Switch - Chip Heath [31]
This anxiety-filled process appalled Laura Esserman, and she had a vision of how it could be different. What if there were a breast care clinic where a woman worried about a lump in her breast could walk in at the beginning of the day and walk out at the end of the day with an answer—either knowing that the lump was no problem, or if it was a problem, having a treatment plan already in hand?
The main barrier to this vision was the lack of coordination among medical departments. If they could be integrated more tightly, then weeks of agonizing waiting could be eliminated, the patient would not have to leave the building, and the experience would be designed around the patient’s needs, not the departments’. That was Esserman’s destination postcard, and it was an admirable one.
But as an associate professor at a large university medical center, Esserman was far down the totem pole, with few resources at her disposal. Even if she could start a breast care clinic, she would never be able to hire or fire the people who might work for it, and she couldn’t even set their salaries. The medical departments, such as radiology and pathology, controlled the purse strings and the resources. The two most commonly used descriptions of the medical school at UCSF were “bureaucratic” and “political.” “The departments have money, and the departments have turf, and you can’t bring them together,” said Meredithe Mendelsohn, who became Esserman’s chief administrative director.
Esserman said, “The radiation oncologists report to radiation oncology. The surgeons report to the School of Medicine. The medical oncologists report to medical oncology. The nurses and staff report to the medical center. The psychologists and social workers report someplace else. So it’s an organizational challenge to make people feel like they belong to something.” Because Esserman wielded so little institutional power, her best assets for creating change were her own tenacity and her ability to sell a vision of what breast cancer care could be.
Esserman and Mendelsohn started small. They set up the Breast Care Center to operate for four hours one day per week. They cajoled the medical departments to start working together in more integrated ways. It took practice, and it took persistence. “Radiology, which does the mammographies, works like a train station,” says Mendelsohn. “If your appointment’s at 12:15, you’re seen at 12:15 and that’s how they operate.” But Esserman’s goal was to build treatment around the patients’ needs, and those needs weren’t always predictable enough to conform to radiology’s schedule. Esserman worked with the radiologists to figure out how to create some flexibility in their traditionally rigid processes.
“We couldn’t take up too much of radiology’s time,” said Mendelsohn, so they figured out how to improvise. “Dr. Esserman would see the patient in the morning, and she was the only doctor that would do it—she was the guinea pig—and then she would send them off, say ‘Go have lunch. Go shopping. Come back at 1:00.’ And during lunch time she would go to radiology, where she and the radiologist would sit and look through all of the images and decide what needed to happen next.”
For the first year, the Center stuck with the one-day-per-week model. Then, once the work was going smoothly, Esserman expanded to two days per week. More surgeons started to get involved, and then nurses, and counselors, and support staff, and the snowball began.
Eventually, the Breast Care Center achieved enough success that it was offered an entire floor in a new cancer center being constructed by