Chapter 05: Uncertain about a Career at MD Anderson

Chapter 05: Uncertain about a Career at MD Anderson

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Description

Dr. Escalante explains her career moves as she was nearing the end of her residency and describes the process that brought her to MD Anderson in 1988, to be part of the new Section of General Internal Medicine headed by Edward Rubenstein. She recalls that she had done a rotation at MD Anderson when she was an intern and found it very difficult to adjust to a context in which patients were doing poorly. When a position opening in 1988, she wasn’t certain it would be a good fit, but decided to take the job for a year to think things out.

Identifier

EscalanteCP_01_20140603_C05

Publication Date

3-6-2014

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Joining MD Anderson/Coming to Texas; Professional Path; Joining MD Anderson; Inspirations to Practice Science/Medicine

Transcript

Tacey Ann Rosolowski, PhD:

Can I ask you—I mean, just since we’re starting, you know, to talk about general internal medicine at MD Anderson, I mean, can you give me a snapshot of, you know, why is it important to have GIM people taking care of oncology patients.

Carmen Escalante, MD:

It was formed, in part, because I think people recognized back at that time and still today our patients don’t only have cancer; they have a lot of other co-morbidities, hypertension, diabetes, heart disease, that need to be taken care of. There are some more subspecialists in the department than there were back then, but still they needed someone to look at everything, that could do everything. And especially the surgeons, when we first started, were very supportive, because they needed someone to help manage their patients before and after the surgery. So Andy von Eschenbach and Helmut Goepfert [oral history interview] were probably the two most supportive people in getting GIM started.

Tacey Ann Rosolowski, PhD:

Wow.

Carmen Escalante, MD:

I mean, they—and we saw a lot of their patients, and back then we did not only inpatient and outpatient consults for general internal medicine, we did what was called Station 19, which is the Emergency Center, and then till a few years ago when they separated it off, all of that was part of general internal medicine. So we staffed Station 19, which later was renamed to the Emergency Center. Back then, all the clinics were called station and a number. There was Station 19A, 19B, and 19C, and B and C were the chemo areas, and A was the Emergency Center.

Tacey Ann Rosolowski, PhD:

Now, let me ask you. I mean, you said the surgeons were very supportive. Were there other subspecialties among the oncologists that were not, that had more questions about whether or not GIM people would be needed or—

Carmen Escalante, MD:

Well, I think it was a new concept. I mean, you know, this was a cancer center. What were internists, general internists, going to do in a cancer center? It was novel idea of, you know, what are you going to do. And I think the oncologists felt like they were internist in part back then, because they kind of did it all. And they had some cardiologists, they had a couple cardiologists, they had a couple pulmonologists and endocrinologists, but the surgeons were kind of holding the bag more so. I think they felt the impact more because the patients belonged to them, yet they had a lot of medical issues, and they liked the idea of one person being there to help them manage their patients.So if there’s something as a sponsor, it was Helmut Goepfert and Andy von Eschenbach. And when I started, primarily we’d go to their clinics and see the consults in their clinics. We didn’t have a space of our own. So I got to know everybody in those clinics. The nurses, they’d call us and say, “We have a patient here. They have this, this, and this. Can you see them?”And I’d say, “Okay.” I’d look—I had a handbook, and I’d say, “Okay, can you keep them until ten o’clock?” And I’d keep all my—you know, we’d make our own appointments, so I was doing inpatient in that. So I’d go see my inpatients. Then I’d go over to Head and Neck Clinic, it was Station—I don’t remember what the number was—54, maybe, and see the patient in one of their rooms, and the patient would go.So we’d schedule on site, you know, and then I’d go to Urology. They may have one next, okay. So I’d go to Urology and see theirs, and the physicians were right there, so I’d talk to them. I knew them all. They knew me. If there was a problem with the patient, I’d say, “Okay, this is what I think. This is what you need to do.” So I knew all the fellows. I knew all the attendings, you know. They’d see me in their clinics.

Tacey Ann Rosolowski, PhD:

So there was very much, I mean, a teamwork mentality about this from word “go.”

Carmen Escalante, MD:

Oh, yeah, yeah. And they were very supportive. Our business grew, I mean just skyrocketed, you know. We got more and more consults. Then Gynecology came on board, and we started seeing a lot of GYN patients. But those three surgical services were the first.Then at the same time, the other person was staffing Station 19, so we had only one person down in Station 19, and back then many of the oncologists would come down and see their own patients. So if you were down there—I remember when I started, GU oncology Logothetis would come down and see his own patients. And then as we saw more and more patients, I think they got more comfortable with us and saw that, you know, we could do a good job and we knew what we were doing, and soon we were seeing everybody, you know, not just the patients of some of the attendings, because they would have the choice, come down and see them yourself, which would take their clinic time. They’d have to stop, come down, see the patient, do whatever they want to do, go back up.

