2009 State-of-the-Institution Address

October 01, 2009

I am delighted and honored to deliver my 14th State-of-the-Institution address as president of M. D. Anderson.

Today I will begin by discussing economic issues because they are the main challenges we have faced together the past six months.

When I stood before you nearly a year ago to deliver this address, I listed a number of financial threats that we must be prepared to meet. Among them were four potential challenges to our income, each of which became a reality within a few months:

• Rising uncompensated charity care.
• A rise in underinsured and uninsured patients, increasing our bad debt.
• A rise in patients insured by government, which reimburses below our costs.
• Postponement or reduction in philanthropy.

At that time, a year ago, I concluded that, and I quote, “we must move quickly to improve efficiency, streamline processes and optimize our use of human, physical and financial resources. Of necessity, there will be some changes in the way we do things, including increased standardization of operations, closer tracking of productivity and adoption of best practices.”

We moved forward to address each of these issues, but not quickly enough.

By March 2009 our financial situation forced us to institute dramatic measures to increase patient care income and reduce expenses. This was a jarring and painful process, but it was successful. In fact, we have achieved a remarkable and exemplary recovery. By the end of the Fiscal Year 2009, only six months later, our growth rate for income had surpassed the growth rate in expenses and our operating margin was secure.

I wish to thank, again, everyone whose efforts contributed to this phenomenal success. The increase in clinical activity we have achieved over the past six months has been the result of a truly remarkable team effort. However, it has taxed the energy of many of our people, as well as the physical limits of many of our facilities, especially our inpatient bed capacity, the Emergency Center and the Ambulatory Treatment Center. Here are some highlights of how our people rose to the challenges:

• Patient access criteria were changed to allow quicker access, and physician templates in the clinics for new patient referrals were expanded. This accomplished, within just a few weeks, a target we had been discussing for a long time: A dramatically successful reduction of average wait times for first appointments from 15 days to eight days, nearly 50% - a major factor in increasing new patient visits. Our faculty, nurses and support staff have served more patients with cancer than ever before in our history, in spite of a hiring freeze and the realignment of some positions.

• As the multidisciplinary care centers increased the volume of new patients, the Emergency Center experienced an unprecedented surge in patient visits. This created tremendous strain on clinical care providers and institutional support systems. Our people pulled together to find creative ways to care for the patients in the Emergency Center, collaborating with other departments such as the Ambulatory Treatment Center and the Symptom Control Center. In addition, with the hospital inpatient census often exceeding 100% and in the face of a severe shortage of empty beds, the inpatient nursing team opened a 10-bed inpatient unit in the Emergency Center to provide care to patients who were awaiting availability of an inpatient bed.

• The increase in new patients dramatically increased the demands on the Pharmacy Patient Resource program, which dispenses drugs provided by pharmaceutical companies – without charge – to help offset costs for patients who don’t have the ability to pay. Using only existing employees, the pharmacy helped a record 4,406 patients, a 54% increase over FY08. They added nine new companies to the program and saved M. D. Anderson $9.1 million in drug costs for uncompensated care.

• And every additional new patient meant more X-rays to be taken and more lab tests to be performed, on services that already were quite busy. But we did it.

History recycles, and our situation the past year is somewhat reminiscent of M. D. Anderson’s situation in 1996, when I arrived. Then, as now, we faced daunting challenges. Then, as now, we expanded our clinical activities and turned around the financial picture, so we could return to our primary goal of doing everything in our power to understand and eliminate cancer. In both cases, our success was due to the remarkable assets we celebrate in our vision statement — the excellence of our people, our research-driven patient care and our science, plus the collaborative and supportive spirit with which we approach everything we do.

Our turnaround in 1996-97 was followed by more than a decade of unparalleled growth and achievement in all four of our mission areas. Today, I believe we can look forward to a similar future by building on the reservoir of creativity and commitment that has always served us so well, provided that we continue to maintain discipline and focus on continuing to balance revenues and expenses.

The lives of people and the lives of institutions are journeys, not static episodes. And all journeys have their ups and downs. M. D. Anderson and its people are no exception. As we seek to reduce the burden of cancer, we are traveling in the current of a river, whose origins we are trying to understand through our research and whose destination we are trying to influence through patient care and prevention. We must be sure the vessel upon which we are traveling is functioning optimally so that we have the best possible chance of achieving our destination, which is our collective mission and the individual missions of everyone at M. D. Anderson.

