Chapter 08: Learning to Build a Research Career

Chapter 08: Learning to Build a Research Career

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Description

Dr. Escalante next describes how she expanded her career vision to include a research program, noting a few mentors, but the general lack of attention to career development within her department. She explains that Dr. Robert Bast [Oral History Interview] came in as Head of the Division of Medicine and changed the requirements for promotion, raising the standards for publications. She describes the process she went through to learn how to write reviews and research papers without formal mentoring.

Dr. Escalante then explains that Dr. Andrew von Eschenbach helped further her career by arranging for her first administrative appointment on the Disaster Committee (which she eventually chaired). She observes that committee work provides valuable opportunities to network and learn about the institution.

Identifier

EscalanteCP_01_20140603_C08

Publication Date

3-6-2014

City

Houston, Texas

Topics Covered

The Interview Subject's Story - The Researcher; Professional Path; The Researcher; Experiences Related to Gender, Race, Ethnicity; Leadership; Mentoring; Patients; Cancer and Disease; The Clinician; Professional Values, Ethics, Purpose, Commitment to Work

Transcript

Tacey Ann Rosolowski, PhD:

I will want to talk in detail about these administrative roles that you’ve been able to serve as a result of those early experiences, but I wonder if in the time that we’ve got remaining today, if it’s okay, we could talk about some of those research projects. What were the first research projects you did that enabled you—and how that all evolved, because there are a number of areas that you’ve done work in. I’d be interested in how your research focus, you know, evolved over time.

Carmen Escalante, MD:

Well, one of the first early things was this project on dyspnea.

Tacey Ann Rosolowski, PhD:

And what is dyspnea?

Carmen Escalante, MD:

Shortness of breath. D-y-s-p-n-e-a. It’s the medical term.So back then Ed had this idea that we should look at all the different symptoms from the Emergency Center, which was Station 19, these acute patients, because we knew pretty much how often they came, and he kind of assigned each of us to pick one. And then we were going to look at who got these symptoms, what kind of cancer, what was it the result of, you know, all kind of variables attached to the dyspnea. And we would get a derivation model with dyspnea particularly to predict who was going to die quickly after they showed up in Station 19, because clinically as we took care of these patients, we knew a lot of them that showed up with shortness of breath were not “do not resuscitates,” okay? They were coming with end-stage disease, short of breath, and when they showed up, we had to hold them if we couldn’t find the attending. And many of these patients, whether they had been spoken to before wasn’t clear, but they didn’t seem to have a clue that things were as bad as they were. So the hypothesis was that most of the patients that are showing up with shortness of breath and certain diseases were probably going to die very imminently.

Tacey Ann Rosolowski, PhD:

Now, I don’t mean to interrupt you, but what causes the shortness of breath? I mean, where—

Carmen Escalante, MD:

A lot of different things can cause it. It could be the tumor. It could be the heart, you know, and a heart disease. It could be pneumonia or infectious process. I mean, there are a lot of different etiologies of shortness of breath. We didn’t really think that the etiology mattered.

Tacey Ann Rosolowski, PhD:

Okay. So the general idea was it was [unclear].

Carmen Escalante, MD:

]That it was like the pathway to the end. So if a lung cancer patient showed up with pneumonia, it might be the final thing. So that’s what we were working with. So what it entailed was getting a lot of patients with a chief complaint of shortness of breath and, back then, going through these paper charts and recording all the data, so that’s what I did, and I did it by—I learned how to do the work from the bottom up. I had no money, and so I actually—I can’t remember if I applied for the first part. So I had no money, so there was this little grant going around, institutional grant, and I applied. I had never written a grant before. Linda [Elting, oral history interview] helped me, got the thing written up, and, miracles of miracles, I got it. It was, like, $50,000.

Tacey Ann Rosolowski, PhD:

And Linda’s last name again?