Tacey Ann Rosolowski, PhD:

Now, what kinds of emergency issues would arise that would require—

Carmen Escalante, MD:

Oh, just like today, fever, neutropenic fever, pneumonias, shortness of breath with heart failure, arrhythmias with—you know, everything you see today. It was a much smaller operation, you know, than what we have in the Center now. And back then, you know, when I first started, I mean, we didn’t even have a computer in our office. I mean, I got one, I guess maybe the second year I was here. I mean, everybody didn’t have a computer and a screen. And you had to call people. I mean, you couldn’t text them or anything like that. We had to call people, and if they weren’t in the office, leave a message. They’d have to call us back. I mean, we didn’t have the Lotus—you know, the email thing like we do now. It was a different world early on back in the late eighties, early nineties, until the technology came in and we did more.

Tacey Ann Rosolowski, PhD:

Now, it seems like this is really kind of a juggling balancing act and— (laughs)

Carmen Escalante, MD:

It was, and we needed more physicians.

Tacey Ann Rosolowski, PhD:

Yeah.

Carmen Escalante, MD:

Because, I mean, like if Ed was out, then we were doing both places.

Tacey Ann Rosolowski, PhD:

Right.

Carmen Escalante, MD:

So shortly after, within six months, we got a third person and then a fourth person, and so it grew very rapidly till about five or six people. I mean, I think as we proved ourself, we got more business, both on the consult side as well as Station 19 side. Back then, nobody cared about billing, you know. You did a little pink form. It’s hilarious when I tell the story of, you know, no one reconciled our bills. I mean, it was—

Tacey Ann Rosolowski, PhD:

When you say that, what do you mean?

Carmen Escalante, MD:

Well, to bill a person, you just had a little pink half slip, so you would just check a level. We didn’t even have to put diagnoses or anything like that. We don’t know what they were doing. And then people just collected these little pink slips and sent them in. So if they didn’t collect them or if they never got there, nobody knew, because there was no reconciliation process like we do now. Like all of our Outpatient Clinic visits, we have a person that goes back and looks to see if a bill is in, you know. Back then, it wasn’t an issue. Nobody tracked and made you aware of how much you billed or what your billings were like. Nobody talked about that. Never, never once was that discussed.

Tacey Ann Rosolowski, PhD:

Interesting.

Carmen Escalante, MD:

Yeah. It was a different era. (laughs) Obviously we must have been doing very well, but nobody was into the finances of, you know, “We’ve got to make sure we bill everybody.” I never got any billing training, you know, to say, “You bill this level when you do this, this, and this.” That came later. I mean, you just billed what you thought, and if you didn’t bill, you didn’t bill.

Tacey Ann Rosolowski, PhD:

Wow.

Carmen Escalante, MD:

And some of the documentation by some of the physicians was one line. You know, we had the big paper charts back then. We didn’t have electronic charts and we didn’t have electronic lab. I mean, you know, you’d get it on a piece of paper or they’d call you if it was high. I mean, it wasn’t at all, you know, like now where you just look in ClinicStation. And if they couldn’t find the chart, you were on your own, and some of these charts were this high, because it followed them. The patients carried their charts from clinic to clinic, you know. So if they had three appointments before, they had to carry these huge things from one appointment to the next appointment.

Tacey Ann Rosolowski, PhD:

Amazing.

Carmen Escalante, MD:

And that’s what you used to kind of find out what was going on with them. I mean, you wonder how we ever survived that and did the right thing. (laughs)

Tacey Ann Rosolowski, PhD:

Yes, it’s amazing. So you weren’t paying a lot of attention or there wasn’t a lot of attention paid to those kind of billing mechanics.

Carmen Escalante, MD:

Yeah.

Tacey Ann Rosolowski, PhD:

But I can’t help but think that there were other areas in which you really had to pay a lot of attention, how do I work out, how do I mesh with people [unclear].

Carmen Escalante, MD:

Oh, yeah.

Tacey Ann Rosolowski, PhD:

So tell me about some of those instances, working out how these services were provided.

Carmen Escalante, MD:

Well, you know, it was a team effort. Basically, as we grew in number, we divided up. Now, we were all 100 percent clinical. I had no free time for about seven years. There was no protected time. You were assigned to do clinical work. It was never discussed how we were going to get promoted. I was told when I asked early on that, “Oh, just do your work and you’ll get promoted.” But there was no set criteria, so you can imagine we were always on service five days a week, full service, so you never had any time. And if there was an expectation, it was you would do it after hours or on weekends.

Tacey Ann Rosolowski, PhD:

Now, why do you think you were told that, or why were the faculty in General Internal Medicine treated in that particular way?

