Four interview sessions: 19 February 2015, 5 March 2015, 26 March 2015, 23 April 2015
Total approximate duration: four hours
Interviewer: Tacey A. Rosolowski, Ph.D.
For supplementary materials:
Please contact, the Historical Resources Center, Research Medical Library:
Javier Garza, MSIS, firstname.lastname@example.org
About the Interview Subject:
Linda S. Elting (b. 10 February 1951, Houston, Texas) came to came to MD Anderson in 1970, working in coding and data collection in the Department of Epidemiology. She joined the faculty in 1991 as an assistant professor in the Department of Epidemiology and today holds joint appointments in the Department of Biostatistics & Applied Mathematics, the Department of Health Services Research, and the Department of Health Disparities Research. Dr. Elting is best known for conducting research on the value of care and the effects of health policy on delivery of care. Trained as an epidemiologist, Dr. Elting has brought a populations-based focus to research on MD Anderson patients and Texas cancer patients in general.
Dr. Elting retired to part time in January 2014. She served as Chief of the Section of Health Services Research in the Department of Biostatistics and Applied Mathematics from 2001 until her retirement. She worked with MD Anderson’s Institutional Review Boards for many years and served as Chair of IRB IV, created to review protocols for non-clinical and community based research.
Major Topics Covered:
Personal and educational background
Career shift from a classified employee to faculty member
The epidemiological perspective on healthcare issues
Creating a unique niche in epidemiology studies: value of care
Research on treatment for infections, value of care, effects of health policy, Texas health care systems
Training clinicians and researchers to take a population focus on treatment and care delivery
History of MD Anderson Institutional Review Boards
Women’s careers at MD Anderson
Mentoring researchers and leaders
MD Anderson growth and changes to MD Anderson culture
Regarding the Transcript and Audio Files
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.
Interview Session One: 19 February 2015
An Early Interest in Writing Serves a Career in Science
Chapter 01 / Educational Path
Inspired by J Freireich and Doing Support Work for MD Anderson Researchers
Chapter 02 / Joining MD Anderson/Coming to Texas
Finding a Way to Have a Research Career at MD Anderson
Chapter 03 / Professional Path
Earning a Master’s in Public Health and a Landmark Study of Infections
Chapter 04 / The Researcher
A Doctorate in Public Health and Appointment to the Faculty
Chapter 05 / Professional Path
Early Research Studies
Chapter 06 / The Researcher
Research Focus Expands to Risks and Outcomes of Care
Chapter 07 / The Researcher
Interview Session Two: 5 March 2015
A Study of Thrombosis Opens New Research Niche in Side Effects
Chapter 08 / The Researcher
Departing from Epidemiology and Conducting Cost-Effectiveness Studies
Chapter 09 / The Researcher
Research on Health Effects of Policy Decisions and a Study of Childhood ALL
Chapter 10 / The Researcher
Providing Data to Inform Policy Makers
Chapter 11 / Overview
Training Laboratory and Clinical Researchers in a Populations Perspective
Chapter 12 / Building the Institution
Interview Session Three: 26 March 2015
Developing the Ambulatory and Supportive Care Oncology Research Program
Chapter 13 / Building the Institution
Training Clinicians to Think Analytically about Research Problems
Chapter 14 / Building the Institution
Developing Health Services Research in the Division of Cancer Prevention
Chapter 15 / Building the Institution
Institutional Review Boards at MD Anderson
Chapter 16 / An Institutional Unit
Interview Session Three: 26 March 2015
A Brief History of Office Space Occupied
Chapter 17 / Personal Background
A Brief History of Institutional Review Boards at MD Anderson
Chapter 18 / An Institutional Unit
Researchers in Relationship to Institutional Review Boards: A Perspective from an IRB Chair
Chapter 19 / An Institutional Unit
Adding Biostatisticians to Research Protocols Raises the Bar of MD Anderson Research
Chapter 20 / Institutional Processes
A View of Women’s Careers at MD Anderson
Chapter 21 / Diversity Issues
Cultivating Talented People Willing to Dedicate Themselves to a Research Life
Chapter 22 / Researcher
Projects Remaining Before Retirement
Chapter 23 / View on Career and Accomplishments
Overview of MD Anderson Presidents and the Effects of Rapid Growth
Chapter 24 / Institutional Change
Interview Session One: 19 February 2015 (listen/read)
Interview Identifier (listen/read)
Chapter 01 (Educational Path)
An Early Interest in Writing Serves a Career in Science (listen/read)
In this chapter, Dr. Elting briefly talks about her parents then sketches her early educational experiences. She explains that though she took science and math courses, she loved to write and planned on focusing on writing and literature when she attended Lindenwood University in Saint Charles, Missouri. She explains how her skill in writing has served her career in the sciences. Dr. Elting talks about the learning environment and then explains why she returned to Houston to attend the University of Houston.
