify what drives the cancer and then hijack it, therefore blocking cancer. He notes that colleagues were very skeptical when he developed the study, but the published results opened up the new field of personalized therapy at an institutional, national, and global level. Dr. Hong notes that he takes a lot of pride in taking this approach from an idea to a force that galvanized an entire field. He believes that this approach can make an impact on cancer science and treatment of cancer at all stages of the disease.
Dr. Hong then notes that as the Institute for Personalized Therapy was being founded, the results of the BATTLE trial gave confirmation that the approach was sound. Dr. Hong explains that personalized therapy requires a different paradigm of treatment and new research modalities based in genomic medicine and he then gives reasons why people were skeptical of the approach at first. He also notes that this approach is fundamentally multi-disciplinary and lists the disciplines that collaborate.
Dr. Hong next speaks briefly about team science –an approach essential to personalized, targeted therapy. He then lists his contributions to cancer science.
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Chapter 08: Administration: Focusing on Collaboration and Education
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
Dr. Hong notes that he came to MD Anderson in 1984 to capitalize on research opportunities but discovered that research was not as collaborative nor as transitionally based as he had expected. He was one of the first researchers to actively reach out to people and also to develop the program projects. In his administrative roles, he actively developed a culture of collaboration: the successes he had with research designed in this way insured that “collaboration was contagious,” with people following the research template he designed.
Dr. Hong also explains that education was also part of the developing culture of collaboration. He names some fellows who have gone on to important leadership positions in the field. He also lists important collaborators with his own projects.
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Chapter 09: The Department of Thoracic and Head and Neck Medical Oncology: Reorganization; A New Fellowship Program
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
Dr. Hong explains the reorganization that integrated the sections of Head and Neck Medical Oncology and Thoracic into a single Department. Dr. Hong headed the section of Head and Neck from ’84 – ’93. Thoracic was included in that section in ’87. The section became a department in ’94 and Dr. Hong was chair until 2001. He explains that he was brought in to head the Section of Head and Neck because of his work on lung and head and neck cancers. Since these were specific to aero-digestive cancers, it made sense to bring in Thoracic. Dr. Hong explains that he developed clinical and research programs. He specifies the links between that integrated these specialties, making it clear that they should be identified as a single unit. (He acknowledges that some physicians still have reservations about sharing their patients, even at MD Anderson.) Trans-disciplinary research depends on a culture of collaboration, which also attracts younger researchers. He notes that the Department of Thoracic and Head and Neck Medical Oncology has been particularly effective at stimulating research. He lists the awards program begun six or seven years ago. Awards to faculty, instructors, fellows, and staff are listed in the annual reports.
Dr. Hong also talks about the Department’s Fellowship program designed to cultivate more young medical oncology researchers. Dr. Hong himself created the Advanced Scholar Program that allows a fellow to extend his or her fellowship period for one year to focus completely on research. He explains why this period is so important for a researcher’s maturation. Dr. Hong also talks about the time, mentorship, and support that physician-scientists need to be successful.
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Chapter 10: Head of the Division of Cancer Medicine
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
Dr. Hong explains that he had no real interest in heading the Division of Cancer Medicine, but he was drafted into the role by the Department chairs (after an external search produced no viable candidates), and their choice was approved by Dr. John Mendelsohn. He took the job out of a sense of obligation to the institution (and took it without an increase in pay). The position allowed him additional opportunities for impact and Dr. Hong explains his commitment to helping departments in the Divison build their team research program. He talks about the process of achieving aligned action among seventeen departments and lists some of the key players in implementing his programs. Dr. Hong next list his accomplishments in the Division: improved quality of the faculty; increased transparency among the departments; raising the bar for research; improved patient care; building the fellowship program; the creation of the Advanced Scholar Program.
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Chapter 11: How Research Has Changed; the Future of the Division of Cancer Medicine
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
Dr. Hong next comments on how the environment and requirements for conducting research have changed, creating “an unprecedented time for translational research.” He observes that one must be opportunistic to survive in the current research landscape. He sees his role as one of inspiring the faculty to open up to the new era of science and research. Dr. Hong then observes that faculty need access to resources to implement their research. With grant monies shrinking, competition is keen, though the NCI and NIH are both encouraging multi-investigator studies more now than in the past.
Dr. Hong observes that he is nearing retirement, and he looks ahead to what is next for the Division of Cancer Medicine. The Division needs a person with passion and great intellectual capacity, he says.
Dr. Hong notes that he continues with his work on chemoprevention and personalized therapy. He uses a football metaphor to explain how he sees his research accomplishments: “I don’t want to take the credit,” he says. “I brought the ball to the 50-yard line.”
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Chapter 12: Administrative Roles; On the MD Anderson Presidents; Looking Ahead to Retirement
Waun Ki Hong PhD and Tacey A. Rosolowski PhD
Dr. Hong explains how he came to serve the role of Vice Provost for Clinical Research, overseeing the institution’s research and laying ground rules for working with patients. Clinical research is “very complicated and requires meticulous attention and rigorous conduct,” he observes. He reviews the range of challenges clinical trials present and also describes the lessons he learned by serving as Vice Provost. Most importantly, he became aware of how much the faculty struggles to conduct research, and his new knowledge of this influenced recommendations he made to the executive administration.
Next, he offers his views on the presidents of MD Anderson. He speaks about Dr. Charles LeMaistre’s role in opening up cancer prevention. Dr. John Mendelsohn was more translational in approach: Dr. Hong notes the similarity in their approaches and backgrounds. (He quips that they play tennis together.) Dr. Hong observes that Dr. Ronald DePinho is a brilliant scientist with vision who fits the institution perfectly. He also notes that Dr. Margaret Kripke was another key leader who understand science and translational research.
Dr. Hong next discusses his role as presidential appointee (under George W. Bush) to the National Cancer Advisory Board (NCAB), a board that reviews research and makes recommendations on allocating funds. He explains process of reviewing proposals (and appeals of rejections). Dr. Hong observes that funding has been flat in the past years and he talks about the impact of this reduction of resources on research. He expresses concern that “America has been powerful and successful because of the substantial funding of research,” but this is no longer the case.
Dr. Hong briefly talks about his work with Chinese cancer institutions while he was President of the American Association for Cancer Research. In 2001 he created a travel fund to bring Chinese researchers to meetings.
Dr. Hong briefly speaks about his retirement plans. He anticipates that he will work with Dr. John Mendelsohn at the Institute for Personalized Therapy.
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Chapter 01: A Family Escapes to Colombia
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter Dr. Hortobagyi describes his childhood Hungary after WW II: the Hortobagyi family was interred in a concentration camp and Dr. Hortobagyi’s father sentenced to three years of hard labor for political differences with the government. (Dr. Hortobagyi explains that he was assigned to work for a townsman collecting manure for fertilizer.) When Josef Stalin died in 1953, the family was granted amnesty and released, and Dr. Hortobagyi next explains how in 1954 the family escaped to Colombia, first walking across the Hungarian border to Austria and settling in a refugee camp, then traveling to Genoa, Italy where the family was able to secure passage to South America as refugees from Genoa. They arrived in Colombia on May 10th, 1957, where Dr. Hortobagyi’s father opened a business in Bogota.
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Chapter 02: Becoming a Doctor
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Here Dr. Hortobagyi sketches his scientific and medical education, beginning with the observation that he never thought of any other profession than medicine even as young person.
Dr. Hortobagyi observes that his mother wanted to be a doctor but couldn’t because of limits on women’s choices at the time. She had an impact on his own choice of profession because she gave him books on science and medicine when he was young.