Carmen Escalante, MD:

I guess we were considered kind of “help” service, that we weren’t—I don’t know. I mean, I’m projecting. Whether we were there just to help the oncologists and, you know, that we weren’t going to cure cancer, I’m not sure. But even with the Department of Medical Specialties, other medical specialties had protected time.

Tacey Ann Rosolowski, PhD:

Interesting.

Carmen Escalante, MD:

But we didn’t, and it took a while to get it.

Tacey Ann Rosolowski, PhD:

Now, we’ve been talking specifically about MD Anderson, but, say, in the country as a whole, I mean, was this overall a new thing, that there were—

Carmen Escalante, MD:

Yeah.

Tacey Ann Rosolowski, PhD:

So there wasn’t—so in a sense, I mean, your role as a generalist within a cancer center was really just being defined—

Carmen Escalante, MD:

Right.

Tacey Ann Rosolowski, PhD:

—as an entirely new—

Carmen Escalante, MD:

Right. You know, we were the first comprehensive cancer center to do it.

Tacey Ann Rosolowski, PhD:

Wow. I didn’t realize that.

Carmen Escalante, MD:

I mean, no one else had internists on their medical staff, and so it was a new thought of how—and once we were here, I mean, there were a lot of things that no one wanted to do that needed to be done, you know, staffing Station 19, helping the surgeons, you know. As we helped more and more of our surgical colleagues, I mean, today we have an anti-coag clinic.

Tacey Ann Rosolowski, PhD:

What?

Carmen Escalante, MD:

Anticoagulation Clinic.

Tacey Ann Rosolowski, PhD:

Okay.

Carmen Escalante, MD:

You know, over time it spread out. IMPAC is kind of what we were doing back then as our Internal Medicine Perioperative Assessment Center clinic, but it wasn’t formalized and we didn’t have space of our own, so we went to everybody’s clinic. But now it’s a huge production that I think stemmed out from those early days, that I hired—Sunil Sahai is the face or the director for that program. But as we went forward, there were all these little pockets of things that weren’t being taken care of that the patients needed care, and, you know, we were internists. We were general internists. We could do a little bit of everything. Like staffing the ATC, the Ambulatory Treatment Center, they needed someone to be available so if a medical issue came up, we could take care of it. And so, you know, we started doing it. We still do it today, so the oncologist wouldn’t have to leave clinic, because sometimes these patients show up for chemo and they have fever or they get chest pain or they have a reaction to one of the drugs. So in the old days, the nurses would call the oncologist. The oncologist would either have to stop or go down there, see the patient, move them to the Emergency Center. So that was one of the things that were added on to our group, to be available so that if something came up, we’d go and take care of it and let the oncologist know, and move them if we needed to move them or treat them if we needed to treat them and let them finish their therapy.

Tacey Ann Rosolowski, PhD:

So it sounds as though at the beginning—I mean, it makes sense with an entirely new role like this—it was very clear what you had to do, but it seemed as though it took a while for people to understand that what you did could be enhanced by actually studying it—

Carmen Escalante, MD:

Yeah.

Tacey Ann Rosolowski, PhD:

—doing research on how these support services were delivered.

Carmen Escalante, MD:

Right, right, because the research aspect didn’t come in for a while.

Tacey Ann Rosolowski, PhD:

Right, and that’s what you need the protected time for.

Carmen Escalante, MD:

Right, right. I mean, it’s hard to do that when, you know, your whole days are assigned to services.

Tacey Ann Rosolowski, PhD:

Sure.

Carmen Escalante, MD:

As we got busier and busier, it just really took off, and everything, over the years, every new program we started has just taken off.

Tacey Ann Rosolowski, PhD:

Amazing.

Carmen Escalante, MD:

So these patients are sick, many times they’re away from home, they have all these medical issues. Even the ones that are local, sometimes their internist just doesn’t feel comfortable managing them because they don’t know all the aspects of the drugs they’re getting. I mean, you know, when we were training, that was like, oh, all these special things happened to these people, and I don’t know how—you know, if you don’t do it a lot, you really don’t have any idea how to manage neutropenic fever or, you know, how to know that radiation to the chest, you can get early angina and coronary disease. So, you know, I was green when I started. I mean, you kind of learn all this on the job. As I took care of people, I mean, I learned. In residency, I hadn’t learned this. I mean, I had two months of oncology in my intern year, and that was it. So coming to a place like this where you had all these very complex patients getting drugs I’d never heard of, or Phase 1s with numbers, it was like, oh, it took a little adjusting, and, you know, curb-siding. “Okay. This is what I think I need to do. What would you do?” kind of thing until my confidence built over the years. (laughs)

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Chapter 05: Uncertain about a Career at MD Anderson

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