Chapter 07: Starting a Palliative Care Service

Chapter 07: Starting a Palliative Care Service

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Description

In this chapter, Dr. Bruera begins the story of how he set up an entirely new palliative care service upon arriving at MD Anderson. He begins by reviewing some of the context discussed at the end of the last session. He anticipated support from Dr. John Mendelsohn and Dr. David Callendar, but administrative shifts brought in new individuals for him to report to. He describes how this shifted perception of this new initiative to bring in palliative care from - the executive leadership wants it- to this newcomer, Dr. Bruera wants it. He describes a conversation with John Mendelsohn that resulted in transferring the Palliative Care Department to the Division of Cancer Medicine under Dr. Waun Ki Hong [oral history interview]. Dr. Bruera then describes how he began to operate in this situation and the importance of a very positive external review of the program conducted in 2003 0r 2004, which enabled Dr. Bruera to go to Dr. Hong with concrete evidence of success. Dr. Hong authorized additional resources to build the program.

Next, Dr. Bruera talks about his strategies for assessing the institution's need for palliative care and support services. He explains why he avoided giving presentations to introduce services.

Identifier

BrueraE_02_20180813_C07

Publication Date

8-13-2018

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; Institutional Politics; MD Anderson Culture; Leadership; On Leadership; Professional Practice; The Professional at Work; MD Anderson Culture; Working Environment; The Researcher

Transcript

Tacey A. Rosolowsi, PhD:

Today is August 13, 2018, and today I’m in Pickens Tower, on the fifth floor, for our second session with Dr. Eduardo Bruera, and I want to thank you for taking the time again today.

Eduardo Bruera, MD:

Thank you, thank you very much.  

Tacey A. Rosolowsi, PhD:

We ended up last time, where you had come to MD Anderson and were talking a bit about your personal vision for what could be accomplished here, between setting up an inpatient service and also setting up an outpatient service, and some of the challenges that you realized you were going to have to confront. So, I wanted to just ask you to start telling that story, of how you began to implement what your vision was for developing this department.

Eduardo Bruera, MD:

Wonderful. Well, I learned a lot about transitions and to which point transitions are extremely dangerous for academic physicians, because you’re moving from a state of certain balance, certain stability, to a world of extreme uncertainty. My uncertainty level increased very dramatically, because a month before I moved, John Mendelsohn phoned me and said Eduardo, Andy von Eschenbach, who is the one who had most of the conversations with you about your transition, has now moved back to GU oncology and we have split his job in two parts; one is going to be run by Margaret Kripke [oral history interview], the other one is going to be run by David Callendar, and then you are going to be reporting partially through them. So basically, I arrived at MD Anderson to report, in a sense, to a senior leadership that had not been able to hear the story and had not been able to say that they really were aware. It didn’t mean that they were necessarily against, but certainly, it had not been one of their priorities, it was not one of the things that they thought was important for MD Anderson. I was arriving from Edmonton with a series of needs, and unfortunately, what I hoped was going to happen, is what happened to me when I was in Canada: that is that Neil MacDonald was the director of the center, would go and say I would like to have a Palliative Care Unit and I have asked Bruera to do it for me, I would like to have an outpatient clinic and I would like Bruera to do it. So that he would in a sense have my back. And because of his enormous reach within the institution, people would say well, I’m going to say yes to this or I’m going to support this, because I still need the good side of Neil to allow me to buy a new radiotherapy machine or to hire three doctors, et cetera. So people in the position of administrative clout can really negotiate getting things done. But of course the language wasn’t that. The language was, Bruera wants to have a unit, Bruera wants to have an outpatient center. Bruera wants to have this or that. Bruera is concerned about the opioid use in the institution. What happened is people started asking, who is Bruera? Well, a guy who is coming from Canada, up north, and of course people who were in my business knew me well, but the oncologists, radiation therapists and surgeons here, had no idea who I was. Of course, their first reaction was no, we’re not going to give him this, we’re not going to give him that, because it’s not something we really care for and we believe in and so on. And who is this guy anyway? So it was a big task, to bring back progressively, some understanding from senior leadership that this was good, this was important. In the process, it required moving from the Division of Anesthesia and Clinical Care, all our department to the Division of Cancer Medicine. That was done by Dr. Mendelsohn, when I went to talk to him and said you know, this is unfortunately not going to succeed where it is because we are reaching a ceiling and we can’t get to the patients. To his credit, John Mendelsohn immediately caught the idea that the program was getting a bit stuck.

Tacey A. Rosolowsi, PhD:

Now, so the Division of Anesthesia and Clinical Care, that was the original department that you were put in?

Eduardo Bruera, MD:

My department was established there initially, in that area, but it became clear that it wasn’t a good fit at that point, because they were not so understanding of what it was that we did. When I went to John Mendelsohn, I said you know, I’m quite happy to resign and to move on. I just want to tell you that regrettably, the arrangements are not allowing us to do this. He thought about it and said, “Well, give me a week or two, Eduardo.” He called me back and said, yes, we’re going to move you under Dr. Waun Ki Hong [oral history interview], who was the head of the Division of Cancer Medicine at that time.