Dr. Hortobagyi then notes that he had very good science teachers in middle school and, under the Colombian educational system, had made a commitment to his profession by his senior year in high school. He talks about his medical education at the Universidad Nacional de Colombia, Bogota (M.D. conferred in 1970). The Colombian system gave Dr. Hortobagyi an accelerated medical education. By the time he was a college freshman, he had the equivalent of a clerkship at the University hospital –the only charity hospital in the city and the only one with a real emergency room. It was a very busy hospital, and during his clerkship in ob/gyn, the delivery room sometimes handled a hundred babies a day. (At times there were two women in a bed.) By the time he received his M.D., Dr. Hortobagyi had delivered 80-110 babies. Dr. Hortobagyi also explains that surgery attracted him and that he has a “type A” personality, which is perfect for a surgeon. He describes his emergency room rotations: 24 hours on, 12 hours off for ten weeks, a system that gave very intensive hands-on training.
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Chapter 03: A Small Town Offers Good Training
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi begins this chapter with a brief description of some of the rotations he completed at the University Hospital, then describes his year serving as a doctor to the small town of Pacho to repay the government for tuition support.(Dr. Hortobagyi describes how the State assessed tuition based on need and merit: by his second year,Dr. Hortobagyi’s tuition was fully covered because of his exemplary performance.) Pacho is located in the Andes and the tiny town has a 100-bed hospital. Dr. Hortobagyi saw the results of violent conflict between gangs of emerald smugglers. He describes treating the victim of a murder attempt. Dr. Hortobagyi describes treating a woman who was continuously pregnant for eighteen years and had sixteen children.
Dr. Hortobagyi explains that the experiences in Pacho taught him that medicine is an art, not a science. He gives other examples of caring for patients and describes the organization of the hospital in Pacho, where the generator was turned off at night so Dr. Hortobagyi had to study by candlelight.
Dr. Hortobagyi describes how he fit into the social life of the small town and how he came to understand how this situation could be comfortable, but ultimately limiting to his professional and intellectual growth.
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Chapter 04: Choosing to Focus on Cancer
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi explains that once he felt the limitations of small-town medical practice, he applied for residencies in the U.S., first going to Case Western Reserve University to serve at Saint Luke’s Hospital Cleveland, Ohio (1971-’74). (He chose Cleveland because of the large Hungarian community, where Hungarian was even spoken at the MacDonald’s.) At this time he left surgery for a more intellectually stimulating, and began thinking about oncology. He also notes that on recognizing the more generous resources and education available in the U.S., he had a crisis about whether or not to return to Colombia.
Dr. Hortobagyi describes how oncology was the “wild west of medicine” and offered a field where he could bring together his thinking on hematology and immunology. He recalls that, during rounds in the early seventies at Saint Luke’s Hospital, physicians would by-pass rooms of patients with solid tumors. He tells an anecdote about two women with advanced breast cancer who were treated only with morphine. He found an article on chemotherapy and once he began treating women with chemotherapy, they lived.
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Chapter 05: Inspired by Dr. J Freireich
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi recounts how, early in his second year of his residency, he attended an American Cancer Society conference in Columbus, Ohio, where he heard Dr. Emil (J) Freireich give a talk. Dr. Hortobagyi notes that no one was talking about curing cancer in the early seventies, and he describes how inspiring it was to hear Dr. J Freireich state that he believed it was possible to cure the disease.
Dr. Hortobagyi explains that hearing this talk inspired him to apply for a fellowship at MD Anderson. He wrote to J Freireich, who approved hired him without even speaking with him.
Dr. Hortobagyi confesses his love of automobiles and tells an anecdote about buying his first car–a blue Dodge Challenger-with no money and no credit.
Dr. Hortobagyi tells how he loaded his belongings in his car and drove down to Houston, despite the fact that everyone told him, “Nobody goes to Texas.” On arriving, he immediately went to the hospital and introduced himself to the head of the Breast Service, George Blumenschein.
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Chapter 06: Developmental Therapeutics in 1974
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi talks about his fellowship in Developmental Therapeutics (DT, ’74 – ’75), beginning with a discussion of the “serious political split” between the Division of Medicine, which focused on patient care to the near-complete exclusion of research, and Developmental Therapeutics, which focused closely on research. Though Dr. Hortobagyi was interested in breast cancer, Developmental Therapeutics had no access to breast cancer patients, handled via the Division of Medicine, and the head of the Fellowship Program, Ken McCready, assigned him to the leukemia service. Dr. Hortobagyi describes his busy days on this service, then recounts how he was assigned to Developmental Therapeutics’ Outpatient Service. Dr. Hortobagyi describes the influence of Anthony Burgess (head of the Outpatient Clinic) and Jeffrey Gottlieb (Chief of Solid Tumors in Developmental Therapeutics).
Dr. Hortobagyi describes his interest in singing. He sang with the Cleveland Symphony while living in Ohio and he auditioned for the Houston Symphony Chorale and sang with them until 1979. He then explains that he was married in 1976 to Agnes, whom he met on a date arranged by his sister.
Dr. Hortobagyi describes some of the research he conducted while in the Department of Developmental Therapeutics. Dr. Jordan Gutterman recruited him to work on immunotherapy research using BCG (Bacillus Calmette-Guérin). He describes DT as a “tornado of intellectual activity” that nonetheless left him little time for innovation and creative thinking.
Dr. Hortobagyi states that his Fellowship in Developmental Therapeutics prepared him with the basic concepts of clinical research. He describes specific lessons he learned and compares his experience with the more structured training programs offered today.
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Chapter 07: Building Knowledge of Breast Cancer in the Division of Medicine
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi explains that he was focused almost exclusively on breast cancer when he finished the first year of his fellowship in Developmental Therapeutics, at which point he shifted to the Division of Medicine (’75 – ’76). He sketches his research projects: preoperative chemotherapy for breast cancer; clinical trials for adjuvant treatment of breast cancer; developing a database of breast cancer patients. He also describes the vacuum of knowledge about breast cancer among the four leaders of the breast service at that time, noting the main question in his mind, “Who was I going to learn from?”
Dr. Hortobagyi provides background on how George Blumenschein became head of the breast service, though he knew little about breast cancer, then provides a sketch of Blumenschein and of Nylene Eckles [M.D., Ph.D), who headed the service for many years.
Dr. Hortobagyi lists other individuals connected to the breast service who did teach him about breast cancer, despite the lack of immediate mentorship. Dr. Hortobagyi then describes how he organized biweekly case-review meetings for everyone involved in breast cancer to “bring together the discipline. ”He explains that it took ten to fifteen years before everyone felt there was a benefit to this multi-disciplinary review of cases. He also describes the process required to encourage specialists to open up to other specialists. He also reflects on what enabled him to get people to work together.
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Chapter 08: Discovering the FAC Regimen for Metastatic Breast Cancer
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi describes his research into drug combinations for the treatment of breast cancer. He begins by stating that no one discovers anything new in science, but rather integrates and builds on knowledge created by others.
Dr. Hortobagyi says MD Anderson was an exciting place when he arrived in 1974, and the field was progressing. He also notes that the original pioneers were at the peaks of their careers or retiring, making room for new researchers. He summarizes philosophical differences between the Division of Medicine and Developmental Therapeutics, noting that the latter had visionary leaders who provided a unique environment for innovation. “Cancer was no longer a disease with no hope. “
Dr. Hortobagyi sets the context for his research by explaining that, at the time, important drugs had been discovered and needed a champion. His mentors were looking at chemotherapeutic agents, and he put them together and explored what would become the FAC combination treatment. Dr. Hortobagyi provides an overview of the drugs included in the regimen (Fluororacil, Adriamycin, Cyclophosphamide) and explains how they were selected and why that combination proved effective. The FAC regimen is still one of the most effective treatments against metastatic breast cancer.
