Her first “light-bulb moment” occurred sometime on a Friday morning in the spring of 1999, probably in the stairwell between her tiny, windowless office on the second floor of the new Halifax Infirmary and the hospital’s Heart Function Clinic two flights up.
Dr. Gabrielle Horne was on call at the clinic that morning—the nurses would page her if a patient needed a doctor—but her thoughts were elsewhere. She was editing a research paper but also, and more importantly, trying to come up with a proposal for her first grant application since returning to Halifax.
Horne is what is known as a “translational researcher.” While she did see clinic patients, her larger role was to go away and think about their problems from new angles, use the questions generated by those clinical experiences to shape her research and, ultimately, to translate her results back into hands-on patient care—as she explains it, “to make a difference for the patients themselves.”
In 1998, Horne had arrived in Halifax, where she’d already done some cardiology training. Armed with a medical degree from the University of London in England, a PhD in cardiology research from the University of Calgary (where she’d also completed her residency training in internal medicine) and a two-year cardiology research fellowship at Indiana University, Horne was ready to begin her medical research career at Dalhousie University and the Capital District Health Authority.
As a relatively untried newcomer, she understood she would have to jump through hoops to get research grants. “The trick for a beginning researcher,” she explains, “is to draw on what you know, but do something a little new. There has to be an element of risk involved, of course, but it should be low risk —no one wants you to fall flat the first time out.”
What could she do that would draw on what she knew—her expertise was in cardiac imaging—be new but not too new, and still make a difference? She was in the middle of pondering that question when she was interrupted by a page from the clinic. Could she see a patient?
The patient had had a heart attack in 1982 that was so massive his heart function was “barely compatible with life.” Still, he’d not only recovered but managed to live symptom-free for the next 17 years. A quarter of patients with similar problems end up back in a hospital within six months of the first attack. This man was in the clinic for the first time since 1982. Horne interviewed him about his symptoms of fluid build-up and worked out a treatment plan. It was all very routine.
She was about to return to her office when the nurse asked if she could see one more patient. This man had suffered a mild heart attack just 18 months earlier but never completely recovered. He’d had frequent episodes of fluid overload in his lungs and body, and been in and out of hospital on a regular basis.
Horne couldn’t help but be struck by the contrast—one patient, with severe heart problems, does “fabulously” for 17 years; another with what, on the surface, appears to be a much less life-threatening condition, spirals downwards….
The cases appeared to defy conventional wisdom, which is that heart failure is caused by a deterioration of the pumping capacity of the heart muscle, which results in the loss of the heart’s ability to pump blood to the body. The problem with that is that medicine usually can’t stop this deterioration, only slow it down. Horne considered. Was there some other factor at play in the case of the first patient, some mysterious something taking up the pumping slack inside his heart? What about the…? What if she…? Could it be…?
By the time she got back down to her office that morning, Horne already knew the subject of her first research grant application. This project, which she concedes now was based on little more than a “hunch,” would be more than “a little new.” But, if her hypothesis was right, it could actually make a difference for heart failure patients.
Gaby Horne’s second light-bulb moment occurred in the middle of a fall morning three-and-a-half years later. This moment would not seem nearly so magical.
It was the morning of Thursday, October 17, 2002. Horne was juggling triage duties in the hospital’s emergency room with routine issues back in her lab when she got a call from her secretary. The secretary had just gotten a call from Horne’s department head. Dr. Horne was to drop whatever she was doing, the secretary said, and return to her office to read an email that was waiting for her on her computer.
Waiting for the too-slow elevator that was the first stage of the five-minute journey back to her office in her lab on the eighth floor of the Abbie Lane Building, Gaby Horne understood and, at the same time, did not have a clue about what was happening and, more importantly, was about to happen to her.
On the surface, Dr. Susan Gabrielle Horne —Dalhousie’s first female MD/PhD in adult cardiology—appeared to be a walking advertisement for the sound judgment of her employers, Dalhousie University, where she held an academic appointment as an assistant professor of cardiology, and the Capital District Health Authority, where she was the director of the QE II Health Sciences Centre’s innovative new Cardiac Imaging Lab.
In the three-and-a-half years since her first light-bulb moment, resident cardiology trainees had chosen her as their “teacher of the year,” the faculty of medicine had awarded her a five-year, $450,000 Clinical Scholar Award to allow her to spend 75 percent of her time on her research and the hospital’s department of medicine had picked her for its Research Excellence Award.