Let’s talk about how we are moving forward to achieve this optimal positioning for our journey. Many of the approaches I presented a year ago, which addressed all seven goals of our strategic vision, can continue to serve as the basis of our action plans. But we will need to modify some of these approaches, based on lessons learned from our recent experiences.

For our consideration today, I have selected two overarching priorities, patient care and research, because of their central roles in our mission. I always enjoy any opportunity to discuss with you our tremendous clinical and academic achievements and our exciting future plans, and I share your pride in the improvements in patient care and advancements in knowledge that we continue to produce at M. D. Anderson. We do lead our field in the fight against cancer.

But today, I will spend more than the usual amount of time discussing how we do our patient care and research, how we carry out our activities. This is because I believe that our institution, like our nation and the world, is still facing a precarious economic situation, plus the possibility of a major upheaval in health care delivery with unpredictable consequences.

I want to emphasize that we all are stakeholders in M. D. Anderson’s success. I continue to welcome opinions and suggestions from our faculty, administrators, employees, volunteers and patients who care about M. D. Anderson concerning the issues I will discuss.

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Patient Care

1. We must continue to achieve greater efficiencies and productivity in the ways we carry out our individual patient care responsibilities, and in the collaborative efforts that bring us together from multiple disciplines to deliver the highest standard of care to our patients.

Easy to say, but hard to do. Peter Drucker, a management guru, has stated that the most difficult and challenging organization to manage is an academic medical center. Most of us are multi-tasking. For example, the clinician who is striving to deliver optimal care and, concurrently, to discover improved treatments. Or the researcher who is trying over a period of years to discover the answer to a challenging scientific question and, concurrently, is participating in collaborative projects with a shared scientific goal. Or the manager who is called upon to oversee the activities of two care centers that deal with entirely different types of cancer. Many of us are teaching and mentoring, and participating in governance and planning committees. And, of course all of us are living lives outside the institution with family, friends, hobbies and community interests. All of our employees face similar challenges.

Moreover, for many of us, what we do affects the life or death of a human being who has entrusted his or her care to us. Since medical care never achieves the precision and reproducibility of outcomes that a scientific discipline would wish for, we cannot be guided by standardized, rigid algorithms; individual ingenuity must be allowed and encouraged. All of these factors add to the challenge of managing the activities of an academic medical center.

This means that for M. D. Anderson to succeed in its mission, all of our people must be empowered to contribute their ideas, as well as their actions. And all of us must feel ownership and pride in what we are doing — individually and collectively. We are better than most academic medical centers at doing this, which helps account for our number one ranking among institutions that deliver cancer care. But we need to be better than we are.

During M. D. Anderson’s short lifetime of less than 70 years, our people have worked together to achieve some truly outstanding accomplishments: Leading-edge multidisciplinary care in our clinics and multidisciplinary research in our SPOREs and Centers of Excellence, numerous contributions to the standard of care for many types of cancer, and education of thousands of investigators and clinicians active in the cancer field. And much more.

Our recent achievements in the economic sphere were only possible because our people are proud of these accomplishments, believe in our mission and are willing to work passionately to secure and preserve it.

Halfway into FY09, we had substantial negative variances in revenues and expenses, and our operating margin was only $4 million. We had anticipated a margin of $45 million.

Over the next six months, we increased our FY09 net revenues to $15 million above budget and reduced our operating expenses to $6 million below budget, resulting in a positive operating margin by yearend of $169 million. A major philanthropic gift near the end of August provided the final increase in income that pushed our operating margin to this high level, which reached $21 million above budget. The primary movers accounting for the additional net revenues over the last half of FY09 were the nearly 2,000 additional new patients and consults that we served each month, and the additional clinical procedures and diagnostic tests that were performed. In addition, our faculty contributed an impressive increase of $23 million in externally-funded research grants and contracts over the year.

And according to what Raymond DuBois, M.D., Ph.D., provost and executive vice president, and I read in a Oct. 1 newspaper, M. D. Anderson will receive nearly $30 million in funding from the federal stimulus bill, and there’s more coming soon. Congratulations to our faculty.