Chapter 02 (Joining MD Anderson/Coming to Texas)
Inspired by J Freireich and Doing Support Work for MD Anderson Researchers (listen/read)
In this chapter, Dr. Elting explains that after a friend suggested she work at MD Anderson to make money for college, she got a job as a clerk-typist in the Tumor Registry, where she learned about diagnoses, anatomy, and treatment. She tells an anecdote about how she came to attend rounds one day in Developmental Therapeutics. The outcomes for patients that day were particularly bad, she recalls, and Dr. Emil J Freireich [Oral History Interview] talked the faculty to remind that that a cure could be discovered at any moment. She says, “I was a goner,” she was so inspired.
Chapter 03 (Professional Path)
Finding a Way to Have a Research Career at MD Anderson (listen/read)
In this chapter, Dr. Elting explains why she rethought her career path so she could come to MD Anderson and conduct research. She was interested in her work in the Coding Department, where she was recognized, and rewarded. She decided to switch her studies to medicine and thought of applying to medical school, however, ultimately attended Houston Baptist University for a degree in Nursing (BS conferred in 1974). In 1976 she began working at MD Anderson working for Dr. Gerald Bodey [Oral History Interview]. She explains the pharmacological studies she worked on and notes the status of research nurses.
Dr. Elting describes the unstructured environment in Developmental Therapeutics, where it was possible to be innovative. Dr. Elting tells a story of taking such an opportunity to aggregate data on one study when Dr. Bodey was away. She observes that some people thought it was presumptuous to take over a task usually performed by a physician, a fact that led to a divide between floor nurses and research nurses, but that didn’t stop many people from simply taking over a task. Dr. Elting notes that in an unstructured environment, mentoring is unstructured as well.
Chapter 04 (The Researcher)
Earning a Master’s in Public Health and a Landmark Study of Infections (listen/read)
The Professional at Work
In this chapter, Dr. Elting explains the work she did under Dr. Gerald Bodey while also attending the UT School of Public Health to work on her Master’s and supplement the information she knew she lacked. She talks about the open environment that provided her with a good learning experience. She notes that she was interested in infections caused by multiple organisms. Dr. Elting explains that she did a large study of polymicrobial septicemia, which still may be the largest study ever conducted.
Next Dr. Elting explains the main lessons she learned during her Master’s program: that she could offer clinicians a view of entire populations (rather than a focus on individual patients); that she could strengthen studies by insisting that the basic research question be articulated. She also explains that she learned to communicate effectively with clinicians and non-biostatisticians by using graphic charts and pictures, rather than tables of numbers.
Chapter 05 (Professional Path)
A Doctorate in Public Health and Appointment to the Faculty (listen/read)
Dr. Elting begins this chapter by explaining that her Master’s program gave her confidence in the quality of her own research questions and helped spur her to pursue doctoral work.
Dr. Elting explains why she never considered leaving MD Anderson.
Next she sketches the skills her doctoral program helped build, particularly computer skills. She observes that computers were not much in use in research at MD Anderson during the eighties.