Perhaps more important, Horne’s initial research proposal—based on her hunch that the septum, a complicated muscle wall between the heart’s receiving and pumping chambers that Horne calls the “cardiac gymnast,” might be helping the heart in cases like the patient who’d been symptom-free for 17 years compensate for sudden changes in pumping function—had generated more and larger grants, morphing into a full-scale multidisciplinary research lab with its own sonographer and nurse, as well as researchers and students from computer science, biomedical engineering and cardiology. Initially, they’d had to develop their own software and build their own equipment—including one piece constructed from a Wal-Mart vacuum cleaner and a specially designed kayak skirt The Trail Shop had ordered for them from BC—but as the buzz about the research grew, companies began to call to offer free equipment. A Dalhousie press release described the lab’s researchers as “global pioneers in a new area of heart failure research.”
The excitement wasn’t surprising. Heart failure is the number one cause of hospital admissions in the western world, including in Nova Scotia, generating a “tremendous amount of suffering and cost.” If Horne’s hypothesis was correct about the role of the septum, then perhaps it would be possible to compensate mechanically for the heart’s failures, changing the way the septum functions inside the heart, protecting the patient from those sudden changes that too often lead to instability and sickness.
Horne is quick to admit she wasn’t “the only person who wondered about the interaction between the heart’s chambers,” but researchers had largely neglected the role of the septum, so it was still “an unknown quantity. If we could find a way to compensate for that, we would solve a problem that really mattered to patients,” Horne explains. “It wasn’t abstract…I felt so privileged to have the chance to be doing this kind of research.”
Horne herself had become one of the medical school’s “good news stories.” She was the chair of Research Awareness Week, and did public relations for the annual Molly Appeal in support of the Dalhousie Medical Research Foundation.
“Overnight,” Horne marvels today, “you go from being a good news story, getting grants, everyone encouraging you…to persona non grata.”
It wasn’t exactly overnight. During the previous year, she’d come under increasing pressure from Dr. Blair O’Neill, the head of the Cardiology Division, to include Dr. Jonathan Howlett, the director of the Heart Function Clinic, as a “prominent” part of her research team. Howlett was himself a well-known researcher who specialized in the management of congestive heart failure and had established the hospital’s heart function clinic the year after Horne was hired.
Horne resisted. “I had a lot of collaborators,” she explained. “I’d put a lot of thought into how to put the team together, to get the right expertise, the communication skills we needed…I told him I’d made my choices.”
There is nothing new about a researcher choosing who she or he wants to work with, Horne notes. She’d once been on the wrong end of such a choice herself. “I’d approached a scientist to talk about his research in hopes of collaborating with him. I thought it was a natural fit. He went away and thought it over, and then came back and told me he didn’t want to go that route. I was disappointed but it was his choice.” She pauses. “I mean, I can’t imagine the sense of entitlement…” Her voice trails off.
Things became so tense Horne, at the insistence of a colleague, hired a lawyer to protect her interests. “I’d rather have a root canal than talk to a lawyer,” Horne says with a laugh. Eventually, she confronted O’Neill and said, “Let’s sit down and work this out, or else I’m out of here.”
“It seemed to be worked out after that,” she says. In September, in fact, she’d returned from a two-week vacation “optimistic” about the future. “But it quickly became apparent that the division head”—Horne carefully describes O’Neill and Howlett only by their positions “to avoid impugning the reputation of another physician”—wasn’t in a “let’s-work-this-out mode.”
On October 8, 2002, Howlett wrote a letter to Horne in which he expressed “concerns about your pattern of behaviour and interpersonal actions, which are a concern to me.” Two days later, Howlett wrote to complain about “your behaviour, personal interactions and conduct” in the clinic and listed eight specific “failures.”
As the conflict escalated, Horne contacted the Canadian Medical Protective Association, a physicians’ self-help organization set up to protect doctors’ integrity, and they dispatched a second lawyer to assist. “I knew I had a problem when lawyers began giving me their cell phone and home phone numbers, and saying, ‘Call me if anything happens.’ I thought, ‘This is not good.’”
Now, sitting in her office Thursday morning trying to read between the lines of the email—which demanded that she attend a meeting with Howlett the next morning at 8am—Horne admits she was “freaking out from all this unbridled aggression and craziness.”
