A Brilliant Impatience

Four jobs, four kids, forward march. Nothing can stop Etta Pisano from chasing progress, whether it’s in the medical lab or in the community. More often than not, she catches it.

Etta Pisano is not, and never has been, Betty Draper.
While she was an undergraduate philosophy/premed major at Dartmouth, Pisano’s boyfriend told her to “stop using words that are too big for people.” He wanted her to be a housewife one day and act like “a sorority girl” for now.

“I even remember the word he criticized,” she says now, laughing. “It was stigma. I had used the word stigma. I remember thinking, ‘Stigma? That’s not even a big word. That’s like, six letters.’ ”

Instead, she chose the guy who also was a philosophy/premed major at Dartmouth — her husband of 28 years, ophthalmologist Jan Kylstra — who not only knew what the word stigma meant but didn’t mind if she used it every now and then in a sentence. It was a solid choice, given that she would go on to study such syllabically abundant topics as “tomosynthesis” and “diffraction enhanced imaging” en route to becoming one of the world’s top minds in radiology and breast imaging.

Etta Pisano is not a shrinking violet.

Her confidence, in fact, borders on other- worldly. She’s never been afraid to voice an opinion, a trait that comes in handy in the four gargantuan positions she holds: as Kenan Professor of radiology and vice dean for academic affairs at UNC’s medical school; director of the Biomedical Research Imaging Center; and director of the N.C.Translational and Clinical Studies Institute, an organization that helps with the process of turning academic research into health care for the public.

She’s never been afraid to discount an opinion, either.When she visited a career counselor during her junior year of college and told him she planned to apply to medical school, the adviser told her she was wasting her time. It was the ’70s, and co-education was just settling in at Dartmouth; at campuses across the country, women still were being turned away from medical schools in favor of men.

Pisano applied anyway and was accepted to many, though not all, medical schools, choosing to go to Duke with her soon-to-be husband. And because she had LSAT scores to salivate over, she also applied to law schools. She got into every one of them, including Harvard.

“The adviser may have been trying to be kind to me, sparing me the effort of applying,” she says. “But I never believed it, not for one second. I just remember thinking:What does he know? And it’s not because I had such great self-confidence.

“It’s just that I thought the person was wrong.”

Etta Pisano is not a superhero.

Even Carolyn, the oldest of the four children Pisano and Kylstra raised while building the kind of careers that anyone would envy, will tell you that.

Sure, Pisano may have been the president of the Chapel Hill-Carrboro City Schools’ PTA council while simultaneously heading up the largest breast-imaging study ever undertaken. And yes, it’s true that, while juggling NIH grants, she was attending Carolyn’s soccer games and co-founding parent groups that would lobby for new schools. She made sure she went in and met the parents at any party her kids attended. She made the time to make sure they knew that, no matter how much of her belonged to medicine, they — Carolyn, Jimmy, Schuyler and Marijke — belonged to her.

“A boyfriend broke up with me once, my first boyfriend,” recalls Carolyn, 23, who writes “Ask the Girl Next Door” for Men’s Health magazine, a column that dispenses advice on sex and relationships to men.“I was 16 at the time, and I was so sad. My mom gave me a necklace, and she wrote me a letter that said,‘I’ll always love you. You will always have me.’ ”

But Pisano has her Kryptonite.“She cannot, cannot function if she can’t get seven hours of sleep,” Carolyn says. “It’s really incredible. She shuts down. I think because her brain is just constantly going, going, going all day long, and then she just maxes out.That’s why she didn’t end up going into obstetrics, because she couldn’t do the nighttime baby deliveries.”

“It’s true,” Pisano says.“I’m like a hummingbird that needs to eat. I have so much energy, but I can’t do it without sleep.”

She decided long ago that you can’t be great at everything. During medical school, Pisano and Kylstra visited the home of a fellow medical student named John Buse, who is now the director of UNC’s Diabetes Care Center. His mother is a University of South Carolina endocrinologist and researcher who has had continuous NIH funding for nearly 50 years.

“We went into the house,” recalls Kylstra,“and it was the biggest mess.There were stacks and stacks of books and magazines, every surface piled to the ceiling.”

“And I remember thinking,” Pisano says, “ ‘She doesn’t care that the house is sort of messy.And look how well-adjusted her kid is.’ ”

“How do you do it?” Pisano asked Buse. “How do you manage?”

“Prioritize,” Buse replied.

“We learned that the important thing is not keeping up appearances,” Kylstra says. “It’s putting effort into the things that count.”

Since that day more than 30 years ago, Pisano has adopted a Voltaire-inspired philosophy on the matter: “The perfect is the enemy of the good enough.”

“She is the only person I’ve ever known who had four NIH grants and four children under the age of 10 at the same time,” marvels Shelton Earp ’70 (MD, ’72 MS), director of UNC’s Lineberger Comprehensive Cancer Center. “Her ability to manage sci- ence, clinical medicine and personal time are second to no one in the world.”

