Chapter 06: A PhD Program and a Professional Focus on Ethics

Chapter 06: A PhD Program and a Professional Focus on Ethics

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Dr. Holleman begins this chapter by explaining that his educational path took a turn because of his fiancée, Marsha Cline, who wanted to go to medical school: he explains how they made the choice to come to Houston. Next, he explains that while looking for work and a course to take, he was offered the opportunity to begin a doctoral program in the Department of Religious Studies at Rice University [Ph.D., 1986, Religious Studies]. This program led to his focus on medical ethics, a specialization he pursued with a Fellowship in Ethics at Baylor College of Medicine [1987-1988]. He developed expertise in primary care medical ethics. He gives examples of ethical issues that can arise and explains that his work changed practice at Baylor.

Completing his fellowship, Dr. Holleman explains, he advanced to faculty status as an Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine [1988-1998]. He describes the theoretical and philosophical focus of the department, whereas his strength centered in communication with patients. He was tasked with starting the Medical Humanities program at and founded the Compassion and the Art of Medicine lecture series/course [in 1989] that is now in its 27th year.

Identifier

HollemanWL_01_20170412_C06

Publication Date

4-12-2017

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Educational Path; Professional Path; Influences from People and Life Experiences; Formative Experiences; The Clinician; Character, Values, Beliefs, Talents; Ethics; The Researcher; Human Stories; Offering Care, Compassion, Help; Patients; Patients, Treatment, Survivors

Transcript

Tacey A. Rosolowski, PhD:

So how did all that evolve in college? You did some of these internships with congressmen during your summers?

Warren L. Holleman, PhD:

Mm-hmm.

Tacey A. Rosolowski, PhD:

So what happened by the end of graduation? Because you ended up getting a degree in something quite different. Or, your PhD

Warren L. Holleman, PhD:

I'm not sure what happened. One thing I know is I fell in love.

Tacey A. Rosolowski, PhD:

Okay.

Warren L. Holleman, PhD:

And the person I married, Marsha Cline, C-L-I-N-E. And I wasn't sure what I wanted to do. She knew she wanted to go to medical school. She was from Texas. Medical school at Texas schools at that time, I think, was $600 a year. I said, "Well, I want to pursue this either political career or go to graduate school in political science, or diplomacy or something," I didn't really know. So we both applied to different places. But once—and I remember at the time, I was applying for a job to work for my congressman. Because I had worked there in the summer, they said, "We like you. When you graduate, if you're interested, we'd love to consider you for a job." So at the time they didn’t have an opening. They said, "Just be patient, something will open up. Just be patient. Come to DC, and within months, things will work out." Well, my wife applied to a couple of medical schools in DC, and they were $30,000 a year. In 1978, that was a lot of money. And Baylor, here in Houston, was $600 a year. So it was kind of a no-brainer.

Tacey A. Rosolowski, PhD:

Yeah.

Warren L. Holleman, PhD:

So we came here, and I just kind of lucked into—I didn't know what I wanted to do. I thought, well, I'll be the person who earns the money. With a liberal arts degree, I found I wasn't very employable. And I remember—this is serendipitous, but I was applying for jobs around Houston from Boston, and not getting anything. I was shocked at how unemployable I was. Coming from a small town, where I just thought I could do anything.

Tacey A. Rosolowski, PhD:

Yeah, sure.

Warren L. Holleman, PhD:

Nobody was even interested in talking to me. So meanwhile, I said, well, just to keep myself happy, I'll take a course—I had heard about Rice University. Sounded like a good school. So I wrote a letter to the chair of the Department of Religious Studies, saying, I'm moving to Houston, I'm going to be working, but I just would like to take a night course or something. Do you have anything like that? And he wrote me back and said, "What if we offered you a scholarship and a fellowship, a teaching fellowship, and you just come here and be a full-time student?" And at the time, nobody would even return my phone call for these little minimum wage jobs, practically. So I said, "Okay."

Tacey A. Rosolowski, PhD:

Wow.

Warren L. Holleman, PhD:

I wasn't really thinking of myself in religious studies. So I got there the next year. I had never taken a course in [it], but I just kind of was interested [ ]. I found that there was an ethics professor there named James Earl Sellers. Dr. Sellers. And I just totally found myself when I took these classes. I said, this is what my life prepared me for, is ethics. It was really social ethics. It was all about studying race relations, and what justice and equality were, and all that stuff. So it was really good for me. Then when I got ready to graduate, though, the jobs were pretty scarce in most areas of ethics, except Medical Ethics. And Dr. Sellers said, "You've got to go where the money is." So I took a fellowship at Medical Ethics at Baylor.