When they did finally meet the next day—with the hospital’s lawyer present— Horne says she experienced another “light-bulb moment. It was clear to me suddenly that this was no longer a situation where I was in a conflict with a professional colleague. This was a situation where I was in a conflict with the hospital. I was seen as an employee, and the director was management.”
On Monday after lunch, Horne was summoned to a meeting with Dr. Elizabeth Ann Cowden, the head of the hospital’s department of medicine, who’d spent the morning meeting with O’Neill, Howlett and another senior cardiologist who was critical of Horne.
Horne’s lawyer, Ron Pizzo, who accompanied her to the meeting, tried to ease her concerns. It will probably just be a meeting where everyone puts their cards on the table, he’d said. “Nothing’s going to happen.” He was wrong.
After a 20-minute recitation of the allegations against her—which had suddenly escalated into new and more damaging charges, including that her research conduct threatened the safety of patients and that she’d breached research ethics in handling patient charts—and a cursory invitation to rebut them, Cowden told her that she was unilaterally “varying” Horne’s hospital privileges on an emergency basis.
“In view of the concern for patient safety,” she wrote in a letter following the meeting, “your clinical duties are being reallocated… You will cease participation in those clinical services where team care is the existent model…effective immediately.”
By banning Horne from treating patients in the clinic, which is where she got her research patients, Cowden, in effect, shut down Horne’s “pioneering” heart research program.
A doctor’s hospital privileges are considered sacrosanct. Unilaterally altering them without a formal hearing is usually only done as a last resort in an emergency—to prevent a drunken physician from wielding a scalpel on a patient, for example. The idea that Horne’s case constituted such an emergency seemed preposterous. “It was quite clear,” Horne says now, “that the facts had nothing to do with it. They didn’t give a toff about process.”
Still, there was now a process. Under the health authority’s bylaws, the hospital board’s Medical Advisory Committee had 10 days to investigate the appropriateness of the variation of Horne’s privileges. Its report would then be submitted to the hospital board’s Privileges Review Committee, which had another 10 days to review the decision and make its recommendation to the board itself.
Twenty days, a month at most, reassuring colleagues told Horne, and it will be over. And she could back to her lab.
They were wrong. It’s been three years and six months. And there’s no way of knowing when, or if, Horne will ever get back to her research.
Perhaps the most frightening thing about what has happened to Gabrielle Horne is that it appears to be happening to other researchers, including at Dalhousie.
In March 2004, the National Review of Medicine reported on a British study that found that “stress and bullying are common problems” for post-grad medical research fellows like Horne. Thirty-eight percent of British researchers questioned in the study—who complained about “belittlement, public humiliation, unjustified criticism, intimidating use of disciplinary procedures, threats, exclusion and name calling,” among other abuses—said they would not recommend their position to a colleague.
The situation for medical researchers working in teaching hospitals is complicated because they usually hold joint appointments at the hospital and university. Their bosses at the university and the hospital will often be the same person with different titles—Cowden, for example, was the chair of the department in the faculty of medicine at Dalhousie and the chief of medicine at the QE II—with very different powers. Within the university, Cowden’s powers were tightly circumscribed by faculty unions and academic freedom; in the hospital there was no union, and her word was law.
And not just in the case of Gabrielle Horne.
On the very day Cowden varied Horne’s privileges, she did the same to an oncologist and medical ethics specialist named Michael Goodyear. The ostensible issue in that case was a dispute over chemotherapy dosages, but it too seemed to have as much to do with the fact that Goodyear, who has been described as “abrasive,” rubbed some people the wrong way.
But not everyone. Goodyear was the oncologist for the late Nova Scotia premier John Savage during his cancer treatment, for example, and Savage’s son, Mike, says he was “very compassionate without providing false hope, very competent and responsive… He and Dad got along very well. provided unvarnished factual info, which Dad craved, and yet provided a sense that there were things that could be done when that was indeed the case.” Savage, now a federal MP, says he wishes Goodyear well and “hopes his ordeal ends as soon as possible.”
Like Horne, Goodyear’s ordeal is ongoing. Less than a year after losing his privileges, Goodyear was removed from his position as research ethics chair—despite a letter of protest from all the committee’s members as well as several former chairs—and told he could no longer treat patients at all. In December 2003, he was locked out of his office and was eventually forced to declare bankruptcy.