Etta Pisano is her father’s daughter.

When Jan Kylstra first met his future father-in-law, the man was running in circles on the beach. He was a jogger back then, but he also needed to watch over Etta’s 11- year-old sister while she played in the sand.

“Instead of running distances,” Kylstra recalls, “he’d run a big loop, so he could keep an eye on her the whole time.”

Kylstra says his wife is the same kind of personality: always multitasking and with a frenetic energy that thirsts for ever more projects to complete.The elder Pisano was an entrepreneurial radiologist; he opened 30 outpatient imaging centers in the Philadelphia area and later sold them to the University of Pennsylvania. His influence on her career was enhanced by Etta’s frequent trips, starting at age 10 and continuing through high school, to the Philadelphia hospital where he worked, the women doctors he introduced to her (all five of them), and the careful way he showed her how the world could open up for her one day.

“He’d say, ‘Here’s my daughter, and I want you to meet her,’”Pisano says.“I remember meeting a woman cardiologist with children — my father made sure I knew she had children.There was a woman who was an orthopedic surgeon who had been in the U.S.Army [Anna M. Brady, the only woman commanding officer of an Army medical unit in Vietnam]. I remember her very well. She was single and maybe middle-aged by the time I met her. And I remember he was really admiring of her. But I didn’t meet them in my home life.There weren’t a lot of women working in the ’60s.”

Pisano’s father saw through the dense pocket of conventional gender roles and lit up his daughter’s future with a powerful ray, laying it before her like proof on film. She knew at age 12 that she wanted to be a doctor. It was visceral. As visceral as the feeling that took hold of her as she watched her mother cook and clean and undertake the work of the 1960s housewife, all ammonia and detergent and flour and sugar. She wanted to spend her life uncovering sinewy densities, not dusty surfaces.

“I was never excited about that as a life goal,” recalls Pisano.“It wasn’t that I regretted her doing it. And I knew I wanted to have kids; I just didn’t want to stay home full time. I remember saying to my mother, ‘This is not what I want to do with my life.’

“I don’t know how she felt about it. We never got to talk about it.”

Etta Pisano’s impatience will save your life one day.

When Pisano is on the phone in her office at the medical school, she drums the desk with her fingers, as if to push the conversation forward, to progress, to accomplish. When she’s speaking eye-to-eye about the projects she’s engaged in, the goal of getting new medical technologies to the public “faster, better, cheaper — period,” it’s the same thing: fingers drumming like a motor, the reverberation of innovation, the hummingbird at work. Her speech is peppered with action; she feels she has no time to waste.

Somewhere, a woman — somewhere, a family — needs her help.

It’s November, and in two weeks, she will fly to Washington on her own dime for her allotted five minutes before a Food and Drug Administration advisory panel, where she will try to convince them to relax the regulatory guidelines for digital mammography devices. Four years have passed since she published the results of the Digital Mammographic Imaging Screening Trial, or DMIST — her landmark two-year, 33-site, 50,000-woman study that proved digital mammography is superior to film in finding tumors in the dense breast tissue that char- acterizes women under 50. Nine years have passed since the technology itself was first FDA-approved.And 17 years have come and gone since she began working on the team that developed digital.

That the devices still are available in only 50 percent of mammography facilities nationwide is the bane of Pisano’s existence, and she has been relentlessly poking the regulatory agency in the ribs since DMIST wrapped, as though trying to wake a sleeping child in church.

She doesn’t understand why the FDA won’t heed her gospel: This technology saves lives. Every minute you waste means another woman’s life can’t be saved.

Right now, the agency requires each new device to prove itself under the strictest of conditions — a clinical trial in which women would have to be double exposed to radiation — despite the fact that the technology they employ is the same as that which was proven safe and effective under DMIST. That means new manufacturers can’t bring their products to market as quickly. Faster delivery would help drive down the now-prohibitive cost of the machines for many facilities and bring them into the preventive health routines of more women.

“We don’t have the urgency that we should. It took four years just to get the money to do DMIST, a study which everyone agreed was a no-brainer,” she says. “Then it took another four years to finish it. Fifty thousand women should be enough.

“I mean, I’m really frustrated about it. I’m a talented scientist who does this kind of work, and I’m going to do one or two of these in my whole career? That’s ridiculous. It should be faster than that.What the heck are we taking so long for?”

She is similarly exasperated by the findings last November of the federally funded U.S. Protective Services Task Force, which advised against mammography screening for women in their 40s. More than a decade of declining breast cancer mortality — and the fact that the committee ignored the superiority of digital mammography over film in that age group — prove the recommendations are ill-conceived, she said.