Carmen Escalante, MD:

Elting, E-l-t-i-n-g.I got the grant, and I can’t remember where in my career I was at that point, but I got the grant. So I was able to get somebody to help me go through some of those charts. That’s basically what it paid for, because we didn’t have electronic records. You had to pull everything. And then we had a statistician, and we did a regression and found some predictors, and actually I think it still holds today. Someone I just saw in the hall—I’d done this years ago, and it was lung cancer—shoot. What else? Lung cancer was a big driver. There were three or four factors, but basically when a lung cancer patient showed up with shortness of breath, most of the time they died within three weeks after the ER visit. So it was really bad prognosticator. So I had a thoracic oncologist. Cathy Pisters [phonetic] was one of my collaborators, and I presented that, I think, at ASCO [phonetic], first time I’d ever presented anything at a meeting, first time I’d written an abstract, first time I’d done a grant. I learned. I learned the hard way, you know, because I’d had no training before. I’d had no formal training. I still had never had—I didn’t do a master’s in public health.

Tacey Ann Rosolowski, PhD:

But also what’s interesting is that when you were presented with this necessity, okay, you have to publish in order to advance here, you didn’t say, “Well, okay, I’m going to go someplace where I don’t have to publish and I can just operate as a clinician.” You decided that you wanted to take on that challenge.4

Carmen Escalante, MD:

Yeah, yeah. I said, you know, it wasn’t an option. It’s like I need to do it. I wasn’t happy that I had progressed so far without knowing I had to do it, because I would have started a lot earlier if I was given the time. Even then I didn’t have the time yet. I mean, a lot of this was if it was a slow day and we didn’t have a lot of patients, or—you know, we didn’t have blocks of time off like some of our other colleagues. I mean, that came later after I was section chief, that I negotiated with Gable [phonetic] to get an extra position so we could do that. But some days you’d have lighter schedules, so you could work, or if we were staffing the ATC, you could work on it. And then having the moneys to help fund that, you know, get a person to help me, helped a lot.And then we did the derivation sets. We had to go back and do the same thing to—I mean the validation set to validate it and did that. So that was some of the earliest work that I did.

Tacey Ann Rosolowski, PhD:

Now, how did your findings have an impact in practice here at MD Anderson?

Carmen Escalante, MD:

Yeah. Back then it was very hard for certain groups to make patients DNRs. I mean, it’s much better today, and for some groups still I think it is. Cathy [phonetic], who was working with me, was always very good about doing that, and I know, because we shared a patient, I know she’s talked to patients using that data. But as far as generally, I don’t know. I mean, I know that the palliative group knew about the data, but I don’t know long-term if that impacted especially the thoracic oncologists long-term. There’s been a lot of change, I think, in attitudes towards talking to people about do not resuscitate and stopping chemo and those kind of things than when I did this twenty years ago. It’s changed. It’s changed, but back then it was not as common, and patients would commonly show up in the emergency room and we’d either have to talk to the family and make them a do not resuscitate or sometimes code people that we really didn’t think it was going to make a difference.

Tacey Ann Rosolowski, PhD:

Wow.

Carmen Escalante, MD:

So, I mean, you know, it certainly helped us to know this, being down there knowing that we need to get on it right away and talk to someone, get the attending on the line, and most times, once you’d talk to them and say, “This patient’s really bad,” and blah, blah, blah, they would say, “Yeah, sure. Can you make them DNR?” So then we would have to have a conversation with this family that we never met before—

Tacey Ann Rosolowski, PhD:

Wow.

Carmen Escalante, MD:

—about—and our patient, and say, “Look, you know.”But it was a terminal pathway. I think what was interesting is it didn’t matter at that point. It was a stage-four lung cancer. If you had stage-four lung cancer, it doesn’t matter why you’re short of breath, whether it’s from the cancer, whether it’s from pneumonia, whether it’s from heart failure, it was bad. It was a bad prognosticator. So that was some very, very early on that I did back then.

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Chapter 08: Learning to Build a Research Career

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