Our successful plans for increasing clinical activity were developed by Thomas Burke, M.D., executive vice president and physician-in-chief, and his clinical operations team, with the tremendous collaboration of the division heads and department chairs and their administrators, the leaders of the multidisciplinary care centers, and the leadership in nursing. The extensive clinical activity data and the business strategy options needed for this effort were gathered together by Leon Leach, executive vice president, Dwain Morris, vice president and chief financial officer, and the whole business office team. Drs. Burke and DuBois led our planning for temporary redistribution of faculty effort and curtailing of expenditures, to increase clinical revenues and preserve cash. Shibu Varghese, vice president for Human Resources, and his team guided us in carrying out our realignment plan. This was a successful team effort involving everyone at M. D. Anderson, from senior leadership to each individual employee in each individual clinical care delivery unit and research program. I wish I could name today the many thousands of you who contributed.

Because we have achieved our budgeted margin, the various incentive plan targets have been met – a very gratifying situation. This means we not only can say thank you for personal sacrifices you have made, but also we can reward employees with margin-triggered incentive compensation and Anderson cash awards for FY09, which will be distributed shortly.

So where do we go from here? How will we achieve a new, less stressful equilibrium, the “new normal” that we all desire? There is an overwhelming likelihood that, because of persistence of the increase in unpaid patient bills and unreimbursed care, we will have to serve more patients than we did prior to 2009 to maintain stable levels of net patient care revenues. These revenues are needed to support our operating margins, which enable us to recruit, create new programs, and build and repair our facilities.

The average number of new patients and consults seen by the front door clinical departments rose from 5,400 per month to a high of 7,200 per month. This year’s budget, set by the Executive Committee and faculty leaders, is pegged to achieve a midpoint between these two numbers, about 6,300 new patients and consults per month. If we meet this projection, this level of increased clinical activity should maintain the desired balance between revenues and expenditures and generate the targeted 5% operating margin. At the same time, this reduced level of clinical activity, compared to the peak, will allow us to live better within the limits of our human and physical resources.

While new patients and consults are a major driver of activity that can easily be tracked, many other clinical metrics are relevant — such as procedures and surgical operations — and appropriate target metrics for measuring clinical activity will vary from department to department. Each clinical department will be asked to continue to improve its productivity and make efficient use of resources, using metrics appropriate for the kind of service it provides.

It will be the responsibility of each clinical department chair to work with their division head and Drs. Burke and DuBois to develop action plans for his or her physicians and caregivers. They will be asked to develop plans for maintaining clinical activity at or above a midpoint between what was recently achieved and what preceded. In the front door clinical departments, the increased caseloads must be more evenly distributed among the clinical faculty, taking into account each faculty member’s clinical productivity (including the activities of the advanced practice nurses who work with them) and taking into account their percent time commitment allocated to patient care. This will enable faculty, who have been busiest with increased numbers of patients during the recovery period, to reduce their clinical activity and pursue their other missions. In contrast, clinicians who have contributed less to clinical productivity will be expected to step up their patient care activity to meet their agreed-upon commitment of clinical effort. The comparative metrics that chairs and other leaders will need to set the individual clinical care target for each physician are now readily available and kept current. They will be used to set expectations and to determine distribution of financial rewards for successfully achieving targeted goals. Again, let me stress, each department can distribute the clinical workload to achieve its productivity goals in ways that best suit its needs and the commitments of its individual faculty members to this and other mission areas.

Dr. Burke has put into place new patient access criteria that will aid the process of reducing clinical volumes, by curtailing registration of patients who are end stage or who already are on satisfactory treatment regimens elsewhere, and by focusing on patients for whom we can offer the greatest benefit of our care and our clinical trials.

We expect to add some additional clinical employees during FY10, but a smaller number than we added in each of the past few fiscal years. This will take into account areas of high patient demand and the capacity limitations of our facilities, as well as the anticipated rebalancing of clinical activities among faculty. Hiring may vary as data on activity and revenues continue to accumulate over the next three to six months, and naturally it will increase as new inpatient beds are added.

Expenses can and must be reduced in other ways, besides controlling the hiring of new employees. We can continue to improve efficiency of operations, partly by personal efforts and partly through better operating systems. We are asking all clinical units to continue to identify ways to improve their efficiency.

One major improvement will be the installation of a computerized appointment and scheduling system for our ambulatory clinics. This is as important as computerized patient medical records for the delivery of optimal and efficient care at a large medical institution like ours. I have mentioned this in nearly every State-of-the-Institution address I’ve delivered for the last decade. The Clinical and Research Informatics Committee under Dr. Burke’s leadership is planning ways to accelerate the IT project designing our outpatient clinic appointment and scheduling system, working closely with Information Services.