“The argument is most people won’t get breast cancer in their 40s. But that’s the way screening is: You always screen more people than will actually have cancer. Women in their 40s are still actively raising children, they’re at the peak of their careers, and they’re active members of the community. So those recommendations seem very nonchalant about the worth of the lives we do save.”

Etta Pisano may be her father’s daughter, but she is her mother’s champion.

The fact is when a mother is taken away from her family, whether from a breast cancer that couldn’t be screened in time or a brain tumor that no one knew about, that family is never the same. And Etta Pisano still needed her mother. Ask any teenager whose parent just doesn’t wake up one day. They still have questions to ask, a legacy to learn. Like, “Why would a talented electrical engineer, a college graduate, a woman running an office of 30 men in charge of computerizing the telephone system in 1955 quit when she got married? Did they make you, Mom? Or was it just what was done?”

And, “Did you ever resent that?”

When a brain tumor takes away a 15-year-old girl’s mother; when seven children are left behind, and you’re the oldest, and you have to take care of everybody; when you’re suddenly sister and parent to a pre-schooler; when you can’t even drive yet, but three months later, on the day you get your license, you’re handed the keys to a Ford wagon and told you’re now the family’s chauffeur …

“It was just so hard,” Pisano says, unsteadiness quietly rocking her voice. “It was very, very hard on my family. It’s just … it’s one of the hardest things that any family can go through, to lose a parent. It’s one of the most devastating life events you can go through.

“I’m sorry,” she says, removing her glasses and dabbing her eyes with unprepared fingers.“I never cry in here. Other people do. Other people have. But I don’t.”

No, she doesn’t cry at work. She manages the egos and emotions, the lives and livelihoods of others from her posts. People are let go; people must be told they could have breast cancer. The educations of hundreds — and dollars numbering in the millions — are in her hands every day. The range of skills required to juggle her responsibilities is great; it requires a tough- ness that Pisano has in spades.

But all heroines have a seed of vulnerability, the switch that turns on the light. And when you take a girl’s mother from her, when you take Etta Pisano’s mother away from her …

“I said to myself, ‘I’m really smart’ — I thought of myself as smart at age 15 — ‘and I should do something for women to keep this from happening to families.’That was what motivated me.”

So you’ll forgive Pisano’s impatience. Because her motherless timeline flows through her veins like a potent stimulant, like an energy drink, like the strongest of coffee. Indeed, that loss — that 37-year- old loss — propels her intellect still.

Maybe she couldn’t save her mother’s life; but, at 15, she knew she could save yours one day. She could save your chil- dren’s and your grandchildren’s.And she could make your lives better.

“My mother was a brilliant person. I’ve always thought, if she hadn’t died, she might have gone back, she would have learned about computers, she would have done something else …”

I’ll always love you.You will always have me.

So for the mother who didn’t get a chance to finish, the daughter began: Her archaic Dartmouth boyfriend. Her small- minded career counselor. Then, the choice of specialty: Radiology over neurology, because brain tumors can’t be turned back, but breast cancers can be beaten, and too many women die from breast cancer. Radiology over surgery, her first love, because surgery monopolizes family time.

Radiology because she had vision.

Next: The chair of the residency program at Harvard’s Beth-Israel Deaconess Medical Center, who told her, after she had given birth to Carolyn in her second year there, that they didn’t have a maternity leave policy: “Doctors have a real macho kind of work ethic,” Jan Kylstra says. “The residency directors liked to tell the story about an internal medicine resident named Pat, who had her baby, and the next day she was back on rounds again and never took any time off.”

Ridiculous, Pisano thought. She went to the president of the hospital and made sure that they formalized a maternity leave policy. She was named chief resident the next year. There was a new kind of macho in town.

She arrived at UNC in 1989, fresh out of residency and eight months pregnant with her second child, Jimmy. Some folks at the medical school were worried; they thought she would leave her new job as residency director after giving birth — it was typical then — but they didn’t know Etta Pisano. Instead, she brought her Harvard act to Chapel Hill, getting loosey-goosey maternity leave policies set in stone at Carolina as well.

In her first year, UNC upped the ante on its Pisano investment, making her chief of breast imaging. “Right away,” Pisano says, “it was obvious what needed to be done: that breast imaging wasn’t good enough, that we needed to improve the tools. So that’s what I’ve been doing ever since.”

She did so first with digital mammography and the DMIST study and then with a new technology Pisano’s lab has created, called diffraction enhanced imaging. DEI, which Pisano plans to market through a company she founded called NextRay, promises to deliver higher qual- ity images than the traditional X-ray at less than 1 percent of the radiation dose — a breakthrough for everyone, but particularly for babies, children and young adults who are most susceptible to the cancer risk that prolonged radiation exposure carries.

She’s also involved in testing for tomosynthesis, an imaging method that takes a “pseudo 3-D image” of the breast, showing it in sections that could more readily reveal tumors that hide behind tissue.