Next Dr. Elting explains MD Anderson rules that made it difficult for her to be promoted to the faculty. She also notes that it was difficult to get some physicians to see her as a colleague when they had known her for years as a nurse/technician. She describes her duties once she was promoted to the faculty.
Chapter 06 (The Researcher)
Early Research Studies (listen/read)
In this chapter, Dr. Elting talks about research studies she conducted just after receiving her DrPH. She worked on two emerging types of infections (alpha streptococcal infection and pseudomonas maltophilia) and explains how here research was constructed to enable her to draw solid conclusions about infection risk factors.
Dr. Elting notes that she conducted this research with Dr. Gerald Bodey’s research money, then explains that she was able to get an independent grant to study how to effectively present data from clinical trials so clinicians would understand and use it. She designed a study using comparing the use of numbers versus pictures in communicating information about drug toxicities and patient responses. It was clear that pictures worked best, and Dr. Elting’s conclusions were adopted at many other institutions. Dr. Elting notes that MD Anderson has always been “behind the curve” in adopting medical records systems.
Chapter 07 (The Researcher)
Research Focus Expands to Risks and Outcomes of Care (listen/read)
Dr. Elting begins this chapter by explaining that the threat of infections was decreasing and so she expanded her research focus to supportive care. She transferred to the Department of General Internal Medicine (GIM) and worked with the Ambulatory Treatment Center.
Dr. Elting notes that she was advised to begin working independently of Dr. Gerald Bodey, as many professionals attributed her research to him because of their long working relationship.
Dr. Elting explains that in GIM she conducted research on nausea and vomiting. She also developed an interest in effectiveness, efficiency, and cost and conducted time/motion studies and studies to demonstrate the effectiveness of expensive drugs that insurance companies were unwilling to cover. She began to study economics.
She then makes observations about her own learning and mentoring styles.
Dr. Elting discusses the first study she conducted independently of Dr. Gerald Bodey: a study of the frequency and outcomes of thrombocytopenia (low platelet count) and the cost/benefits of transfusion versus drugs to treat the condition. This study brought her recognition and established her as the primary researcher in the field of risk and the outcome of care.
Interview Session Two: 5 March 2015 (listen/read)
Interview Identifier (listen/read)
Chapter 08 (The Researcher)
A Study of Thrombosis Opens New Research Niche in Side Effects (listen/read)
Dr. Elting explains how her study of thrombosis in cancer patients enabled her to establish a new research niche.
She explains how her study of thrombocytopenia led to her interest in thrombosis and helped shape her approach: looking at individual patients at MD Anderson and carefully describing symptoms in this large population in a way that had relevance to current practice. This was the beginning of her focus on side effects, she notes.
Next, Dr. Elting compares her approach to the typical retrospective study often conducted by fellows. She notes that the most frequent question she received from reviewers was, Are these symptoms as bad outside of MD Anderson, in ordinary practice? She explains why MD Anderson has a different patient population, but notes that it was possible to generalize this information to the general population and she began to look at expanding studies accordingly.
Chapter 09 (The Researcher)
Departing from Epidemiology and Conducting Cost-Effectiveness Studies (listen/read)
Dr. Elting talks about how her interest in value of care evolved.
She sets context by noting that in the 2000s many states began requiring that hospitals report the quality of results, making available data about procedures and surgical outcomes. Dr. Elting was able to look at toxicities that caused death and fees for procedures. She explains that expensive and effective new drugs were available to treat toxicities, but insurance companies were unwilling to cover the cost. She says that she initiated cost effectiveness studies to demonstrate that the more expensive drugs ultimately saved money. Her studies were very successful at convincing payers to change their policies. She then talks about the reactions of her colleagues to her change in research direction.
Dr. Elting explains that this research took her away from traditional epidemiology and allowed her to differentiate herself, a fact that was critical to her success.
Dr. Elting tells a story about a period when General Internal Medicine didn’t have enough beds because they were filled with patients made too sleepy to function by their anti-toxicity medications.