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Chapter 09: Treatment for Locally Advanced Breast Cancer
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi explains that at the same time that he was working on the FAC regimen (Fluorouracil, Adriamycin, Cyclophosphamide), he was also influenced by one of his mentors, Jordan Gutterman, who was experimenting with immunotherapy. Dr. Hortobagyi added BCG (Bacillus Calmette-Guérin) to the FAC regiment. Though unsuccessful, this study opened a new path, as it revealed that a patient’s baseline immune status determined her responsiveness to chemotherapy. Dr. Hortobagyi explains how this observation led him to look at locally advanced breast cancer (LABC), a disease that required extensive surgery and radiation for little effect on patient survival. (MD Anderson was seeing 300-400 cases per year and still sees many more cases than other cancer institutes: Dr. Hortobagyi explains what causes this disease and why it is so much more prevalent in the South.) Dr. Hortobagyi also observes that medical oncology was not respected in the seventies, but in the case of LABC, they relented. Studies were begun using the FAC regimen for LABC and also inflammatory breast cancer. The multidisciplinary regimen involved the drug regimen, surgery, then chemotherapy. Dr. Hortobagyi explains that 90% of patients had an objective response, with 10% showing a complete response. Patients were less disfigured and showed a much greater survival rate.
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Chapter 10: A Great Step for MD Anderson: Building Multidisciplinary Teams
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi begins this chapter by stating that, in 1975, he was disillusioned by the lack of collegiality at MD Anderson, and so he invited individuals from many disciplines (including Developmental Therapeutics) to discuss cases, explain, their different perspectives on treatment, and collectively determine the best combination and order of measures. Slowly, he notes, they were able to build mutually respectful teams. He describes some of the clinical trials that emerged from the collaborations. Dr. Hortobagyi affirms that this interdisciplinary work represents one of the greatest steps forward at the institution, one that created teamwork twenty years before the creation of the official multidisciplinary breast center.
Dr. Hortobagyi next explains that, in the seventies some leaders at MD Anderson considered randomized clinical trials immoral because they would withhold from some patients’ therapies believed to be more effective than what was in existence. Dr. Hortobagyi himself believes that clinical trials are an important tool for medical science. He sketches the development of thought regarding ethics and randomized trials and explains other reasons why physicians do not believe that randomized trials are necessary. He observes that that oncology is “light years ahead” of the rest of medicine in accepting their value. He tells a story that demonstrates how radiology does not see the benefit; he also notes that there are no controlled trials comparing, for example, proton therapy to conventional electron beam therapy. He sees a similar situation with the treatment options for prostate cancer, and states that it is “tragic” that there is a lack of evidence-based information for major decisions. Dr. Hortobagyi then compares the laboratory research scenario to the complex challenges characterizing clinical investigation of living human systems. He states that much of what physicians do has no basis in fact. He goes on to talk about the economic impact that such decisions can have. He compares the $1000 one might spend on adjuvant therapy to the $200,000 one can spend on a full regimen of neoadjuvant treatment, surgery, and chemo, noting that his group has done cost-benefit studies to insure the money on these treatments is well spent.
Dr. Hortobagyi points out that very expensive treatments cannot always be exported to other institutions. Randomized trials provide a way of determining how effective treatments are at each cost level and therefore provide a logical way of seeing incremental benefit. This provides a sound basis for making decisions on which treatment methods to adopt for the greatest public benefit.
Dr. Hortobagyi explains that he is not a “purist” who insists that every point be demonstrated through randomized trials. He advocates the identification of basic questions and treatment options in each specialty and a strategy of comparing them via Comparative Effectiveness Research methods.
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Chapter 11: Adapting LABC Treatment for Stages 2 and 3 Breast Cancers
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi begins by explaining that the LABC (Locally Advanced Breast Cancer) treatment involved six months of chemotherapy, surgery, radiation, and treatment with hormonal Herceptin. His group then decided to expand the regimen to stage two, and stage three tumors and they designed a national clinical trial comparing the regimen with a protocol that performed the surgery first. Dr. Hortobagyi explains that new regimen offered advantages even though the effects on the tumor were not statistically greater than with surgery first. He points out that it was not possible to do a randomized trial at MD Anderson in the seventies, and so the process of clearly demonstrating the regimen’s value was greatly prolonged. To explain why surgery was the last to participate in randomized trials, Dr. Hortobagyi mentions that a 1980 conference in Tuscon brought the discussion to a head when Dr. Chuck [Charles] Moertel (a proponent) debated the issue with Dr. J Freireich (an opponent). It was clear that most of the oncology community in the country supported randomized trials and that MD Anderson had to evolve. The NCI became involved and spoke to institution leadership about the need to initiate such trials and the culture of the institution changed accordingly.
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Chapter 12: From Adriamycin to Molecularly Designed Drugs
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi explains that he was the first to introduce Adriamycin into adjuvant therapy, responding to the fact that many patients were referred to the breast service after surgery (though MD Anderson surgeons were not referring patients to them). Adriamycin was combined with the FAC therapy and accepted as a standard of care by the 1990s. MD Anderson was also the first institution to report that Taxol was just as effective as Adriamycin when used in the FAC regimen and it was accepted as a new standard. His group then worked with Taxotere, which was demonstrated effective. Research in the eighties was frustrating and his group tested about forty drugs, with little to show for it. He talks about the process of drug development and notes that the community ran out of ideas for a time.
During this same period there was a move to more molecularly designed chemicals as well as the discovery of oncogenes, tumor suppressor genes, and a burst of enthusiasm for the human genome project. This fertile scenario led to the development of the major targeting agents such as Herceptin.
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Chapter 13: The Breast Cancer Research Group –Bringing Together Clinicians and Basic Scientists
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi explains that frustrations with research motivated him to accept a 1990 invitation from Dr. James Cox [Oral History Interview] to pull together a comprehensive group to study breast cancer. The Breast Cancer Research Group linked radiologists, surgeons, and other specialists, as well as basic researchers interested in the disease. This request came at a time that the administration wanted to enhance the quality of research and to make it more collaborative and translational. Dr. Hortobagyi also notes the growing suspicion, at the time, that basic scientists would spend their time doing research for its own sake, without necessarily linking their research questions or discoveries to patient care. He explains that the process for awarding grants prevented scientists from taking bold steps or thinking outside the box. Dr. Hortobagyi describes the challenges of getting the specialties to work together. He describes setting up talks with luminary scientists and researchers –for only very low turnout. Laboratory scientists communicate differently than clinical specialists, he notes. Their days are also organized very differently, which made it difficult to find a time when everyone could gather. In addition, the institution offered no incentives for communication across specialty lines –and he says this is still true. He offers observations on Dr. Ronald DePinho’s support of basic scientists.
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Chapter 14: An Initial Translational Research Project: A Drug to Attack HER2-positive Breast Cancer
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi talks about his first experience with translational research. He explains that while leading the Breast Cancer Research Group, he identified individuals with a collaborative mindset (Robert Bast, Gordon Mills, Mien Chie Hung [Oral History Interview]) and undertook translational research for the first time. They had success addressing resistance to chemotherapy with gene therapy, but the field progressed, and the results were not competitive. Combining forces with Mien Chie Hung, they then used the gene product E1-A to kill cells specific to HER2-positive breast cancer. The procedure worked, but they lacked resources to take the product to the drug phase.