“She’s just an unusual blend of someone who understands imaging from the actual physics side all the way through not only patient care, but large-scale clinical research, understanding how imaging affects the population,” says Earp, the cancer center director. “Her scientific breadth is remarkable.”

“But I’m impatient,” Pisano says.“I’m really impatient. I look at my life and I say to myself, with luck, I have 30 more productive years, 30 years that I can contribute to society.What can I do next? What can I do that actually affects people and helps people?”

Pushing some ‘adaptations’

In the 20 years since coming to campus, she has helped captain efforts to stop the tenure-track clock for one year when major life events occur, to boost salary equity on campus and, more recently, to keep UNC’s big female minds focused on their careers — particularly after they have families — through the Working on Women in Science program.

Although women earn half the science and engineering bachelor’s degrees awarded in the U.S., they comprise only 28 percent of science and engineering faculty nationally.Women in higher positions, like Pisano, are even rarer; women account for fewer than 15 percent of full professors in the life sciences and less than 10 percent in the physical sciences.

That Pisano also has managed to become vice dean of a major medical school makes her the Halley’s comet of women in science.

“I know how hard it is to raise small children; I really do,” says Pisano, who worked part time when her children were young, and often from home. “And it’s not OK to say that a woman or a man who cares about his family and who wants to spend time with his family has to adapt to the workplace. We need the workplace to make some adaptations.”

Carolina presented Pisano with the University Award for the Advancement of Women last spring for her efforts.

“People like Etta have established the ground rules on how we treat each other here,” says Lisa Carey, medical director of the UNC Breast Center, who arrived in Chapel Hill 10 years ago with two small children of her own and one on the way. “She really is a force of nature.”

After interviewing with Pisano and getting the job at UNC, Carey remembers going to enroll her child in preschool, only to discover that Pisano was also the president of the parents’ association. “I thought, ‘Is there anything this lady can’t run?’”

Over lunch with a friend one day, Pisano decided to begin CATS — Citizens Advocating for the Schools — to drum up support for a third high school in the Chapel Hill/Carrboro school district. She interviewed potential principals.

She embarrassed her children by coming to school to make speeches. She endorsed candidates for office through a popular listserv that she operated — a kind of blog before there were blogs.

“I spent so many hours at county commissioner meetings and school board meetings and town council meetings, all about political issues,” says Pisano, who stepped down from school involvement when she became vice dean three years ago. (Her youngest is a sophomore at Carrboro High, while both her sons attend UNC.) “I liked helping the schools solve problems.”

Pisano has held political fundraisers at her home, and she was recently appointed to the Sustainable Community Visioning Task Force for the town of Chapel Hill, a group charged with setting an agenda for growth in the next decade. She can speak thoughtfully and in detail about town infrastructure, health care, work life, the school system.

“She’s passionate about many things, and when she is, she’s not afraid to do something about it,” Carey said.“She’s unusually willing to weigh in and be part of the solution.” She sounds, in fact, like a woman who could run for office one day.

“I have thought about it,” she admits.

“Maybe at the end of my medical career, when I’m retired. I could see doing that. It might be something, who knows?”

Her husband says if she does run, he thinks she wouldn’t be satisfied until she reached the governorship, possibly even the national level.

Congresswoman Pisano. Senator Pisano.

No miracles

The world has opened up to Pisano, just as her father showed her it could; because time and again, the 5-foot-4 woman has stood at its doors with a big, gleaming brass key, with answers. The people on the other side would have been fools not to let her brilliant impatience in.

“I’m proud of her for being a great mother and wife, and following her dreams at the same time, and being able to pull it off,” Jan Kylstra says. “Which is kind of … almost miraculous.”

Miraculous is the word that’s used often to describe Pisano’s juggling act. Even Carolyn, who graduated from Dartmouth last spring, has begun to feel daunted by the far-off future prospect of managing a family while working the long hours she does now. “And my mom’s like, ‘Are you crazy? Didn’t you see me doing this growing up? It’s possible.’ It’s funny that I’m as apprehensive about it as I am, given that I’ve had such a great role model for how to do it.”

When Pisano gets that question,“How do you do it?” she tells them, “I’ve never felt stressed by it. It was much harder when my mother died and we had seven kids at home. That was like a thousand times harder than what I do now, or even did throughout my children’s upbringing, you know? I was 15 years old.

“I tell them I have confidence that I’m going to make the right decision; I try not to feel guilty; I’m not a perfectionist — you’ve seen my kitchen, it’s not like we’re eating off the floor in there — and I have great help. That’s basically it.

“By no stretch of the imagination is what I do miraculous.”

Beth McNichol ’95 is a freelance writer in Durham and a former associate editor of the Review.

Copyright 2010 UNC General Alumni Association

From the March/April 2010 issue of the Carolina Alumni Review.