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learning and improving cancer treatments was too long and too expensive, with implications for patient outcomes. As Sue Dubman, now at Genzyme but at one time in the informatics division of the National Cancer Institute, showed me, recruiting patients for clinical trials consumes about 20 percent of the enormous cost of drug development, and the slow pace of signing up doctors and patients causes delays in evaluating new drugs and other treatments. Could these costs and delays be cut? Furthermore, although important information came out of the clinical trials, hundreds of thousands of women were being treated every day and information about what was working and what wasn’t from those everyday experiences was being lost. So, Esserman had two other objectives: to build an informatics system to capture more of the data from treatment outcomes and to increase the ease and speed of enrolling patients in clinical trials.

All of these worthy objectives confronted opposition. Although Esserman ran the cancer center, she did not have line authority or budgetary control over the separate academic departments such as surgery and radiology—each with its own budget and priorities—that would need to come together into a single facility to provide the one-stop service she envisioned. Moreover, UCSF was famous for its fundamental scientific research, and patient care was less of a cultural imperative. Academic medical centers faced financial challenges, particularly in California with its high proportion of health-maintenance organizations, which made investment in informatics difficult. Academic physicians were trained to compete for funding and prestige; that individualistic, competitive culture would have to change if patient data from multiple sites were to be combined for analysis about what did and didn’t work. To compound her other difficulties, Esserman was, by her own admission, quick to anger, impatient, and often neither able nor particularly interested in seeing things from the perspective of others, particularly those she saw thwarting her efforts. At the time I wrote a case about Laura Esserman in 2003, it was unclear how much of her agenda she would be able to accomplish. Many people who saw the case thought her efforts were doomed.3

By 2009, the answer was clear: Laura Esserman was well on her way to doing it all. Already by 2003 she had the facility and brought together the resources that provided patient-centered care and fulfilled the promise of less delay in the diagnostic process from initial symptom through mammography to biopsy and then a plan for treatment. Breastcancertrials.org, a website where patients could enter their own information and get matched with appropriate clinical trials, had been piloted in the San Francisco Bay area in 2008 and was rolling out nationally in 2009, speeding the process and cutting the cost of enrolling patients. And project Athena, an unprecedented effort that brought together five medical facilities throughout the University of California system to build a database covering the treatment of thousands of patients, was well under way, sponsored by the university’s system-wide leadership and encouraged by the UC Board of Regents and its chair, Richard Blum. Laura Esserman had also evolved in her leadership skills. In her story, and in the examples of others we will see in this chapter seeking to build influence and get things done, there are important lessons for everyone attempting to acquire the power to make change and the resources to build their reputation and career even as they overcome opposition and setbacks along the way.

OVERCOMING OPPOSITION: HOW AND WHEN TO FIGHT

Because people come from different backgrounds, face different rewards, and see different information, they are going to see the world differently. Consequently, disagreements are inevitable in organizations. Unfortunately, many people are conflict-averse, finding disagreement disagreeable and avoiding surfacing differences of opinion and engaging in difficult conversations with their adversaries. As school