EMPIRE BUILDING Jeffrey Romoff and the ascent of the University of Pittsburgh Medical Center Darrell Sapp, Post-Gazette
	Dr. Thomas Starzl talks to television media after a news conference for the 20th anniversary of the first liver transplant in Pittsburgh. THE SERIES Part One: How a stagnant psychiatric institution led to UPMC's growth Tomorrow: 1985-1996, the Presbyterian Hospital complex consolidates and Mr. Romoff becomes president. Thursday: Join an online chat with author Steve Levin about the series
	Online Graphic: UPMC's Hospitals and Facilities
	Photo courtesy of Jeffrey Romoff
	Jeffrey Romoff was the leader of the "The Jeff Romoff Orchestra." A TIMELINE 1981 Transplant pioneer Dr. Thomas E. Starzl hired. 1982 First heart/lungs transplant outside of California conducted at Presbyterian University Hospital, led by Dr. Bartley Griffith. Dr. Thomas Detre named associate senior vice chancellor for the health sciences at the University of Pittsburgh, overseeing schools of medicine, dentistry, nursing, pharmacy, public health and health-related professions. Surgeons successfully implant an automatic cardiac defibrillator for the first time in state history. 1983 Presby opens world's first Specialized Neurosurgical Center, combining standard guided surgery with CT scan imaging. Pittsburgh's first pancreas transplant is done. Through May, Presbyterian University Hospital surgeons had done 49 heart transplants since 1980, and 149 liver transplants and 176 kidney transplants since 1981. Dr. Detre announces plans for comprehensive cancer center for research and treatment that will include all six University of Pittsburgh-related hospitals and CMU scientists in partnership with University Health Center institutions. Jeffrey Romoff's first wife, Vivian, dies of breast cancer. FDA approves cyclosporin for use in transplant surgery. 1984 Stormie Jones, 6, undergoes world's first heart/liver transplant at Children's Hospital; surgery is performed by team of 18 surgeons and nurses led by Dr. Starzl. Mr. Romoff's second marriage -- to Maxine Ketterer, an administrative assistant -- occurs. University Health Center/Eye & Ear Hospital approved for $9 million expansion and Montefiore Hospital for $7.5 million expansion. Dr. Detre named senior vice president of Pitt.

Dr. Thomas Detre and his protege, Jeffrey A. Romoff, were nearly inseparable in the early 1980s. If one was seen walking near the Western Psychiatric Institute and Clinic in Oakland, the other probably was not far behind.

Since arriving at WPIC in 1973, Mr. Romoff had overseen the Detre-ordered revamping of the clinic's medical residency program, and he had provided critical management skills in the day-to-day operation of WPIC.

As the local and national health-care scenes began changing, the two men's relationship deepened and expanded. In their eight years together, WPIC's budget had increased from $6.5 million to about $60 million and federal research grants had gone from an insignificant $200,000 a year to $13 million.

Now Dr. Detre was looking into new fields of medicine, such as liver transplantation, and he saw the emerging trend of managed care as an area of high concern. Dr. Detre needed Mr. Romoff's help in his quest to mold Presbyterian University Hospital and the University of Pittsburgh's medical school into world-class institutions.

The two seemingly had little in common. Dr. Detre, then 59, was an urbane Hungarian immigrant with Old World manners, the respected general overseeing the battle from a distance. Mr. Romoff, then 35, was an arrogant, overbearing New York transplant, the bloodied field colonel, disliked and avoided.

Co-workers and associates from that time describe Mr. Romoff as "abrasive," "loud" and "obnoxious." Because Mr. Romoff was perceived to be Dr. Detre's eyes and ears, people were reserved around him.

Dr. Detre often kept Mr. Romoff behind for "haircuts'' after staff meetings, critiquing him and pointing out when he'd said the right thing in the wrong way. "The fact that it was right doesn't necessarily mean you should be saying it or saying it the way you said it," he told his young associate.

Several times a day Mr. Romoff visited Dr. Detre's office in the WPIC building on O'Hara Street to find out what his boss was thinking.