Chapter 10 (The Researcher)
Research on Health Effects of Policy Decisions and a Study of Childhood ALL (listen/read)
In this chapter Dr. Elting talks about her current research focus on the health effects of policy decisions made by state and local governments.
She begins by noting that there is no federal health policy in the United States, so policy decisions made at a “semi-macro level” have an effect locally on subpopulations. Dr. Elting gives an example from Texas health care.
Dr. Elting explains that to study these effects, she began to study outcomes by volume of cancer procedures. She then gives an example of a study she conducted on the availability of mammogram machines across Texas, showing that in areas with no machine, patients suffered more late-stage breast cancer. She notes she is currently working with a pediatric surgeon looking at pediatric cancer in Texas.
Dr. Elting notes that few families can afford care for childhood cancer. She explains the funding of the study and its impact. She gives an example of partnering with the University of Texas Medical Branch to produce video talks and other educational materials for communities and primary caregivers. She mentions some other efforts to disseminate information beyond academia.
Dr. Elting talks about why Texas is an interesting state to study and why it allows conclusions about how barriers to care operate and affect outcomes. She talks about interventions her office has helped to create.
Chapter 11 (Overview)
Providing Data to Inform Policy Makers (listen/read)
Dr. Elting begins this chapter by talking about how the Affordable Care Act has had an impact on the study of health outcomes. She also notes that the ACA has provided an opportunity for her to provide information to the state legislature in Austin and influence the conversation about healthcare. As an example of the issues she might take on, she explains her work on Medicaid has shown that people who have gaps in insurance coverage have worse outcomes than those with continuous coverage. The latter is ultimately more cost effective.
Next Dr. Elting talks about the mechanisms her office uses to deliver information to Austin. She explains that, as a public institution, MD Anderson can only educate, not lobby. A report goes to every legislator. Individuals specifically interested in public health receive an email and those who interact with legislators on behalf of health issues also receive information.
Chapter 12 (Building the Institution)
Training Laboratory and Clinical Researchers in a Populations Perspective (listen/read)
In this chapter, Dr. Elting talks about Project 4, a training initiative run by Dr. Carlos Barcenos to inform junior faculty about health policy issues and encourage them to integrate a population-focus into their thinking and research. She gives examples of how they encourage this integration and how the training changes the faculty’s thinking about resource allocation, the cost of care, and what insurance can and cannot accomplish. Dr. Elting explains that the participants will become leaders in their fields and educators of the next generation of oncologists, so this training is key to shift their practice and contributions to how the healthcare system works.
Interview Session Three: 26 March 2015 (listen/read)
Interview Identifier (listen/read)
Chapter 13 (Building the Institution)
Developing the Ambulatory and Supportive Care Oncology Research Program (listen/read)
In this chapter, Dr. Elting talks about her roles as Director of Clinical Epidemiology and Informatics within the evolving Ambulatory and Supportive Care Oncology Research Program (1992 – 1998), housed in the Department of General Internal Medicine.
She explains the vision and goals of this new research program, designed to provide data to guide initiatives to de-hospitalize chemotherapy patients to outpatient status and she brought quantitative methods to this clinical department.
Dr. Elting talks about research conducted when a new group of antibiotics became available, making it easier to treat infections and fevers in chemo patients. She explains that the research conducted in the new program shifted the standard of care from inpatient to outpatient treatment. She notes that this was considered “a wild and crazy thing to do,” very risky and dangerous.
Dr. Elting talks about how the study offered a leadership opportunity. She reflects on the success of the program.
Chapter 14 (Building the Institution)
Training Clinicians to Think Analytically about Research Problems (listen/read)
In this chapter, Dr. Elting talks about how expanding General Internal Medicine’s research program allowed her to train clinicians in analytical thinking. She explains how physician’s generally think about clinical problems, defines what analytical and quantitative thinking are, and the effect that training in these methods has on clinicians.