Tacey A. Rosolowski, PhD:

Right. I saw that on your CV, yeah.

Warren L. Holleman, PhD:

And went into Medical Ethics for a few years, before I then went back to school and studied mental health.

Tacey A. Rosolowski, PhD:

Okay. In '86, you got your PhD, and then you were in the Ethics program at Baylor College of Medicine, '87 to '88.

Warren L. Holleman, PhD:

Yes.

Tacey A. Rosolowski, PhD:

Yeah, okay. Okay.

Warren L. Holleman, PhD:

Then I sort of went on the Baylor faculty as a, quote, "Medical Ethicist." And I did that for a few years. But I wanted to have more of a clinical role. I got interested in community health. All that stuff about justice and equality and fairness in terms of social justice issues were still on my mind. And I found that in community health, that's where they were trying to make healthcare accessible to all people. So, well, that's a whole other story, but when you're ready, I'll tell that story.

Tacey A. Rosolowski, PhD:

Yeah, well, I guess, you know, that's a pretty long period of time. What were some of the key moments for you during that time, that you feel helped form you and crystalize your thinking in these areas?

Warren L. Holleman, PhD:

Yeah. So when I got to Baylor, my focus was doing Medical Ethics in the primary care area. Most Medical Ethics at the time was in ICUs, ERs, specialty areas, and dealing with sort of the dramatic issues of death and dying. My fellowship was split between ethics and family medicine. So I developed an expertise in what I call "primary care Medical Ethics;" just the ethical issues that arise in an outpatient visit in an ambulatory clinic. There were a lot of things there that I thought were fascinating, that no ethicist was even thinking about.

Tacey A. Rosolowski, PhD:

Such as?

Warren L. Holleman, PhD:

The first thing that I had some success with in terms of publishing was, I noticed patients would come to the doctor's—so what I would is hang out at the nurse's station and just team up with the supervising physician who was supervising the residents. And I would just "cruise for cases," I would call it. And then we'd do case conferences on those cases. And I noticed over and over, patients were coming in, asking for sickness excuses. "My son is sick and unable to go to soccer practice or school today." "I am sick and unable to go to work today," that kind of thing. And I noticed there was no scientific basis for anything that was being done. It was just very—if you liked the patient you signed it, if you don't know them but you liked them, you'll still sign it. You'll have no way of knowing if they're even sick. I learned there's all kinds of abuses. Some doctors' offices were selling sickness excuses.

Tacey A. Rosolowski, PhD:

Oh, my gosh!

Warren L. Holleman, PhD:

Literally. There were nurses or—in one case there was a receptionist who, you wouldn't even see the doctor. She would sign the doctor's name for, like, $10 a pop. So everybody was going to that clinic for sickness excuses. That was the worst. But basically, we would have patients that would come in. One doctor would say, "Well, I'll sign it," and another doctor would say, "No, I won't sign it." There was no agreement on what the standards were. Then the next level up was what was called, at the time, "pre-employment evaluations." And pre-employment evaluations were just another thing that there were no standards for at all. And what got my attention, I remember this was the beginning—early in the AIDs epidemic. And a patient with HIV applied for a job as a secretary at a business. The resident said that the pre-employment examination gave him four choices. One, fit to work, no major problems. No problems. Another is fit to work, minor problems, but they can be addressed. Third was sort of fit to work if these changes are made, and then unfit to work. Something like that. So the resident goes around to the faculty saying, "Which box should I check for an HIV patient? He's currently able to work at this time"—that was before AZT and all that was working—"We know that within a year he won't be able to work." So he went to four faculty, and each one checked a different box.

Tacey A. Rosolowski, PhD:

Oh, my gosh.

Warren L. Holleman, PhD:

And I said, "Somebody needs to figure that out." So I sort of partnered with the family physicians and wrote papers about those things. And it wasn't the sexiest thing in the world, but it was a much more common experience for the average patient than being on an intubator in an ICU. Being intubated in ICU. So I thought it was very practical. And nobody else was writing about that.

Tacey A. Rosolowski, PhD:

Did the papers that you did, and the areas where you worked at Baylor, did people change practice on the basis of that?