So it was natural in 1981 for them to discuss Dr. Thomas E. Starzl. The transplant surgeon from Colorado had been hired at Pitt by Dr. Henry T. "Hank" Bahnson, chairman of the surgery department, who had performed the state's first heart transplant in 1968. Dr. Starzl was a risky hire because organ transplants still had an uncertain future -- Medicare didn't pay for them and survival rates were low for some types of transplants.

Dr. Detre and Mr. Romoff believed it a worthwhile risk, envisioning Dr. Starzl's arrival as a boon to the growth and prestige of Presby and the Pitt medical school. Clinical research and tertiary care surrounding a world-class transplant program could generate tremendous revenue. That revenue, they reasoned, could be plowed back into the hospital through the hiring of top clinicians and researchers, whose work could attract patients and federal grants, in turn generating more money. It was the exact model of success they had followed at Western Psych.

Dr. Starzl was known worldwide for completing the world's first liver transplant, in 1963. By 1967, half the liver transplants in the world were performed by teams he trained. During his next 13 years at the University of Colorado at Denver, he led the search for transplant anti-rejection drugs and was founding president of the American Society of Transplant Surgeons.

At the time of Dr. Starzl's hire, Presby's transplant program was oriented toward kidneys, although corneal and heart transplants were done at Eye & Ear Hospital and Children's Hospital, respectively. Dr. Bernard Fisher had performed the city's first kidney transplant in 1964 and by 1981 nearly 60 were done annually.

Dr. Starzl wanted to make Pittsburgh a world center in transplantation. In a letter that spring to Dr. Bahnson he wrote, "It is electrifying to envision the way in which cardiology, endocrinology, hepatology and gastroenterology (as well as nephrology) can be affected if various organs in otherwise well patients can be reliably replaced. In our university and professional lives, I feel that we are in a crusade..."

Making a transplant center
But Dr. Starzl's program initially suf- fered. His first four liver transplant reci- pients died, and he admitted that the program experienced "a slipping of gears." It would be two years before the program truly succeeded, after Dr. Starzl's pioneering use of the anti-rejection drug cyclosporine made Pittsburgh a destination for surgeons from around the world who wanted to learn from his team.

Today, Dr. Starzl says the liver transplant program and the hospital's transplant center "certainly could not have reached the full flower," without the patronage of Dr. Detre and Mr. Romoff.

"Tom and Jeff were the protectors of the program," he said. "I recognized very well that they were joined at the hip; if you were talking to one, you were talking to the other."

By 1983, insurance companies had begun covering the cost of transplants, leading to centers opening across the country. That year, it was estimated that more than 90 percent of the physicians at the country's two dozen liver transplant centers had trained with Dr. Starzl.

Everyone from governors to Fortune 500 executives to foreign leaders used Presby's transplant services, which began generating money that was used, as Dr. Detre and Mr. Romoff had envisioned, to develop more programs and hire more people. Pittsburgh earned the name "Transplant Capital of the World." It was said that Dr. Starzl's work was the biggest economic and prestige boost for the University of Pittsburgh since Dr. Jonas Salk developed the polio vaccine there 30 years earlier.

The revenue infusion began paying off. Mr. Romoff announced in early 1983 that WPIC planned a $3 million, five-story addition to its Educational Research Building. That April, Dr. Detre revealed plans for a comprehensive cancer center for research and treatment that would include the University Health Center -- the six University of Pittsburgh-related hospitals -- plus scientists from Carnegie Mellon University.

By then, Dr. Detre was Pitt's associate senior vice chancellor for health sciences, a position that gave him control over the schools of medicine, pharmacy, dentistry, nursing, public health and health-related professions. Mr. Romoff worked 80-hour weeks during this time of expansion. But while his career was taking off, his personal life was jolted by the news that his wife, Vivian, had terminal breast cancer.

The two had met when they were 16 at a community theater in New York; she was an actress, he played the trumpet. Mr. Romoff was in the school orchestra and earned All-City honors in the school band. Outside of school, he led a three-piece group, "The Jeff Romoff Orchestra," that played the Borscht Belt.

He came from a family of musicians. His father was a studio bassist. An uncle was a conductor on "The Andy Williams Show." His siblings played instruments.

