In late 2010, I was approached about developing, de novo, a NAPBC-accredited breast center at a hospital in downtown San Antonio.  At the time, I had been retired from pathology for eight years and was living on a ranch in the Texas Hill Country.  Understandably, I was reluctant about returning to work (and the big city), particularly since I had only a hazy idea about what a breast center actually was.  Before dismissing the offer out of hand, though, I visited five accredited breast centers—two in Montana and three in Texas.  I was particularly impressed with the breast center at Community Hospital in Missoula, Montana.  The nurse navigator there used the COPE Library as her main source of patient educational material and NurseNav software for tracking patients.  She also showed me the big notebook that she had received during her EduCare training and called it her bible.  I was very impressed with her approach to navigating patients.  In fact, I loved the concept of a breast center with its chief purpose being to assist patients throughout their breast cancer journey.  I decided to accept the job.

In May 2011, I was hired at Metropolitan Methodist Hospital to be the Director of the Breast Center.  On my first day, I was shown to a windowless, closet-sized office on a patient floor.  There were some empty shelves, an empty file cabinet, and sheets of dust on the countertops.  There was no computer; there was no fax machine; there was no printer; there was a phone, but it was not activated.  I was to soon learn that there would be no significant secretarial or marketing support and, most troubling of all, there were no plans to hire a nurse navigator.  What’s more, the person in Administration who had championed the idea of a breast center (and with whom I had interviewed) had just been promoted to CEO at another hospital; the remaining people in Administration had even less knowledge about breast centers than I did—and, as far as I could tell, their other responsibilities were more pressing than the new breast center.

To many people this would have been an unacceptable departure point for establishing a new breast center, and, truth told, a part of me wanted to call it quits right then and there.  But, another part of me was drawn to this seemingly insurmountable challenge.  For starters, no one else in San Antonio had been successful at developing a hospital-based, accredited breast center.  What did I have to lose? Besides, I liked the idea of being my own boss.  That I was the boss of no one in a dusty little room was beside the point—sort of.

Despite my lack of experience, I did have enough sense to know that the glue of any breast center is a nurse navigator.  Soon after I was hired—before there was even an acceptable place to meet with patients—I was able to convince Administration that a nurse navigator was, indeed, essential and began searching for someone who was qualified and might be interested in the position.  At the time, Lorraine Infantino had, among her other duties, the responsibility for administering conscious sedation to patients undergoing stereotactic biopsies.  She seemed like the perfect candidate.  Unlike me (a pathologist who had spent most of her professional career behind a microscope), Lorraine had vast experience with direct patient care.  Much of her career had been as an OR nurse, but she also had past administrative experience, including being the Director of an oncology floor.  Lucky for me, she was interested in the position of nurse navigator but agreed that specialized training was indicated.  Taking at face value the solid recommendation of the nurse navigator in Missoula, we signed up for the August 2011 EduCare training sessions in Atlanta.

That trip to Atlanta turned out to be a watershed event for Lorraine and me.  After just four days with Judy Kneece and her colleagues, we had a much clearer idea about how to proceed with our fledgling breast center—a sharper big picture, you might say.  For me, one of the most important realizations was that no two breast centers are the same.  People involved with developing a new breast center must be creative and resourceful, because what works at one center may not work at the next.  That seemingly self-evident concept gave me the confidence to trust my own instincts and to use old-fashioned common sense when I encountered a problem or identified a need.  Interestingly, this also made me less afraid of making mistakes.  When I was a pathologist, there was zero tolerance for error, but when starting a breast center, trial and error is okay, maybe even essential.  After all, administrative flexibility ultimately furthers the goal of never compromising patient care.

Lorraine came away from her training in Atlanta with a much better grasp of her role as a nurse navigator.  The experience also helped her refine her philosophy for navigating patients:  (1)   while providing emotional support and education, she avoids directly influencing the patient’s treatment decisions or interfering with the recommendations of the patient’s physician(s); (2)   while helping the patient surmount barriers to health care and services, she also attempts to empower the patient during this difficult time by helping her to help herself.  This is done by providing individualized, accurate information and by “greasing the skids” for the patient with phone calls and emails.

So, where are we now?  Well, for one thing, we’ve been out of the closet, so to speak, for nearly a year.  We have a little suite of offices with a patient library and a break room and some nice artwork on our walls.  We have computers and printers and a fax machine.  We hold bimonthly Category 1 CME breast cancer conferences that are well-attended by medical staff and hospital personnel.  Arguably most important, though, is that we now have a champion in Administration.  The significance of this cannot be overemphasized.   And, as a concrete measure of just how much progress we’ve made:  Metropolitan Methodist Breast Center will have an onsite survey for NAPBC accreditation on August 22, 2012.  If successful, ours will become the first hospital-based, accredited breast center in South-Central Texas.  Not bad.  Not bad at all.

Deborah Douglas, M.D. is the Director of Metropolitan Methodist Hospital Breast Center in San Antonio, Texas.  She is an eleven-year survivor of breast cancer, a retired pathologist, and is the author of Foot Soldiers:  Stories from the Breast Cancer 3-Day Walk.