Goodyear, who is still fighting the case, declined to be interviewed on the advice of his lawyers, but James Turk, the executive director of the Canadian Association of University Teachers, which has taken up the cudgels for both researchers, calls Horne and Goodyear “canaries in the mine.”
As word leaked out about what was happening to Horne and Goodyear, Turk says he got at least half a dozen calls from Halifax-based researchers with similar concerns. Some, he says today, have since left the province to continue their careers elsewhere.
Gabrielle Horne’s own case was initially taken up by the Medical Advisory Committee, which advises the hospital board on issues of patient care, teaching and research. The committee could produce no evidence to support allegations that Horne’s research was compromising patient safety, but recommended remedial action for what was described as her “lack of collegiality.”
The case was then passed on to the Privileges Review Committee, another board advisory committee that considers issues involving hospital privileges. After what Horne calls “a six-month scab-picking exercise” that resulted in no conclusions, both sides agreed to a CAUT-suggested mediation with Toronto-based Martin Teplitsky, one of Canada’s most successful arbitrators, who has solved disputes at institutions as different as Air Canada and the University of Toronto.
On June 6, 2003, the parties—Horne and her lawyer, Ron Pizzo; Cowden, Capital District Health Authority CEO Donald Ford and two hospital in-house lawyers; and Dalhousie’s academic vice president Sam Scully and university lawyer Karen Crombie —met in Halifax with Teplitsky to begin discussions. CAUT’s Turk, who had meetings in Toronto that day, was planning to fly to Halifax that afternoon to join the talks but he got a call shortly after noon telling him not to bother. They had already reached a settlement.
The settlement, drafted by lawyers for Capital Health and the university, declared that “the parties agree that this is a full and final settlement of this matter and that neither party shall take any action against the other.” Under the terms of the deal, the two sides agreed that they’d resolved all of the “research protocol issues” and that Horne would return to the heart function clinic as an attending physician. Horne had to borrow Ford’s pen to sign the document.
Almost eight months after Horne’s privileges were suspended, they had a deal.
Or did they?
It turned out that, according to the health authority, the deal wasn’t a deal after all.
After months of fruitless negotiations over the role of “mentors” mentioned in the agreement—Horne says she was quite willing to agree to having clinical and research mentors but they couldn’t agree on mutually acceptable candidates—Horne’s lawyer became so frustrated he went to court to force the authority to live up to the deal.
In court, the health authority’s lawyers argued—incredibly—that its chief executive officer, Ford, didn’t have the legal power to negotiate a settlement on behalf of Capital Health. The settlement was nothing more than a “proposal” that might form the basis for a “proposed settlement.” The “full and final settlement”—as it had been described in the agreement—would first have to be considered by the Privileges Review Committee and its report sent to the board for its consideration before there could be any end to the dispute.
Although Justice Donald Hall noted in his February 2005 judgment that the authority’s in-house counsel “appeared at first to have taken the position that the negotiated settlement was a binding agreement,” the law was on the authority’s side. The hospital CEO didn’t have the legal power to make a deal on behalf of the hospital board.
“I regret that I have had to come to this conclusion,” Hall wrote, “as it appears to me that the matter has been going on for an unduly lengthy period of time, which undoubtedly is involving great expense to the public and Dr. Horne, as well as hardship and stress for all.”
For all, of course, except the lawyers. According to estimates compiled by CAUT, Capital Health had been spending half a million dollars each year on outside lawyers—not even counting the costs of its in-house legal team—since the dispute began. That money, CAUT’s James Turk pointed out, could have paid for 92 hip replacements, or 57 heart bypasses, or 229 cataract surgeries.
Making a difference for patients in a very different way.
In January 2004, CAUT announced what it described at the time as the “largest investigation” it had ever undertaken into the Horne and Goodyear cases. But Capital Health refused to cooperate since CAUT, which represented the researchers in their roles at the university, didn’t have jurisdiction within the hospital. According to Dr. Andrew Padmos, the health authority’s vice president of research and academic affairs, CAUT “have the same jurisdiction in cleaning up the harbour as they do in this issue.”
To make matters worse for Horne, Capital Health informed her in June 2004 that it would no longer provide “bridge financing” to keep her lab staff and trainees in place until the privileges issue was resolved. Horne’s lawyer wrote to the board asking them to intervene, “but their lawyer returned the letter to us saying their clients were not concerned with such matters.”