Mr. Romoff had music but he didn't have friends. He was a loner in high school, spending Saturday mornings trying to score tickets to on- and off-Broadway double-features. He has never attended a high school reunion or made any effort to contact former classmates. "The past is past," he says with a shrug. He and Vivian married the summer before Mr. Romoff's senior year at City College of New York. Over the next 17 years they endured several "transitions," as Mr. Romoff calls them, ranging from the birth of two daughters, to buying a house, to moving from Connecticut to Pittsburgh. Mr. Romoff considers life changes and professional conflicts as variations on the same theme.

"In hindsight, [transitions] are always put together as natural acts," he says. "I have had all kinds of transitions. I see them in hindsight as part of the story of my life.''

It's a theme Mr. Romoff has followed since before high school, that life's good and bad moments, as well as professional ups and downs, are isolated events best experienced without excessive scrutiny. It's better to keep looking forward.

Dr. Detre recognized this trait as a positive administrative attribute for building an academic medical center. Another was Mr. Romoff's willingness to carry out his directives, such as firing employees.

Mr. Romoff was smart and didn't mind letting people know it. Dr. Detre also found him to be creative and industrious with a good sense of humor, sides he rarely showed to others.

"Of course he had weaknesses," Dr. Detre said. "The question is, what kind of laundry list do you want? Will everybody love him? No, everybody won't love him. So what? People who are very active in what they are doing obviously have certain personality characteristics that not everybody will like.

"Did I love to alienate people? No. Did I feel that I should tolerate it? Absolutely. If you're responsible for an organization, you have to balance your views about people you work with with the goal of the institution. You can't have it both ways. It's not possible."

Mr. Romoff was more blunt.

"Neither Dr. Detre's nor my public personas were models that were pleasant or whatever," he said. "But the success of Dr. Detre and the subsequent success of myself as a leader has rarely been disputed."

In July 1984, 13 months after Vivian's death, Mr. Romoff, then 38, married 31-year-old Maxine Ketterer, an administrative assistant in the construction and maintenance department at WPIC. At home were his daughters, who were 14 and 5 at the time.

Managed care appears
With stability at home, Mr. Romoff could join the so-called "medical arms race." Large community teaching hospitals, such as Allegheny General, Western Pennsylvania, Shadyside, St. Francis and Mercy, were broadening their services. Now they were proposing to do everything -- including transplants -- within their walls, dimming the differences between them. Advertising increased, focusing on "one-stop shopping" for medical care. Outpatient treatment was adopted as a way to save money. Soon, Allegheny County's four dozen hospitals, clinics and institutes had a surplus of beds.

Spiraling medical costs nationwide led to the growth of managed care, a concept that had been around since the early 1900s.

The Health Maintenance Organization Act of 1973 supported health insurance market competition and made an effort to reduce hospital costs by rewarding physicians for cost containment. Between 1977 and 1987, HMO membership increased from 6.3 million people to 29.3 million.

Consumers, long used to choosing their physician and paying for that service, found themselves bewildered by complex insurance arrangements. New health care industries arose to meet employers' demands for inexpensive care.

Hospitals had to control costs. An added difficulty for the University Health Center hospitals was overcoming the inherent operational differences of its independent institutions. The hospitals -- Children's, Magee-Womens, Presby and Eye & Ear -- had their own boards. Services were duplicated, and sometimes the facilities worked at cross purposes.

Dr. Detre and Mr. Romoff realized that to save money, the health center hospitals had to work together. The two earlier had commissioned a study on integrating Presby and Eye & Ear. It recommended a holding company model with the two hospitals ultimately merging, or sharing services. Dr. Detre and Mr. Romoff believed that route would allow them to replicate their WPIC success of an integrated continuum -- clinical care, academics, research grants and first-rate hires attracting more patients and more income -- on a larger scale.

"I rarely have trepidation about things that are new," Mr. Romoff said. "I have a sense of anticipation, a sense of excitement, a sense of adventure. We understood what worked. We understood that taking clinical revenue and channeling it back to academic excellence, and then recruiting the finest [people] -- we understood exactly how it worked."

The question was how to get there.