Dr. Hortobagyi then explains that, at the time, individuals and institutions had little understanding about the legal issues attached to intellectual property and about raising money for development.
Dr. Hortobagyi explains that John Mendelsohn changed the Development Office and helped fund drug development. He also hired legal expertise so the intellectual property of individuals and the institution would be protected. Dr. Hortobagyi sketches the costs of drug development, noting that one can only develop a drug by partnering with industry and one “can’t do that without going to bed with the devil.”
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Chapter 15: The Next Phase of Gene Therapy Research and Funding from the Breast Cancer Research Foundation
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi describes the next phase of his gene therapy research. He begins by explaining that the funding organization, the Breast Cancer Research Foundation, was started by Evelyn Lauder when she was diagnosed with breast cancer. Dr. Hortobagyi and others were asked to be scientific advisors. The Foundation brought together powerful women who raised a great deal of money, a lot of which came to MD Anderson. The gene therapy project was also funded by a SPORE grant. Dr. Hortobagyi sketches the state of the gene therapy projects. He explains why it was difficult to secure NCI funding for the E1-A project then discusses why it is so difficult to deliver a gene product. He tells the story of a University of Pennsylvania project in which some children died from gene therapy; an event that helped turn the NCI away from funding this kind of research. He then describes how the Breast Cancer Research Foundation uses different criteria than the NCI to award money to high-risk projects. The BCRF is now funding such areas of research as cancer vaccines, early genetic screening, the development of targeted agents, and diagnostic tests.
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Chapter 16: Studies of Pro-Apoptotic Molecules: Translational Research and Thinking Outside the Box
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi talks about two related studies of pro-apoptotic proteins (which instruct cancer cells to commit suicide) and reflects on the kind of creative thinking that leads to great discoveries. He begins by explaining how he and Dr. Mien Chie Hung decided to submit a “truly different” proposal to the Breast Cancer Research Foundation (BCRF), one based on the observation that a gene product from Adenovirus-5 and E1A could cause HER2 positive cancer cells to commit suicide. This research proposal was partially funded by the BCRF and also by a SPORE grant. This gene therapy successfully transformed HER2 positive cancer from the most difficult to the easiest disease treated and has been applied to head and neck and other cancers. The next project was based on the observation that the Bik protein in the BCL-2 family was pro-apoptotic. Dr. Hung produced the genetic variant, BikDD, with an enhanced destructive effect.
Next Dr. Hortobagyi describes the new view of cancer that emerged in the 1990s as a result of discoveries in cell biology, and how this has influenced research. In the early 90s, he explains, physicians were working with ideas that had been known in the basic sciences at least ten years earlier. Dr. Hortobagyi explains that through his conversations with Dr. Mien Chie Hung, it began to dawn on both of them how to transport the basic science information into a new context. Dr. Hortobagyi notes that it’s “an epiphany” to take a laboratory observation and then visualize its possible applications in clinical settings. He also connects his ability to think in these translational terms to his interest in setting up multi-disciplinary teams. He then explains an “inherent contradiction of translational research”: despite the prevailing wisdom that scientific thinking is disciplined, and logical, truly important discoveries require that you become undisciplined and think outside the box. Traditional thinking leads back to existing knowledge.
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Chapter 17: Thinking Outside the Box to Stage the World Summit Against Cancer for a New Millennium
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
To demonstrate thinking out of the box, Dr. Hortobagyi describes how he and Dr. Charles Jacquillat organized an important millennium event for the Congress of Anti-Cancer Therapy (formerly the International Congress of Neoadjuvant Therapy). He describes the “crazy” way of free-associating that led them to envision (and successfully plan) the World Summit Against Cancer for a New Millenium held in Paris. The event also introduced the Charter of Paris, a list of patients’ human rights. Between fifty and sixty nations sent delegates to sign the Charter; MD Anderson president John Mendelsohn went to Paris to participate in the signing, and there is a photograph of the document in the Rose Building on MD Anderson’s main campus. Dr. Hortobagyi also explains the purpose of the Charter–to draw attention to the fact that in most countries, cancer patients are undertreated, ill-treated, or ignored. He notes that the UACC adopted their Charter and that in 2012 the World Health Organization adopted the Charter as a basis for its continued efforts to encourage governments to improve patient care.
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Chapter 18: Therapy to Block Angiogenesis
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi talks about research on anti-angiogenesis therapies funded by The Breast Cancer Research Foundation. He begins, however, by noting that once he had embraced the understanding that breast cancer is multiple diseases, rather than a single pathological phenomenon, he realized that other colleagues and basic scientists needed to undergo the same “epiphany.” “We all needed to learn more and go beyond our slice of the world” in order for diagnosis and therapy to progress. Dr. Hortobagyi then describes his work on anti-angiogenesis therapy. He defines angiogenesis and lists MD Anderson faculty who have contributed to understanding the process. He then describes early work with Endostatin and Angiostatin, early anti-angiogenesis agents, which never provided adequate results because of their very short half-life. Work on the subject revived when Genentech developed Avastin (bevacizumab), a drug that caused tumor regression, but that also created serious side effects. Dr. Hortobagyi next explains that, with the revival of the field, he and Dr. Hung developed the Endo-CD project (Endostatin-cytosine deaminase fusion protein) which was similar to gene therapy in that it involved molecular manipulations in vivo. He and Dr. Hung worked with molecular processes to make the earlier drug, Endostatin, more effective. He describes the chemical construct they created: a chemical compound with no activity was linked to Endostatin and used as a vehicle to deliver Endostatin directly to tumor vasculature. Another activating agent was then administered to activate Endostatin. With the drug so locally attached to the tumor, side effects were minimized.
Dr. Hortobagyi notes that during work on EndoCD, he was also conducting clinical trials on Avastin. He describes the disappointing results. He notes that the pharmaceutical industry had looked to the drug as a potential “cash cow,” and he explains how the drug became a political issue in insurance reimbursement.
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Chapter 19: A New View of Breast Cancer and Research on HER2 Positive Breast Cancer
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi talks about the next stages for breast cancer research. He first provides a snapshot of how breast cancer was viewed ten to fifteen years ago. He then traces the many forces that came to together to revolutionize the understanding of the disease, which is now seen as many chemically and genetically unique diseases, rather than a single phenomenon. The factors Dr. Hortobagyi lists are a new understanding of the significance o estrogen receptors in cancer cells, the completion of the Human Genome Project, the completion of gene expression profiles of various breast cancers, investments by the government in the ‘war on cancer,’ and the pharmaceutical industry’s investment in cancer treatment drugs. By the mid-2000s, all of this work had led to an explosion of knowledge about the significance of breast cancer subtypes.
Dr. Hortobagyi then talks about his work on HER2 positive breast cancer. He notes that through his work on Herceptin, he was involved in advancing the understanding of this breast cancer subtype. He describes how he organized yearly by-invitation meetings of researchers: this event led to many collaborations that advanced the field. Dr. Hortobagyi then explains that his role in research changed. With more involvement in administration, he did more coordinating and facilitating of research for others. He notes his involvement in national organizations. He explains that in 2005 he joined the Southwest Oncology Group and became chair of the breast cancer committee, responsible for coordinating research. Dr. Hortobagyi comments on how important such organizations are for extending MD Anderson’s reach and to generate enough participants in clinical trials.