The following spring, after the courts had ruled in favour of the health authority, CAUT wrote to then-premier John Hamm, imploring him to intervene because “at some point responsibility has to be taken for restoring a broken system.” CAUT also attempted to put pressure on Dalhousie, which it claimed had recently moved from being “an ineffective defender of its faculty member to one of her attackers” by rescinding Horne’s clinical scholar award because of “her failure to report significant research activity.” CAUT’s letter described Horne’s treatment as “Kafkaesque.”
Many in the hospital’s medical staff agreed, and worried about what the hospital’s treatment of Horne and Goodyear might mean for them.
In the summer of 2004, five of the hospital’s most senior doctors called an emergency staff meeting to discuss the issue. The hospital refused them permission to meet at the hospital, so more than 120 doctors and other medical staff trudged through the rain to Dalhousie’s Tupper Building so they could talk about their concerns. The result of that meeting was the re-establishment of the district’s Medical Staff Association, which had become moribund after Nova Scotia’s health care system was reorganized in the late 1990s, concentrating power in the hands of the new capital district authority.
On October 20, 2005, three years less a day since the suspension, the newly revitalized staff association made an announcement. It was appointing three respected, retired physicians and its president, Dr. John Sullivan, who, coincidentally, was himself a former head of the hospital’s cardiac surgery division, to investigate the allegations against Dr. Horne.
Ironically, Sullivan says, few medical staff, even within the cardiology division, knew the details of the allegations against Horne. “No one really talked about it so, when I went into this, I went in with an open mind.” He approached members of the board’s Privileges Review Committee. “I asked them point blank if they knew of any smoking gun here, anything that I should know going in. They said, ‘We can’t tell you.’ It was all about confidentiality. But we looked at all the evidence, everything, and there was nothing there. There was no smoking gun.”
Its December 5, 2005, report was unequivocal. After examining all three allegations against Horne—that her research threatened patient safety, that she’d breached research ethics and that she lacked collegiality—the committee found “no documentation to support the allegations… All the evidence presented indicated that Dr. Horne’s research program functioned in the same manner as that of other members’ research programs in the clinic and division. Dr. Horne was transparent with her colleagues and attempted to involve them in reviewing her studies.”
The committee’s report shows that, within days of the suspension of Horne’s privileges, 22 of about 30 doctors in the cardiology division wrote letters of support for her, and members of her research team came forward to say the charges against her were bogus. “I am honoured to be part of her team,” wrote one. Added another: “I have never worked for anyone who is more sensitive to the needs of each individual…In my opinion, allowing this to continue another day is giving permission to those in positions of power to act without any validation or accountability.”
The committee concluded that the allegation that Horne lacked collegiality was “nebulous and the most difficult to address,” but it added the charge was “not substantiated nor consistent with the documented history of Dr. Horne as a highly valued resident and Fellow; with the high regard for her by the nursing staff and patients; with the adulatory letters of commendations” her bosses had written before her privileges were varied; “with the large number of individuals who wrote letters corroborating Dr. Horne’s collegiality, and finally and most importantly, by the fact that Dr. Horne had developed multidisciplinary research collaborations requiring significant collegiality, transparency and compromise.
“Dr. Horne had developed a unique, externally funded research program that has been irreparably altered,” the committee concluded. It said the health authority should “expeditiously re-examine these issues and reinstate Dr. Horne’s full privileges.”
That didn’t happen. “We went to the chair of the board with our report and he refused to look at it, refused to even read it.” Sullivan pauses. “This whole thing,” he says with disgust. “It’s fueled by the lawyers. They’re getting rich off this. The board didn’t even know what was going on.”
The Canadian Association of University Teachers, stymied by its failure to get cooperation from the health authority or action from the provincial government, which argues it has no authority in the dispute, stepped up pressure on Dalhousie to put pressure on its partners at the Capital District Health Authority.
In November, it wrote to university president Tom Traves, threatening to censure Dalhousie if it didn’t press for what it calls “procedural fairness” and do more to support its beleaguered medical faculty member. Such a censure could have profound consequences for Dalhousie—under censure procedures, CAUT’s 48,000 academics across Canada would be urged not to accept appointments at Dal or participate in university academic conferences, and academics world-wide would be asked to do the same.