Dr. Elting ends this chapter by explaining what she learned from working with clinicians in this way. She notes that her role as Director of Research (1998-1999) in the Section of General Internal Medicine was simply an expansion of her role as Director of Clinical Epidemiology and Informatics.
Chapter 15 (Building the Institution)
Developing Health Services Research in the Division of Cancer Prevention (listen/read)
Dr. Elting talks about her role as Chief of the Section of Health Services Research (2001 – 2013) and explains the department affiliation.
She sketches the research focus on the outcomes (including economic and business outcomes) of treatments, not the treatments themselves.
Dr. Elting explains why she was selected to take on this role and how she was asked to head the section and “go find a department to be in and make us famous.” She explains why she identified the Department of Biostatistics and Applied Mathematics as the most likely home.
Dr. Elting then sketches this administrative history of the Departments of Biostatistics and Applied Mathematics. She describes the challenges of finding a way to work with other department members whose perspectives were different and notes a landmark moment of finding common ground for collaboration.
Dr. Elting notes that her appointment to the role of Vice Chair of the Institutional Review Board raised the profile of Health Services Research and further credentialed her and her Section.
Chapter 16 (An Institutional Unit)
Institutional Review Boards at MD Anderson (listen/read)
Dr. Elting sketching her role in MD Anderson’s Institutional Review Boards, including establishing a new IRB when the board overseeing clinical research didn’t serve the needs of non-clinical researchers. She talks about the role of the research review committee (PBHSRC) that also looks at protocols.
Next, she sketches a history of IRBs at MD Anderson, first established in 1966, before the federal requirement to establish such review processes. She explains how attempts were made to create effective processes that would not slow research.
Next, Dr. Elting explains the value of IRBs and traces how their role has changed as more resources have been provided to support monitoring.
Dr. Elting explains that the computer system that enables efficient entry and management of data has lagged behind the development of IRB processes and causes problems with the system. She also notes that when HIPAA requirements were set in place without consideration for researchers, they “crippled” the IRB.
Interview Session Four: 23 April 2015 (listen/read)
Interview Identifier (listen/read)
Chapter 17 (Personal Background)
A Brief History of Office Space Occupied (listen/read)
Dr. Elting begins this funny chapter by announcing that she has “done some homework.” She goes on to explain that she has had twenty-four different offices at MD Anderson, two of them in buildings that were ultimately imploded. She notes that the fact that she was asked to relocate before the implosion, and jokingly adds that she sees this as proof that the institution values her work.
Chapter 18 (An Institutional Unit)
A Brief History of Institutional Review Boards at MD Anderson (listen/read)
Dr. Elting begins this chapter by reviewing the proliferation of IRBs at MD Anderson. She discusses the reasons why they were necessary and how they have emerged as pressures on researchers were changing. She explains why the mid-nineties were a key time for rising resources to fund IRB oversight. She explains that when HIPAA went into effect, MD Anderson’s Compliance office became more concerned about adherence to proper policy.
Next Dr. Elting talks about the need for IRB oversight given ethical issues that have arisen with the increase in genetic/genomic research and increases in projects involving ‘big data’ requiring that personal health information moves from institution to institution.
Chapter 19 (An Institutional Unit)
Researchers in Relationship to Institutional Review Boards: A Perspective from an IRB Chair (listen/read)
In this chapter, Dr. Elting responds to the observation that many researchers have an adversarial view of IRBs. She underscores the importance of training in IRB issues and then explains that she was responsible for formalizing MD Anderson’s IRB training program for new faculty members and research nurses.
She explains her strategy of addressing IBR mistakes while she served as Chair (Institutional Review Board IV, 2003-2005). She gives examples of the kinds of issues that would arise and explains why they appear, particularly in the social sciences departments.
Dr. Elting notes that the IRB she chaired was formed to handle issues arising from research projects, such as hers, conducted in the community with non-MD Anderson patients. She explains the issues that would arise and gives examples of creative solutions to these unexpected situations.