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Chapter 20: Breast Cancer Service at MD Anderson in the Late Seventies
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi talks about the state of breast cancer services at MD Anderson and in the country in the late seventies. He begins explaining the position of the Breast Cancer Service within the institution, lists his colleagues, then notes that the non-surgical treatment of breast cancer was evolving in the seventies (and eighties). Dr. Aman Buzdar shared Dr. Hortobagyi’s commitment to research, and they both learned how to treat breast cancer via an “empirical” process that was common in institutions at that time, when medical oncology was not yet a specialty and institutions lacked formal training programs of the type common today. In general, health care institutions were less structured than they are today, and researchers had much more freedom.
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Chapter 21: The Breast Cancer Service: From Section to Department
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi first compares the formal processes by which Section Chiefs are recruited today with the informal process by which Dr. Hortobagyi first came to serve as Alternative Section Chief of the Breast Medical Oncology Service under Dr. George Blumenschein. Dr. Hortobagyi became Chief in 1984 when Dr. Charles LeMaistre removed Dr. Blumenschein. Dr. Hortobagyi then explains how, in 1992, institutional politics drove the re-classification of the Breast Medical Oncology as a Department.
Dr. Hortobagyi explains how his understanding of his administrative role evolved, beginning with his role as Alternative Section Chief, when he was “so junior that he didn’t know much.” Dr. Hortobagyi explains that as he matured, he came to understand that he had his own ideas of how work should be organized. He lists some of his first contributions to the Section/Department: he recruited the first three research nurses to the service; he and Dr. Benjamin worked with the Texas legislature to pass a bill in support of physicians’ assistants and nurse practitioners; he was the first to recruit nurse practitioners; he recognized the need to grow the department to grow the number of grants and research support and he visited other institutions to better understand what a breast center should look like. He describes his “gradual awakening” to the idea that the breast center should be re-thought from a patient-centered perspective. He then strengthened the Department to support clinical research, moved on to build up the educational mission of the Department, and finally integrated translational research into the Department and into the process of recruiting new faculty.
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Chapter 22: Creating a Patient-Centered Breast Service
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi notes that there was huge resistance, at first, to integrating all services associated with the treatment of breast cancer. He then talks about what convinced people this was the best move, beginning with the case of Eva Singletary, a patient who was literally followed throughout her treatment, beginning with the moment she set foot in MD Anderson for a diagnosis. This exercise revealed that the institution was organized in a bureaucracy centered, rather than a patient centered, scheme. Dr. Hortobagyi explains that there was also a rise in patient load and a concurrent rise in MD Anderson’s reputation. MD Anderson faculty were also publishing important research, which drives growth and the institutions’ reputation, Dr. Hortobagyi says. He then goes on to explain how MD Anderson discoveries have indirect effects on patient referrals.
Dr. Hortobagyi explains that, when the new Breast Center was constructed, there was a “retrenchment” as physicians were afraid that they would give up their own territory in a situation based on collaboration. A decade later, the Breast Service is based on a mentality of sharing and shifting traditional ideas of how a service should be run.
Dr. Hortobagyi gives the example of making room utilization more efficient, then explains that in the new “pod” layout of the Breast Center, it is easy to find a specialist for a consultation, sharing weeks of works ups.
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Chapter 23: Regulations on Clinical Trials and New Research Projects in Breast Medical Oncology
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi begins this chapter by talking about how clinical trials helped build a multi-disciplinary mentality in Breast Medical Oncology. He then observes that increasing costs and institutional/national regulations on clinical trials holds back research efforts. He then explains how he developed the research infrastructure in Breast Medical Oncology, beginning with his development of clinical trials with FAC and inflammatory breast cancer. Pharmaceutical companies provided drugs for these trials and other resources. Dr. Hortobagyi describes the different cost components of a budget for a drug trial (nurses, data managers, etc.). As the numbers of trials increased over time, he explains, research simultaneously became more complex, and he gives the example of his first research nurse, who could handle eight or nine clinical trials, while today many more individuals are involved.
Dr. Hortobagyi then gives an overview of regulatory practices governing trials, which also add to the complexity of research. He notes that a few people decided to be “slippery or dishonest,” and their actions resulted in a burden of regulation for everyone that slows research. He also describes how regulation has increased the cost of health care and absorbed the efforts of the best investigators, tapping their energy for tasks that add no value to their research.
Dr. Hortobagyi describes how difficult it was to set in place all the pieces required for an optimal research structure, underscoring how important it was to strategize for resources, efficiency, and to work within budget constraints. He returns to subject of physicians who lack leadership training, and who need these skills to manage complex initiatives. Dr. Hortobagyi gives an overview of the tasks he managed: providing the highest quality of care; insuring that all faculty and staff work at their highest level; influence the development of the Breast Center; increase research productivity, coordinate research activities, ensure that research breaks even; foster careers; educate the next generation.
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Chapter 24: Mentoring, Career Support, and Education in Breast Medical Oncology
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi discusses his efforts to support faculty careers via mentoring and administrative decisions. He begins by noting that the grant application process can be used strategically to encourage faculty to work together.
Dr. Hortobagyi notes that it is very challenging to lead bright people, and a leader must empower then and build on their strengths. He compares the “one size fits all” approach he took many years ago to his newer, nuanced approach of recognizing people’s different strengths. He notes how he developed listening skills. He gives an example of how he continuously challenges people in positive ways so they can stretch, and underscores how important it is for a leader to be transparent about the purpose and goals of decisions to reduce conflict and increase faculty/staff buy in.
Dr. Hortobagyi gives the example setting expectations for faculty on clinical contracts versus those on 75% research contracts. Every month a report shows how much income a faculty member generates. Transparency is important to motivate faculty and to guide them through tenure and promotion hurdles.
Leadership principles are the same in all organizations, Dr. Hortobagyi says. However, it is especially difficult to lead in academic institutions. Dr. Hortobagyi explains why medical academics are “fiercely independent.”
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Chapter 25: Education in Breast Medical Oncology
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi explains that medical education includes two parts: the technical information a physician needs to practice and learning that comes via mentoring. Dr. Hortobagyi describes good mentoring and the kinds of career questions a good mentor can help a fellow or young faculty member confront.
He then discusses principles of research mentoring and how it is connected to funding of medical education after the M.D. He notes that a fellow has six or more years of training after the M.D., but is “still green behind the ears,” a situation in which mentoring is key for preserving quality of care and research.
Dr. Hortobagyi ends this session with the observation that he himself did not have strong mentors, but he observed how strong mentorship influenced the careers of many of his colleagues.
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Chapter 26: A Brief History of Breast Medical Oncology
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi begins an overview of the evolution of Breast Medical Oncology and the Breast Center. He recalls that in the early days, the Department needed to communicate better to develop patient care. As an example, he points out that scheduling sequential consults with specialists could take weeks, greatly slowing progress on a patient’s treatment plan. Bi-weekly meetings were established with all related specialties to aid communication and come up with a majority view of what needed to be come. Dr. Hortobagyi explains the specialties represented and how some individuals resisted collaboration on treatment plans. He notes that it took years for difficulties to smooth out, but that patients were happy and grateful. Dr. Hortobagyi says that the patients had figured out that it was good to get their doctors talking to one another. The multidisciplinary meetings were an educational tool and an instrument for cultural change in the department, he observes. Surgeons had been in charge of managing breast cancer, but slowly imagers and breast medical oncologists made inroads and with good results. He also says that conflict over treatment plans could give rise to clinical trials to prove a point (e.g. demonstrating the benefits of different types of surgery and of integrating chemotherapy at different stages of treatment and in combination with radiotherapy and immunotherapy).