Tacey A. Rosolowsi, PhD:

Now let me ask you, how soon after your arrival did you have this conversation with Dr. Mendelsohn?

Eduardo Bruera, MD:

Two and a half years, more than two years.

Tacey A. Rosolowsi, PhD:

Oh, okay, so you kind of bashed your head against the wall for quite a while.

Eduardo Bruera, MD:

Oh yeah. Two or three years it was. Two and a half years about that, two or three years in which we were kind of banging our head on the wall, because we were desperately trying to get the unit going, to get the Outpatient Center going, to get the growth in referrals and so on, and also to get some of the research going. But when the division does not really understand what you are about, it cannot be supportive, because it would be kind of failing to their own values. So we had to go to a place where they could understand what we were doing. Then to his credit, Dr. Hong took us and he basically honored some of the commitments that were made before I arrived, that we already delayed by about three years. He looked at my letter of offer, he looked at what he were doing, and he banged his hand on the table and said, “We’re MD Anderson, we’re going to honor our commitments, we’re going to get the unit going,” and basically that’s what he did.

Tacey A. Rosolowsi, PhD:

Wow.

Eduardo Bruera, MD:

He went up to Dr. Callendar and he went to other people and said, “We’re going to get this unit done because we said we were going to get this unit done.”

Tacey A. Rosolowsi, PhD:

Now, the division, Dr. Hong’s Division of Cancer Medicine?

Eduardo Bruera, MD:

Yes.

Tacey A. Rosolowsi, PhD:

Right, okay, just making sure.

Eduardo Bruera, MD:

He was the one who finally said, we are going to do this, we’re going to do an external review. When the moment came to do an external review --and our department was the first department to undergo an external review of all the departments in the Division of Cancer Medicine-- and we fortunately passed that external review with great recognition from the reviewers from Harvard and from Memorial Sloan Kettering. So we had reviewers from our competitors that came to review our program. After the review, he felt reassured that the support he had given us was worth it. Then he also supported us further, to allow us to get more positions and to start creating an environment where oncologists and other people would really start seeing us walking the corridors and seeing patients.

Tacey A. Rosolowsi, PhD:

What was the year, if you can recall, where you went through that external review?

Eduardo Bruera, MD:

Well, the year in which we moved might have been 2002, and the external review may have been 2004, 2003, 2004, so it was a year or two after the move.

Tacey A. Rosolowsi, PhD:

Now, tell me a little bit more about once you got the support of Dr. Hong, what were the steps you took to develop things, because I’m sure in the process, you also began to look around the institution and say oh, I hadn’t thought of that, I hadn’t thought of that.

Eduardo Bruera, MD:

I had already gone through the strategy, before we moved to Cancer Medicine, of meeting with a small group of leaders that were busy clinical leaders from the institution, and have breakfast with them, pay them for breakfast and ask them for their thoughts, their advice. And also in the process of doing that, sell them the type of work we did, and ask them to send us some patients and see if that works for you.

Tacey A. Rosolowsi, PhD:

Who were some of these folks that you met with?

Eduardo Bruera, MD:

We met with physicians from Cancer Medicine, the majority, but also some gynecological surgeons, GYN oncologists, and I think they were mostly Medical Oncology and GYN oncologists, because those are physicians that, especially at that time, had a lot of continuity with the care of the patients. The surgeons and radiation therapists are more episodic care. They get involved but they do their treatment, and sometimes the patient doesn’t follow with them. Oncologists and GYN oncologists continue very much on the care, and so we thought that those might be an easy target and we started getting some initial referrals from them, and then what we did is we avoided going into any presentation, any auditorium or any presentation in public, about our program, because in absence of data, all opinions are good, and we knew that in general, opinions about person centered care and palliative care at that time, were seen in a very unfavorable way. And so people with great prestige in the house might be very negative or very derogatory of our comments about what we wanted to do, so we kept a very low profile until we had seen a couple of hundred patients. Then, once we had data from a couple of hundred patients, then we were able to start doing some presentations in auditoriums and grand rounds, because what we were doing was not just showing that the patients were referred to us, that nothing went wrong, that the patients were feeling better, that the referring doctor was going home earlier. We were doing some publications and papers and by the way, some of the ones who have been sending patients are here in the audience and if you want to ask them, you can now ask them. Those presentations started, in a sense opening the field a little bit more for us. Now, colleagues that had never referred a patient before started saying, well, I’m going to give these people a trial. We made a policy of being very, very available. We started covering the service twenty-four hours, seven days a week. Our center, from the very inception, started taking patients on the same day. So if a doctor had a patient who was uncomfortable or having a bad time, they could send the patient, that same day to our center. We still have that policy right now. That also made us very nice for them, as compared to other clinics in the hospital, that were a bit harder to get a patient to. We were very, very accessible, both in the inpatient service and in the outpatient service.

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Chapter 07: Starting a Palliative Care Service

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