Chapter 20 (Institutional Processes)
Adding Biostatistician to Research Protocols Raises the Bar of MD Anderson Research (listen/read)
In this chapter, Dr. Elting explains how it became a requirement to include a biostatistician to all MD Anderson research protocols. When Dr. Don Berry was recruited to head the Department of Biostatistics, this new requirement was a condition for accepting the position.
Dr, Elting agreed with his requirement and talks about its significance. She explains how important a biostatistician’s view can be in designing and protocol as well as interpreting data. (She comments on the design of research conducted by pharmaceutical companies.) She talks about the positive effect on MD Anderson research.
Dr. Elting observes that PIs were at first skeptical, because they didn’t know how they would pay for biostatistics services, but Don Berry secured substantial funds from MD Anderson to provide this support free of charge and most people were happy to have the help.
Chapter 21 (Diversity Issues)
A View of Women’s Careers at MD Anderson (listen/read)
Dr. Elting offers observations and personal experiences to illustrate changes in the climate for women at MD Anderson.
She talks about challenges when she was not accorded respect or opportunities. She notes that she was the fortieth woman at MD Anderson to be promoted to full-professor.
Dr. Elting observes that the executive leadership at MD Anderson expresses concern about women’s representation, but this was not repeated at the mid-level of management until Dr. Elizabeth Travis [Oral History Interview] began working on advancement for women. Dr. Elting explains why she was reluctant to align herself with the Women Faculty Organization and Women Faculty Programs. She observes that women have an equal chance at becoming a department chair, but not at rising any higher. She explains why this is the case.
Dr. Elting points out some differences in the ways that men and women look at their subject matter, particularly the way men are quicker think in entrepreneurial ways about their work. She explains how she developed this perspective.
Chapter 22 (Researcher)
Cultivating Talented People Willing to Dedicate Themselves to a Research Life (listen/read)
Dr. Elting talks about her mentoring strategy of identifying talented people who can dedicate themselves to the demanding life of a researcher and principle investigator. She talks about the role of senior faculty in weeding out junior faculty who will not be worth a department’s investment.
Next, she explains that leadership involves a wide range of skills, including presentation and fund-raising skills and the ability to sell their ideas to for-profit companies.
Dr. Elting observes that too many women accept roles that involve a lot of work, but that do not showcase their skills. She talks about her style of mentoring women for leadership.
Chapter 23 (View on Career and Accomplishments)
Projects Remaining Before Retirement (listen/read)
Dr. Elting first talks about the writing and research she will focus on in her remaining time at MD Anderson. She notes that she is very proud of her work on the Institutional Review Boards (she was the first woman chair of an IRB) and her early work on treatment outcomes. She says she never realized how much her work on controlling infection effectiveness mattered until her mother was treated for cancer.
Dr. Elting recalls that when she came to MD Anderson nearly everyone died from infection. She notes that it could be a depressing place, but the researchers and support people who stayed helped each other through that time and achieved great things.
Dr. Elting also observes that she was one of the first people at MD Anderson to look at health issues from a population perspective. She is pleased at how far the institution has come in supporting that research.
Chapter 24 (Institutional Change)
Overview of MD Anderson Presidents and the Effects of Rapid Growth (listen/read)
Dr. Elting begins this chapter by sketching the approaches of MD Anderson’s presidents. (She worked under all of them.) She observes that R. Lee Clark was primarily focused on patient care. Dr. LeMaistre [Oral History Interview] was an “ambassador president” who worked well with the University of Texas System. Dr. Mendelsohn [Oral History Interview], she says, brought a research perspective and now Dr. Ronald DePinho [Oral History Interview] is moving MD Anderson into new areas of science.
Dr. Elting states that MD Anderson’s next challenge is to determine how to function as a research institution and deliver care at the same time. She explains how MD Anderson has “seesawed” between these two poles over time. She observes that the negative press the institution is receiving is a function of the institution growing big very rapidly in an environment of financial complexity. She asks, How big is big enough? She observes that the institution has lost its cohesive feel. She compares MD Anderson with the Dana Farber Institute, which has remained small and focused.