Dr. Hortobagyi describes the successes that came from multidisciplinary discussions of treatment. “We were leaders in breast cancer management,” he says. “Everything we proposed and developed has survived the test of time.”
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Chapter 27: An Overview of Research Issues
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi explains that recruitment of research nurses and research managers was a key to strengthening the research mission of Breast Medical Oncology. He then moves to a related discussion of conflict of interest, noting monetary dimensions of conflict of interest are only “the tip of the iceberg.” He explains that a Principal Investigator has a vested interest in the success of a clinical trial. The research nurse thus serves as unbiased party to collect and manage data. He explains the decision not to permit principal investigators to look at data before all the results of a trial are in.
Dr. Hortobagyi recalls the controversies at MD Anderson regarding the running of clinical trials, which some researchers believed were unethical. The discussions revealed, however, how difficult it is for a researcher to be unbiased and that the process of generating data needed management to insure that results were unimpeachable.
Dr. Hortobagyi notes the reasons why scientific misconduct was not discussed in the 70s and 80s.
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Chapter 28: Physician Extenders and a View of the Coming Physician Shortage
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi explains that he worked with Dr. Robert Benjamin to encourage the Texas Legislature to pass laws enabling the use of physician extenders, then notes that this profession will play an increasingly important role as oncology moves forward. He then moves to a related subject: the shortage of physicians in chronic illnesses. Dr. Hortobagyi explains that he became a ‘pseudo-expert’ in the area when he was president of the American Society of Clinical Oncology and conducted a study which projected that, by 2020, there available physicians would only be able to cover 2/3 of the hours required by patients for treatment. He then lists the causes of this projected shortage and what is going to be result. He observes that Medicare patients are already seeing the effects, as they are having difficulty locating doctors. He also notes that, in the aftermath of the study, little has been done to ease the shortage. “How we deal with that will define us as a society,” he says, and notes the other diseases that will experience the same shortfall as cancer.
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Chapter 29: The Evolution of Breast Medical Oncology and the Breast Center
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi continues to sketch the evolution of the Breast Service. He describes first, tiny Breast Clinic on the ground floor of the Bates Freeman Building, where about 800 patients per year were seen. From there, the Clinic moved (to where the Anderson Network offices are now located), then to the Rose building, then to the Faculty Tower. The faculty made a real effort to influence the design of the clinic when it moved to the 6th floor of the Rose Building. Dr. Blumenschein developed a list of what was needed, but he was unfortunately ignored, though they “got more real estate” and faculty offices were next to the Breast Clinic. Many more advances were made when the Clinic moved the new Cancer Prevention Building. Dr. John Mendelsohn requested input from administrators on design requirements, and Dr. Hortobagyi notes that his was a fairly public and transparent process. Dr. Hortobagyi wanted all functions located in the same area: offices, clinics, surgical suites, radiation therapy, and laboratory research related to breast cancer. (Not all of this was accomplished.)
Dr. Hortobagyi describes the “shift in your mind” that takes place when one adopts a logic of multi-disciplinary care for a service. He describes the importance of collegiality and “geography” for overcoming the “separate republics” that prevent physicians from working together. He reviews what is needed to get people working together, including the development of translational research projects and recognition of the importance of imagers and pathologists to what breast medical oncologists do. Dr. Hortobagyi notes that the Clinic was able to implement multidisciplinary care effectively for the first time when it moved to the Cancer Prevention Building.
Dr. Hortobagyi next notes that the practice of multi-disciplinary care would evolve if medical schools laid the foundation for inter-specialty interaction. He explains how MD Anderson’s compensation system fostered interdisciplinary. He comments on the current administration (of Dr. Ronald DePinho), stating that decisions have been made that will change MD Anderson culture to the detriment of research and education.
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Chapter 30: Stepping Down as Chair of Breast Medical Oncology
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi explains the issues surrounding his decision to step down as Chair of Breast Medical Oncology (effective on 31 August 2012). In part, he realized he no longer wanted the leadership position, he explains. In addition, cultural changes at MD Anderson have created a shift so that businesspeople, instead of physicians and scientists, now lead the institution. He talks about how medicine in general is “in a profound state of disarray,” and these factors dulled his enthusiasm, as MD Anderson is currently asking “how can we function optimally within this (dysfunctional) system,” not “how can we change the system.” He also notes that leaders should not remain overlong in their positions. He lists some of the personal interests he would like more time to pursue (music, literature, poetry, history) and also notes his interest in medical policy issues. Finally, he observes that his professional life took precedence in the early part of his career, and now his private life is perhaps more important to him.
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Chapter 31: Contributions to International Policy Issues
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi begins this chapter on his work with international organizations by explaining why he has such firm professional connections in Hungary and Europe as well as in North and South America, and Latin America. He then talks about the Breast Health Global Initiative (which he co-founded) and a major project: developing guidelines for the treatment of breast cancer, taking into account the realistic availability of resources. Dr. Hortobagyi explains, for example, that in some areas of Africa, a physician may perform a mastectomy as a diagnostic procedure, and the samples must be sent to far-off labs for study, with results coming back after six months. Dr. Hortobagyi explains how the BHGI set about creating guidelines for minimal levels of care for breast cancer where possibility for care is extremely limited. Methods include using physician extenders as well as training women from the local community to give care. The Initiative has also developed research projects to study how to implement the guidelines. Guidelines were developed, discussed, published, and then republished in three different versions after more public discussion. Dr. Hortobagyi describes how fascinating it has been to participate in this project and he hopes it will force governments to rethink their obligations to their populations.
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Chapter 32: The MD Anderson Presidents
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
Dr. Hortobagyi first gives an overview of R. Lee Clark and sketches a portrait of MD Anderson in 1974, when Dr. Clark recruited him. Dr. Hortobagyi tells a story to show how solicitous the Texas Legislature was of R. Lee Clark’s requests for money. He goes on to talk about the many good recruitments Dr. Clark secured as well as his incredible vision. Dr. Hortobagyi then describes the situation in Texas in 1941, when Dr. Clark conceived of the new Cancer Center, then describes his administrative style. Dr. Hortobagyi recalls his fellowship period and notes that Dr. Clark always knew who he was and remembered the project he was working on. Dr. Hortobagyi also remembers that fellows would sleep on a couch in Dr. Clark’s office, and he’d nudge them out in the morning when he came in.
Dr. Hortobagyi praises Dr. Clark’s practice of developing international connections. As a result, he says, MD Anderson trained many international students who became leaders in the global cancer community. Dr. Hortobagyi then shifts to Charles LeMaistre, offering background on his research, then noting that he was a more reserved administrator, with primary skills in political interactions with the Legislature and with higher education. He talks about the difficult years of Dr. LeMaistre’s tenure, when about two thousand employees were laid off, “dampening the spirit of the institution.”
He then shifts to John Mendelsohn, who was able to “lift the institutions spirits in an hour” by going on record and saying that MD Anderson was doing fine. Dr. Hortobagyi give some background on Dr. Mendelsohn’s administration, noting his fundraising skills, his innocence, candor, and ability to talk to anyone. He describes him as “a communicator.”
Dr. Hortobagyi then talks about the growth of the Development Office under Dr. Mendelsohn and his ability to recruit good people. He also notes that Dr. Mendelsohn “didn’t have a mean bone in his body,” which was a disadvantage when it came to making painful decisions. Dr. Hortobagyi offers an example of decision making about laboratory space that was held back because of this limitation. He also observes that Dr. Mendelsohn’s administration was tarnished in the last years of his tenure and that he became more enclosed with his inner circle and lost touch with the faculty. Dr. Hortobagyi then shifts to Dr. DePinho, saying that he was a surprise choice, never having led a patient-care institution. Dr. Hortobagyi hopes that he picks up those skills and that the four missions stay in balance.