In addition, Dr. Burke’s committee is focusing on projects that are creating our electronic medical record (EMR). In health care today, an EMR is essential infrastructure. The design and application of EMR systems is at the forefront of health care initiatives on a national level. We know that electronic clinical information will be a future requirement by Medicare. An EMR is therefore an urgent, inevitable and necessary element for the continued success of our institution as a leader in clinical care and translational research. Electronic clinical data elements of patient care can provide immediately extractable, reproducible and objective information for making clinical decisions and tracking a patient’s progress. Most importantly, an EMR will facilitate transparent and timely data exchange with our patients’ external providers. An EMR with structured clinical documentation is equally important to our translational and clinical investigators, as it can lead to more effective integration and interrogation of research results and help us to collect the data needed to meet regulatory requirements for clinical trials. It also can facilitate and streamline reporting to clinical regulatory and quality oversight agencies, and improve the accuracy and efficiency of our coding and billing systems.

In 2010, we will engage in the incremental implementation of electronic clinical tools we now have available, and we will step up the completion and dissemination of pilot structured clinical documents that still are in the development and pilot phase. Among the tools that are in active deployment in our multidisciplinary care centers are electronic chemotherapy order sets, consent forms, patient needs assessment and the patient history database. Electronic procedure notes are being tested in the head and neck and cardiology clinics, and some hospital units are testing electronic lab order entry. Primary medical evaluation forms, history and physical exam documents, and consult and progress notes are in programming and development.

To succeed in the crucial transition from paper documentation to a full EMR, we will need the active and engaged participation of all physicians, mid-level providers, and other clinical care employees involved in the process. In the spirit of our core values, I invite and challenge all of you to actively participate in this important change initiative when the opportunity arises. Creation of electronic operating systems for each individual clinical unit at M. D. Anderson requires some customization of the general templates that have been developed. This can only be accomplished through participation and commitment of time by the unit’s clinical team. It will take a few years of hard work, with continued outstanding leadership and support from the Information Services Division. I thank those who already have spent thousands of hours on these projects. Once in place, these new systems will improve efficiency and save time for all of us.

Let me remind everyone that we will be reviewing our Five Year Strategic Vision for Making Cancer History® during FY10, as we do every five years. The second version of our Strategic Vision was published in 2005, with very few revisions of the original year 2000 document. All leaders and managers and many employees will have the opportunity to participate in the current review. We are especially interested in focusing our seven strategic goals and their accompanying strategies on opportunities and constraints that are prevalent today. These may differ from the plans we agreed upon when we began this process more than a decade ago. Today, resources are less plentiful and we are a much larger institution. Both of these realities force us to focus more on selected opportunities for enhancing our mission. In parallel we must prioritize, and agree on reducing or eliminating activities that are not as essential for our mission — a process we began during our realignment efforts over the past six months.

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Research

2. As a second parallel institutional priority of major importance, we must continue to support our research programs, recruit and nurture the very best scientists and investigators, and provide the space and financial resources needed both to support our new recruits, and to enable growth for productive researchers on the faculty.

Three years ago, deliberations with key faculty leaders led to an integrated plan to strengthen and expand targeted research programs in departments, centers of excellence and institutes that gather our research into six overarching themes: basic research, prevention, translational research, clinical trials, health care delivery and quantitative sciences. Our plans are bold and innovative. They have the support of our External Advisory Board and other panels of experts, which we invite to review our research activities. And they have the support of our Board of Visitors, which has passed the two-thirds mark in a campaign to raise $1 billion primarily for research and education at M. D. Anderson over a six-year period.

Dr. DuBois’ efforts to move this research agenda forward were temporarily interrupted by the restrictive measures we were forced to put in place six months ago to reduce expenditures and conserve cash. Researchers on our faculty were forced to curtail expenses and delay some of their plans. Fortunately, due to the turnaround we have achieved, restrictions on research expenditures of institutional funds, grants and philanthropy have been relaxed; professional development activities and associated travel are back in place in accordance with our normal policies; and recruitment of new research faculty is beginning to open up. Depending on our continued positive operating balance during the next six months, which will be closely monitored, we hope to resume recruitments to most priority programs during FY10.

Dr. DuBois is working with the Research Strategies Advisory Committee (RSAC) and the division heads to be strategic in the recruitment of new investigators to M. D. Anderson. We are in a stronger position to attract the very best scientists compared with a decade ago, and we will take advantage of our gain in reputation and research accomplishments to continue to raise the bar. CPRIT recruitment funds also will enhance our ability to recruit the top investigators in the world to join our faculty.