Warren L. Holleman, PhD:

Yeah. So our department did, Family Medicine. And we changed everything, yeah. And I think we did a good job. So I felt I made a practical contribution there, as a person who wasn't really a doctor or anything. It's ethics—I like that. Ethics wasn't just cerebral or philosophical, or an exceptional situation; do you pull the plug or not—it was a very common, everyday that nobody had thought through.

Tacey A. Rosolowski, PhD:

Interesting. Yeah. Yeah. So what were some of the other—

Warren L. Holleman, PhD:

And by the way, it was at that time that—I forget how all this worked—I guess it was through the professional organization that there was a decision—I don't know if it was just in family medicine, or also general internal medicine, that doctors would no longer do pre-employment exams. They changed the whole definition. They called it "pre-placement exams," and they avoided all those ethical quandaries. They avoided doing all those things that were wrong, basically. And I think our work had a little bit to do with that. So I've always been proud of that.

Tacey A. Rosolowski, PhD:

Very cool. Yeah. Yeah. Well, I think you're right. People, when they think "ethics," it seems like such a lofty word that it's something you apply to those extraordinary circumstances. But, in fact, we live it every day.

Warren L. Holleman, PhD:

Yeah.

Tacey A. Rosolowski, PhD:

In sort of the micro—the tissue of social interaction, yeah.

Warren L. Holleman, PhD:

The first paper I did on that was called, "School and Work Release Evaluations." That's not a very sexy title. My mentor at the time was a man at Baylor who was one of the top best known medical ethicists in the world. I think I can say his name. It's Baruch Brody. And I had tremendous respect for him, but I always felt I could never be him. He was a brilliant philosopher, and I was not at all, a philosopher. He's very cerebral. And I wrote this paper, and I was so proud of it. And I said, "I’m going to send it to JAMA." And he said, "You need a reality check, here." And then I said, well, I'll try another mentor. I went to this other famous person, and he gave me basically the same feedback. So I sent it anyway, and it got accepted immediately. (laughter) And so I always enjoyed that. But I think it was because nobody else was writing about it.

Tacey A. Rosolowski, PhD:

Your mom would have liked that story.

Warren L. Holleman, PhD:

Oh, yes. Yeah. Yeah.

Tacey A. Rosolowski, PhD:

That's a good one. (laughs)

Warren L. Holleman, PhD:

Yeah.

Tacey A. Rosolowski, PhD:

Well, congrats on that. That's a pretty good publication.

Warren L. Holleman, PhD:

I mean, there's always a lot of luck involved with those things.

Tacey A. Rosolowski, PhD:

Sure.

Warren L. Holleman, PhD:

But if you don't send it in, you know it won't be accepted.

Tacey A. Rosolowski, PhD:

Yeah. You can't win if you don't play, as they say.

Warren L. Holleman, PhD:

Exactly.

Tacey A. Rosolowski, PhD:

Yes. Exactly. And you never know when the time is right for something. And obviously it was, with JAMA.

Warren L. Holleman, PhD:

Yeah. I mean, I've always—I've had many thing rejected over the years that I thought should not have been, or should have been looked at more closely. Just rejected outright. But every once in a while, the opposite happens. You know? You're not expecting it, and it happens. It gets accepted. So I credit the editors. I know they must get hundreds of things—

Tacey A. Rosolowski, PhD:

Sure they do.

Warren L. Holleman, PhD:

—a week, and they sort of flip through them, and they have to make decisions very quickly.

Tacey A. Rosolowski, PhD:

So tell me about kind of next turning point, big moments for you.

Warren L. Holleman, PhD:

Yeah. So when I was embedded with the Ethics Department at Baylor, as I said, it was a very cerebral department. They had three of the top medical ethicists in the world there, they all came from philosophy backgrounds. I was totally out of my league with those guys. I was a very practical kind of person, and not cerebral, and not a philosopher. They would quote Heidegger and Kant, and I didn't quote them at all, especially in the hospital room. But what I was pretty good at was sort of talking to the patient, and listening to the patient. And I remember one time, we were in a situation where it was really painful, and we were talking with the patient like it was a philosophy class. And I said something about, "Shouldn't somebody hold the patient's hand?" And I remember the Medical Ethicist there, who was my mentor, said, "We don't hold hands." And that was a seminal moment for me. And I said, "I want to be the person who holds hands." Because I thought that's one thing I'm good at. So that's one thing. I said, "Either I've got to find what's now called a "Clinical Ethics Department," which is what we have here at MD Anderson—they hold hands. Rather than a sort of Theoretical Ethics Department, which is what Baylor's orientation was. It was a great department, but it wasn’t as clinically oriented. So that was the first thing. The second thing was, Dr. Brody, sort of recognizing that I wasn't like him, very wisely said, "Well, we've sort of got ethics covered here, except for the Primary Care Ethics. So you do that. But then with the medical students, instead of teaching in our Ethics curriculum, why don't you start a new curriculum in Medical Humanities?" And that was a very good fit for me. And I'm still, to this day, connected with some of the things we started at Baylor. One of the things, I guess, that's lasted the longest, was a program called "Compassion and the Art of Medicine." I think it's in its 28th year now. And it started out as a lecture and performing arts series to try to introduce the medical students to the idea that medicine is an art as well as a science, and that a caring, empathic spirit is an essential ingredient to a healing relationship with a clinician, which isn't what I'd experienced in Ethics. So we had the typical speaker in that series was either a doctor who was kind of a role model of compassion; either through just the ways they interacted with patients, or maybe they had started something for underserved patients, that kind of thing. Worked with homeless patients. A doctor or a nurse. Another type of speaker would be a patient or family member who was articulate in reflecting on what it was about the care that made a difference. And some of those patients were actually artists. We had actors, sculptors, painters, photographers come in, and through their art they would tell their story. We had a lot of one-man, one-woman shows, either drama or comedy, talking about their experience at being a patient. And those are always powerful. So it started as a lecture in performing arts series, open to the public. But within the first year or so, I realized—I don't remember exactly how this came about, but I applied to the Curriculum Committee to make it a course. So after some challenges, it was approved as an elective course. I remember I got a letter back from the Curriculum Committee saying, "Members of our committee do not—some members of our committee have reservations about the relevance of this to medical education." I wish I had saved that letter. Maybe I did. "But we're going to approve it and let you try." So that was the challenge I needed. I sort of became my mother then. And within three or four years, it was the largest course in the medical school, larger than any required course, because it was open to first and second-year students. So we got up to an enrollment one year, I think, of 220 students. And there were only 160 per class.

Tacey A. Rosolowski, PhD:

Wow.

Warren L. Holleman, PhD:

So it became very popular. They then expanded it so that for a while there, in addition to the lectures, we had discussions afterwards, and then we had small group discussions. And then I would have reading assignments, and one or two papers. Became a full course.

Tacey A. Rosolowski, PhD:

So what was the content when it expanded to course? The course format?

Warren L. Holleman, PhD:

Nothing changed, we just would have discussions reflecting on the presentations, oftentimes with the speaker present, which was kind of cool. We would have a period where—so I would have second-year students serving as small group leaders, who had taken the course the year before, and they would split up in small groups at some point so that you could have a small group discussion of the issues. We would have a discussion guide for each class. And I would sort of bounce around to the different small groups. The content was the same. In addition, they would read a book or two by one of the speakers generally, or else on a topic related to one of the talks.

Tacey A. Rosolowski, PhD:

And what did people—what did the students say was the impact of having this exposure to this material?

Warren L. Holleman, PhD:

They felt that it humanized their medical education, that the first and second-years of medical school are mostly about didactics and information. They kind of come there thinking, "I'm going to be a doctor," but the first year and a half to two years, it feels like a jolt. They're not—at that time, back in 1989 when this started, they weren't seeing patients at all. Now they do see a few patients from the beginning, which is wonderful. I'd like to think that maybe this had something to do with it. We had some other electives, actually, that got them to seeing patients, too. But anyway, they felt that this—typical response was, "This reminded me of why I went into medicine in the first place." Because at the time, there was nothing in the first two years, that all you were doing was learning the Krebs cycle and memorizing tons of stuff for tests. And you weren't working—the only patient you had was your cadaver, which wasn't exactly... Yeah. So anyway, that was an exciting time for me, because at first I thought, "What have I gotten into?" I don't really like Medical Ethics, and yet my title is Medical Ethicist. But I think the Primary Care Ethics was good. When I found that, I said, yeah, I don't feel comfortable in the ICU, I don't feel comfortable—I don't really like hospitals. But I loved the outpatient setting. And the second thing was, the Medical Humanities, I had a lot of freedom to experiment, and I started all kinds of different electives. And the one I told you about was the big one, but there were a number of small ones.

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Chapter 06: A PhD Program and a Professional Focus on Ethics

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