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Chapter 33: Fostering Collaboration and Collegiality
Gabriel N. Hortobagyi MD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hortobagyi explains that he is most gratified that he was able together a diverse individuals interested in breast cancer into a collaborative and collegial group. He reflects on his own leadership style: a reluctant leader, but one that is good at organization and gets pleasure from seeing others grow. Dr. Hortobagyi lists some of his leadership principles. In closing, he says that it is wise to remember that one looks good because of others. He makes some comments on awards and notes that he is currently enjoying his “senior statesman” status.
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Chapter 01: A Nursing Student Discovers MD Anderson and Oncology Nursing
Deborah A. Houston and Tacey A. Rosolowski PhD
In this segment, Ms. Houston talks about her family background and the path that led her to oncology nursing. Born into a military family, she moved a great deal as a youngster. As her mother and aunts were nurses, she followed in their path, attended Texas Woman’s University in Denton, Texas. She began to work at MD Anderson while still in nursing school (in ’68 or ’69), choosing Anderson over Methodist Hospital, because of the higher wage ($18/8 hour shift). She describes her responsibilities at this time (dressing changes, for example). When she did her clinical rotation at MD Anderson, she was so impressed with the culture of work and care for the patients that she decided to become an oncology nurse.
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Chapter 02: Why Oncology Nursing is Unique
Deborah A. Houston and Tacey A. Rosolowski PhD
Ms. Houston describes how important a nurse is during the frequent “life ending” situations of cancer. She explains how a nurse gets to know patients and helps them confront all dimensions of their disease, though she also describes how uplifting it is to see patients beat cancer, as she was able to see when working with many lung cancer patients. She gives an example of a life-ending situation with a patient she particularly admired, and who spoke with her about how he could help his family during the rapid progression of his small-cell cancer.
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Chapter 03: Nursing and Nursing Management at MD Anderson in the Seventies
Deborah A. Houston and Tacey A. Rosolowski PhD
In this segment, Ms. Houston talks about the progression of her nursing career. She first summarizes her experiences as Staff Nurse (“72 – ’76), when she worked with a number of units: Surgical, Thoracic, General, and Head and Neck. The separation of these units causes her to observe that although multi-disciplinary treatment was a goal from MD Anderson’s inception, it became a reality in the 90s with centralization of patient services. She also comments on the role of nurses in the team of care providers, noting that before the hiring of physicians assistants, nurses helped physicians manage their patients. Next she talks about her role as a teacher and mentor once she became a Nurse Manager (Head Nurse) in 1976, and she helped nurses under her to learn how to care for lung and esophageal patients. At the time, there were only three people in nursing staff development (now there are over thirty).
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Chapter 04: Nursing Administration and a New Setting of Multi-Disciplinary Teams
Deborah A. Houston and Tacey A. Rosolowski PhD
Ms. Houston sketches the next phase in her career (’79 – ’97): her move from Associate Director of Nursing, to Director of Nursing, and then into the position of Center Administrative Director of Hematology. (She was the first Center Administrative Director.” She summarizes the scope of her responsibilities in each role and then focuses on the restructuring MD Anderson was going through at the time to create “centers” for Radiation Therapy, Hematology, and other services in order to create continuity of care as patients shifted from being in-patients to out-patients or vice versa. This was part of a general institutional push to create “multi-disciplinary care environments.” Ms. Houston describes the reporting chains in these centers and the teams –made up of a surgeon, a medical oncologist, a radiation oncologist and a nurse, among other service providers. She confirms that giving clinics autonomy in this manner represented a cultural shift in MD Anderson, and its goal was greater cost effectiveness. She explains why this goal was not achieved. She then describes the roles that nurses served within the new structure. At the time, leaders in the field of nursing were becoming more vocal about the importance of nurses. At MD Anderson, however, she feels that nurses were involved as an afterthought and because individual physicians understood the role nurses play in organizing patient care, helping the physician to assess the patient, and supporting the patient who must ask the physician about his/her care. At the end of this segment, Ms. Houston talks about her role on the selection committee for the Ethel Fleming Arceneaux Outstanding Oncology Nurse Award, which recognizes the central role nurses play in patient care.
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Chapter 05: Director of Nursing and Center Administrative Director
Deborah A. Houston and Tacey A. Rosolowski PhD
Here Ms. Houston goes into detail about the operation of the different units she administered during the nursing phase of her career. She begins by speaking about the stresses associated with serving as a Director of Nursing ((’86 – ’95) in a “very physician-driven environment.” She notes some of the initiatives she took on: adding services for patients and a mentoring program for nurses, as well as setting up a satellite laboratory on the eighth floor of the Ambulatory Care Clinic. (In-patient nurses would work a week in the Clinic so they could see patients who had gotten better.) She then talks about her role as Center Administrative Director of Hematology responsible for four inpatient units. Most patients, she observes, were involved in research studies, and she describes the difference between nurses focused on patient care and research nurses, but goes on to explain the research element of all nursing at MD Anderson, as clinical nurses help the patient understand the investigational protocol.
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Chapter 06: Inspirations and Observations About Changes in Nursing
Deborah A. Houston and Tacey A. Rosolowski PhD
In this segment Ms. Houston talks about people who inspired her. Renilda Hilkemeyer, “a phenomenal nurse and pioneer,” and the first Director of Nursing at MD Anderson, inspired Ms. Houston to be progressive. She learned how to conduct project and test out new work flows from Joyce Alt, the second Director of Nursing. And her late husband, Gary Houston, the first male nurse hired at MD Anderson and a Nurse Manager, involved her in many programs. This segment also includes Ms. Houston’s observations on how technology has increased the pace of care delivered, creating a rush in the work place and altering nurses’ relationship to patients and each other.
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Chapter 07: A Career Change to Information Systems and the Challenges of New Technology
Deborah A. Houston and Tacey A. Rosolowski PhD
Ms. Houston talks about how MD Anderson did not offer much leadership development support in the seventies. In the mid-seventies, she became involved in the Oncology Nursing Society (at both the local and national level) to build her leadership skills, and also absorbed a great deal via on-the-job training. Summarizing the qualities of a good leader, she says, “A good leader can go on vacation and no one knows you’re gone.”
She then describes her shift in career from nursing to Information Systems: despite the fact that she knew nothing about computers, Dr. Mitchell Morris invited her to come to work on the Electronic Records Committee in 1997 because of her experience with both in-patient and out-patient care and her knowledge of forms and documentation (and because she was a fun person). Next, Ms. Houston describes the first project she worked on as Coordinator of Clinical Systems –Patient Care Information Systems (’97 –’99). She was part of a group comprised of two others from MD Anderson and 4-5 consultants from a software company, and strategized adoption of the Computer Based Patient Records. One of the first tasks, as she said, was to involve more MD Anderson staff and phase out the consultants. MD Anderson was an “early adopter” for technology and worked with software for dictation, pharmacy orders, and records. She stresses that they were looking for software that could assign a patient a single record number that would follow him/her across in-patient and out-patient care. She explains why this is important for patient safety, particularly those receiving chemotherapy whose total dosages must be closely monitored.