A number of factors need to be taken into account that, overall, could have a very positive impact on our research capabilities and plans.

• We soon will open new laboratory space in two south campus research buildings (SCRBs). SCRB III, which is due to open in 2010, will house the Center for Advanced Biomedical Imaging Research in over half of its space. Three additional floors of unassigned and unfinished research space can be built out when the need is demonstrated. SCRB IV, which will house the Center for Targeted Therapy and the Department of Experimental Therapeutics in the majority of the space, will open in 2011. We also have some areas of unassigned laboratory space on the main campus and on a leased floor in the Texas A&M research building.

• We have land on the south campus to accommodate future construction of additional research facilities. Locations for future expansion on the main campus include our MRI facility, and the sites of the UT Mental Sciences Institute and Dental School, which we have purchased from the Health Science Center. A second basic science research building can be placed in the future on the Dental School site adjacent to the Mitchell Basic Sciences Research Building, and we are committed to expansion of research space for pathology and laboratory medicine on the main campus. Construction funds are included in the final phase of the Capital Campaign, and will be the subject of proposals submitted for federal and state funds. All in all, we can be optimistic that space necessary to accommodate new research facilities and replace outdated facilities can be built over the next decade, if our margins remain stable.

• M. D. Anderson is in a strong position to benefit from the $3 billion Cancer Prevention and Research Institute of Texas (CPRIT) during the next decade. More than 600 proposals are in draft form, and Dr. DuBois is coordinating submission of applications, to meet any limits set by CPRIT and to ensure that we can provide the 50% match of institutional dollars required for CPRIT awards. The first round of applications is due this fall.

• The provost’s team has responded to a number of issues raised by the research faculty. There now is agreement that the Graduate School of Biomedical Sciences will add a second, separate division focusing on degree-granting programs in the clinical sciences and, potentially, population sciences, and a new program in experimental therapeutics is ready for submission to the Regents and the Coordinating Board. Thanks to all the people who worked so hard on those projects. A new institutional mentoring program has been initiated, to deal more effectively with the needs of young faculty who are initiating their research programs in a very challenging funding environment. We are proud that UT System is adopting our mentoring program for all of its branches.

• Today, innovative research requires collaborative projects in the laboratory and in the clinic, yet collaborative contributions generally receive less attention when promotion and tenure is considered. Dr. DuBois is undertaking a thorough review of our criteria for appointments and promotions with input from many faculty committees. Also planned is creation of new titles for non-tenure track faculty that avoid use of the term “non.”

• Our high-potential physician-scientists are receiving special attention from division heads, department chairs and the provost. These include advanced clinical fellows, instructors and beginning assistant professors, who seek to carry out competitive laboratory research, while also providing care for patients. Depending on their priorities and skill sets, these individuals can end up in a number of career pathways, which may, or may not, include directing their own laboratory research programs in space assigned to them. Their training and mentoring need to be specifically geared to their personal career aspirations and their skills. A major goal is for M. D. Anderson to train or recruit additional young physician-scientists who are equipped to make major breakthroughs in laboratory investigation with relevance to clinical oncology, and have the research time commitment (typically more than 75%) and depth of experience to succeed in this goal.

• The career pathway for young faculty who wish to focus their research on clinical trials also will be reviewed and strengthened. The costs of an elaborate institutional infrastructure and the faculty time commitments required for initiating and carrying out clinical trials are both increasing, and they must be addressed. In the spring of FY09 we agreed to curtail the number of clinical trials, and to attempt to initiate trials with the highest novelty and impact. Credit for important contributions in designing and executing these trials needs to be imbedded in our promotion and tenure evaluation process. We must address these topics, because we owe answers to our faculty and because we must live within budget constraints. Let me assure our outstanding clinical investigators that I believe our cutting-edge clinical trials are a major factor in attracting patients to M. D. Anderson, and in meriting our status as the nation’s number one cancer hospital.

• A number of academic programs were especially disadvantaged in their plans for expansion because of the timing of the hiring freeze and curtailment of expenditures. These included the Clinical Cancer Prevention and Epidemiology department in the Cancer Prevention and Population Sciences division; many Centers of Excellence, especially in the Institute for Basic Sciences; and the Bioinformatics and Computational Biology department in the Quantitative Sciences Division. These programs are moving forward, or will do so during this academic year. Dr. DuBois has led us in achieving successful recruitment of outstanding chairs for the departments of Experimental Radiation Oncology; Gastroenterology, Hepatology and Nutrition; Clinical Cancer Prevention; and Laboratory Medicine — a fine track record during a challenging year. Searches are now open for the head of the Diagnostic Imaging and the chair of Epidemiology.