Perhaps not surprisingly, Dal did respond—Traves wrote to the authority’s board chair, expressing the university’s “profound and continued concerns” about the treatment of Horne and Goodyear—but it wasn’t quite enough to convince CAUT to rescind its threat. Last weekend, the matter came up at CAUT’s regular executive committee meeting in Ottawa. Although it held off on proceeding with the formal censure process until November, it pointedly warned Dalhousie it expects action—and soon.
In the three-and-a-half years since Horne’s hospital privileges were unilaterally—and supposedly temporarily— altered, both Elizabeth Ann Cowden, the chief of medicine who varied Horne’s privileges in 2002, and Donald Ford, the CEO whose signature on the 2003 settlement agreement was repudiated by his own bosses, have resigned their positions.
For her part, Gabrielle Horne says that after all this time she’s “lost any personal connection with the way life used to be, and now it’s impossible to conceptualize what the future might be.” But she can’t quit, even if she wanted to. “Until this is settled,” she says, “I couldn’t get privileges anywhere else. I have to clear my name, or I’ll never get out from under.”
Geoff Wilson, a senior communications advisor for Capital Health, says the procedural universe is still unfolding as it should. The board’s Privileges Review Committee has finally filed its report with both parties and it has been referred to the full board—“the final decision maker” in the process—for review.
But Horne says she and her lawyer are challenging its report for focusing on “alleged collegiality problems” while giving short shrift to the reality it found no evidence to support the allegations that her research exposed patients to risk, which, she notes “was the primary reason for the variation of my privileges.
“The report is not a basis for settlement,” she adds, noting that the “only basis for a settlement would be complete re-establishment of the research program, to the point where it would have been if none of this occurred.”
Dr. John Sullivan, the staff association’s president, has read the privilege committee’s massive, three-inch thick report. “It is very damning,” he says, then adds, “and it’s a piece of junk. Ground zero, the only thing they can say is that she didn’t show the proper respect and deference to her peers. Three- and-a-half years later, and the best they have to justify what amounts to a case of professional homicide is that Doctor A can’t get along with Doctor B…That’s it. That’s all.”
The still-unanswered question in all of this, of course, is why. Why did this happen in the first place, and why—after the board’s own medical advisory committee cleared her of violating patient safety and ethics rules, and after Elizabeth Cowden and the board’s CEO signed off on a settlement agreement to end the dispute in June 2003, and after the hospital’s medical staff association independently exonerated her after its own investigation—is it still going on?
Why is Dr. Gabrielle Horne not back in her research lab doing research that could make a difference for patients?
Perhaps because this dispute seems so otherwise inexplicable, there have been dark hints—but no evidence—that there’s more to the case than we know, or can be told. “Although he refused to get into details,” the Daily News reported on June 24, 2004, that Dr. Andrew Padmos, the authority’s vice president, insisted the complaint against Horne “was not simply a case of professional jealousy. ‘This is a lot more than anything that could be characterized as short term, or silly, or insignificant,’” he told the newspaper.
Officially, the Capital District Health Authority still says it “won’t be offering comment or opinion on any details that are part of the ongoing deliberations.” As for why it’s taken so long, its spokesperson will only say that, on various occasions, both parties agreed to waive the timelines for resolving the issues.
Horne says that’s bunk. While she concedes she did ask for extensions “of a few days” for filing some specific documents, she says she never agreed to an open-ended waiver. That, she says, “would be like a surgeon consenting an otherwise healthy patient for removal of an ingrown toenail, and then proceeding as though this was equivalent to consent for an above-knee amputation. I would no more consent to conducting an open-ended investigation while my research program and career are being destroyed, than I would let them take off my leg.”
Which brings us back inevitably, inexorably, to Why?
John Sullivan believes it has a lot to do with professional jealousy. “I’ve been here for 30 years and Gaby Horne is the best researcher we’ve ever recruited in that time. She was the first independent researcher in the division of cardiology in years, and her lab was attracting millions and millions of dollars. She was doing ground-breaking stuff, stuff that would have put Dalhousie and Halifax on the map. But there was one guy she didn’t get along with, and she refused to allow him to bully her.”
CAUT’s James Turk says the reason could be as complicated as the fact that Horne was the only female MD/PhD in a traditionally old-boys’ clinical environment, or it could be as simple as “office politics.”
As to why it has dragged on for so long, he shakes his head: “I wish I could answer your question.”