Next Ms. Houston explains that Clinical Systems purchased a brand new product from Cerner Millennium [Health Information Technology] (though they stopped implementation a couple of years later). They adopted the Cerner Millennium product to speed requests for records and processing pharmacy orders, as well as to coordinate and consolidate patient care by reducing repeated work. She stresses that the MD Anderson record systems provides data in the form that MD Anderson users need. She is particularly pleased with the electronic reporting of laboratory data and vital signs. In contrast, she outlines the continuing challenges with regularizing data entry for physician dictation. Information Systems has adopted a system form M*Modal that processes natural language. The aim is to move physicians away from their habitual way of dictating to a structured output that can be electronically reported and searched.
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Chapter 08: Recognizing Nurses and Nursing: The Brown Foundation Outstanding Nurse Oncologist Award
Deborah A. Houston and Tacey A. Rosolowski PhD
In this segment, Ms. Houston talks about winning MD Anderson’s first award for an Outstanding Nurse Oncologist (1982). (She has also served on the section committee.) She briefly recounts the history of the award then describes some of the peculiarities: it carried a $10,000 cash award (now $15,000), given at a Board of Visitor’s dinner, but awardees had to keep the honor secret (no longer the case). She describes the criteria used to select the Outstanding Nurse from among the names presented by nomination: going beyond MD Anderson’s very high standards for patient care and also making an impact developing programs and materials.
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Chapter 09: Information Systems at MD Anderson
Deborah A. Houston and Tacey A. Rosolowski PhD
Ms. Houston begins this segment by briefly describing what led her 1997 decision to shift from nursing into Information Systems after agreeing to serve on MD Anderson’s Computer Based Records Project. She then talks about how Information Systems has fit into (and driven) the 2005 restructuring and combining of Departments. She notes that much of her role involves serving as a liaison between Information Services and Clinical Operations and gives the example of working with critical care providers while implementing the Picis system to do preoperative evaluations and various kinds of documentation. She also notes that Information Systems was first perceived as a “top down” initiative, but after the 2005 restructuring, this shifted as “clients” within the institution requested services and support. She explains how IS is funded and how she helps Dr. Thomas Burke, M.D., Executive Vice President and Physician in Chief, prioritize the IS projects funded. She describes some of the challenges of satisfying the requests for IS support. They have funds, but a great deal is already committed to ongoing projects. With the case of Infection Control, for example, they have funds, but not enough people to implement and support a new IS initiative, and contracting this support would increase the price.
Next, Ms. Houston describes the challenges that come from MD Anderson’s desire to always have the newest, most cutting-edge products. In Information Systems, this can mean purchasing newly developed software that may not be ready for full-blown use. The challenge of working with MD Anderson: patients have one record that follows them across inpatient and outpatient care, so providers can keep track of all procedures and drugs given. Chemotherapy administered in the hospital must be added to treatment given in the Ambulatory Care Clinic to avoid exceeding safe dosages. Ms. Houston then talks about how unique the laboratory systems are at MD Anderson and the high volumes of tests they perform, all of which have to be tracked by computer-based patient records.
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Chapter 10: A Reality Check for Information Systems: Building Systems for Teams
Deborah A. Houston and Tacey A. Rosolowski PhD
In this segment, Ms. Houston talks about the role she has served “an interpreter” in building information systems at MD Anderson. She explains that her 27 years of experience in patient care have enabled her to represent users’ needs in Information Systems. When information services are planned, she understands how work flows in clinical situations, how providers integrate record-keeping and data entry into their work day, and how they relate to screens and the organization of applications. While Director of Enterprise Applications in Management Information Systems (’99 – ’05), she also set up a class for technical staff about cancer, so they would have some idea of the real life situations that Information Technology users at MD Anderson deal with. Ms. Houston also notes that on first joining IT she sometimes heard, “What’s that little nurse doing here,” and won respect by performing well also noting the increase in numbers of women in the field and change in attitude. She then expresses concern about how her skill set will be replaced after her retirement, given her unique view and the respect and collaborative networks she has built over the years. In a discussion of ClinicStation software, she gives an example of her ability to facilitate users’ understanding that technology may not be the solution to their problems if what is needed is a change in work process.
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Chapter 11: Medical Records and System Design for Faster Work and Better Patient Care
Deborah A. Houston and Tacey A. Rosolowski PhD
In this segment, Ms. Houston explains a number of devices and services that IS has implemented to facilitate work at MD Anderson. She first talks about the Alkek Hospital Bed Expansion, and how the building’s design made it necessary to give nurses the VOCERA hands-free communication device. She explains why the attempt to install tablet computers in patient rooms to document vital signs and other information was unsuccessful (and how other computers are being installed) and explains the electronic white boards installed to monitor patient status. Next, Ms. Houston explains the decision made in 2005 to adopt ClinicStation. She talks about the assessment strategy and what this software allows. She explains that Information Systems has developed ClinicStation into a certified Electronic Medical Records system that meets government standards, The government takes an interest, she says, because electronic records should bring down the cost of healthcare. At the end of this segment, Ms. Houston talks about how Information Systems customized ClinicStation to suit MD Anderson needs.
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Chapter 12: Information Systems as a Service Provider
Deborah A. Houston and Tacey A. Rosolowski PhD
Next Ms. Houston notes that she plans to retire in three to four years, and by that time she would like to see efficient data entry for nurses and computerized systems for physician documentation, as well as completion of the project, Institutional Bar Code for Patient Safety. All of these initiatives, she says are key to safety and productivity. They are also tangible and achievable goals. As she looks back on goals already accomplished, she pleased to have started the hematology laboratory for patients and also gratified with the success of the Perioperative and Critical Care Informatics group that she directed from ’06 to ’09. MD Anderson faculty and staff are quick to ask for new technology, but the challenge is getting them to actually use it, Ms. Houston says.
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Chapter 13: Perspectives on Changes at MD Anderson Culture and Contributions to the Institution
Deborah A. Houston and Tacey A. Rosolowski PhD
Ms. Houston begins this segment by observing that since the seventies, MD Anderson has grown so much that it is impossible to know everyone, and interactions have become more impersonal. Technology has contributed this, as people email and text one another instead of communicating by phone or fact-to-face. Reflecting on whether the Institution can become too large, Ms. Houston observes that the Regional Care Centers return in a sense to the more personal feel of the old, smaller MD Anderson. In the case of Information Systems, she says, there is no quality compromise as the institution expands into remote units. In the case of overseas units (Global Oncology), she notes there is always a question about whether patient care is delivered in the same way as in Houston.
Next Ms. Houston says that her greatest concern is to find her replacement. She hopes that people in Information Systems will continue to foster a culture in which “everybody has worth” and can feel successful in what they do. MD Anderson has given her tremendous opportunities for success and to make friends. Once she retires, she intends to indulge her love of travel (especially taking cruises), her dogs who are like her children, and her various hobbies such as needlework.
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Chapter 01: Choosing Biochemistry: A Window into the Complexity of the Universe
Mien-Chie Hung PhD and Tacey A. Rosolowski PhD
In this chapter, Dr. Hung traces talks about his life and studies in Taiwan, before leaving for his Ph.D. program in the United States. He first talks about his family and what the perspective he gained on administration from the family business. He notes that his two years of military service (1973 – 1975) taught him discipline. He sings a few bars of “Fools Walk In” to demonstrate his good singing voice.
Dr. Hung then explains why he wanted to be a scientist and traces the growth of his interest in laboratory work and biochemistry from the National Taiwan University (B.S. Chemistry ’73) and Masters (’77). He explains his Master’s project: isolating a protein in snake venom to understand its structure and function as a cardiotoxin. Dr. Hung shares recollections of his student days. He defines primary, secondary and tertiary protein structure.