• Dr. DuBois is working closely with Mr. Leach and the business office to obtain a complete breakdown of funds from institutional revenues that are used to support research. The preliminary numbers show a contribution of $167 million to research, exclusive of expenses for indirect costs. Salary support for the research time of clinical and basic science faculty accounts for $66 million, with the majority going to faculty in the clinical departments. When complete data are available at the level of each department and each research program, Dr. DuBois plans to review allocations with faculty leaders to consider the optimal future distribution of institutional funds for research.

• Finally, during a period when the time commitments of faculty and the challenges to our operating margins are prominently on our minds, it is worthwhile for us to carefully evaluate the commitments that faculty and the institution are making to the efforts of M. D. Anderson Global Oncology. Much has been achieved, but some faculty have raised concerns that the current organization of our extramural and global activities may detract from their contributions to our mission. We all recognize the value of extramural collaborations — both clinical and academic — with partners outside of Houston and worldwide. The world's leading cancer center must have robust outreach activities, disseminating our best practices and research capabilities, to merit this level of recognition. And our clinical, research, education and prevention programs have all gained from fruitful external collaborations. After reviewing our experience carefully with all stakeholders, the Executive Committee will decide on the optimal organization of our global activities for the future.

M. D. Anderson has a track record of spending substantial portions of institutional funds generated primarily from patient care revenues on research and other activities. It is worthwhile summarizing these investments for you. The slide shows the total investment of institutional funds in three major areas: unfunded clinical care, research and education. Data from 2003 and 2008 are presented for comparison. You can see that total institutional funding for research has more than doubled, and actually outpaced the 62% increase in extramural funding for research over the same period. The research figures shown here include indirect costs and cost sharing of faculty salaries on grants, which frees up dollars in the grant for use in research. The research figures do not include the capital costs of constructing our research facilities.

Clearly this rate of accelerated institutional support of research must be watched closely, and we must commit to prioritizing use of precious research resources. Again, I will abstract and paraphrase what I discussed in my State-of-the-Institution address last year:

“The Laboratory Space Committee of the Research Council has established metrics and carried out internal peer review of the research productivity of our laboratory scientists, and the Clinical Research Impact Committee has assessed the productivity of our clinical investigators. These data plus the reports from departmental reviews provide assessments of research productivity. The faculty have expressed strong sentiment that the institution should make a greater effort to selectively reward those who are making the strongest research achievements with increased resources and support, including space and protected time for research. This process has begun, and it remains a major goal for Dr. DuBois to continue these efforts, with the clear understanding that rewards to some faculty for excellence in research, such as increased laboratory space or time for clinical investigation, will mean that research resources for others will shrink – all based on peer review. I believe that each faculty member has excellent and valuable skills to contribute to our collective mission, and for some it may be primarily in patient care, education or clinical prevention, rather than in research. We must recognize and reward, appropriately, faculty who make contributions to each of our four mission areas.”

Let me emphasize that we need to act expeditiously, but there is time for Dr. DuBois to work closely with clinical division heads and research department chairs to do this with substantial faculty input and continued peer review, in setting priorities and making the tough choices concerning allocation of our resources.
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This address has not touched on many of the new activities and accomplishments at M. D. Anderson over the past year. Instead, I have concentrated on some key issues we will focus upon together over the coming months, addressing how we carry out patient care and research. I am confident that we have the collective wisdom to plan well and choose wisely, always remaining nimble enough to respond quickly if external events in the national economy or in health care reform take a turn that challenges us again.

I include the yearly updated chart showing our growth statistics over the previous decade. And we continue to surpass all expectations in our record of truly unmatched successes.

Thank you for your dedication to M. D. Anderson and its mission, and for supporting our leaders and each other during trying times, as well as good times. This is an exceptional academic medical center, setting the national and world-wide standard for advancing medical science and patient care in the field of cancer. I am committed to doing everything in my power to ensure that we are secure in this position, and that we will continue to lead in the future, based on the accomplishments of the individuals and teams who work together at M. D. Anderson. I know that each of you join in this commitment. Our patients, and cancer patients everywhere, are the ultimate beneficiaries.

Thanks very much.

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