Chapter 07: Coming to MD Anderson to Learn Palliative Care on the Job
In this chapter, Dr. Fisch explains how he moved to MD Anderson from a position as Assistant Professor at the University of Virginia Health Science Center in Charlottesville. He recalls management issues in Charlottesville that helped convince him to take another position. He talks about presenting a paper on cancer and depression at a conference held by the American Society of Clinical Oncology. There he met Dr. Eduardo Bruera, who had been recruited to set up a palliative care program at MD Anderson. Dr. Fisch describes the advantages of the offer he was made to join MD Anderson to help establish that program, working from the Department of Critical Care and Anesthesiology.
Joining MD Anderson/Coming to Texas; Joining MD Anderson; Professional Path
Tacey Ann Rosolowski, PhD:
So what opportunities did that all open up? I mean, this was like a watershed moment.
Michael Fisch, MD:
Yeah, so that’s a watershed moment, and it did two things. One, so I took my first job back at the University of Virginia. My strength of my clinical training was genitourinary medical oncology, which is the strength of IU’s work. Then I also had a combined appointment in the Department of Health Evaluation Sciences. A guy named Bill Knauss [phonetic] and Al Connors [phonetic] was there, and these were very highly regarded health services researchers. Bill Knauss had led the support study, a big famous study at the time. Anyway, I had great mentors. And I had two offices. So I had a combined appointment. I had an office in this place and then I had an office in Hem/Onc, and I had this tremendously busy clinical life doing all the GU cancer care. But also it’s like living two lives. Then I’d try to be a health services researcher in between the lines. So you can’t imagine how much work that is. It was just playing two career hands at the same time, but you can do that in the first—you know. You’re young. You’re fired up. I wrote an R01. I didn’t know any better, so I wrote an R01 and a P30 grant and an ASCO Young Investigator Award. I mean, in the first two years I was there, I was building a practice, I was working as a clinical trialist with ECOG, and I wrote a trial there. In fact, I started to work on a trial that I’d gotten going during my fellowship, a Prozac vs. placebo for advanced cancer patients, coming basically out of that question from that V.A. patient. That V.A. patient question led to a retrospective chart review study that I did as part of my MPH about how frequently antidepressants were being prescribed in cancer patients. So I figured out how to use the electronic record and do that project as part of the MPH. Then we formulated this prospective trial with the Hoosier Oncology Group, which was a consortium that my IU colleagues were leaders in, and they helped mentor me to put that study together. So I was running that trial now at UVA and being a trialist and writing this health services research stuff and just working hard. What happened there in my first two years is that UVA seemed to have some resource constraints and, I think, really conceptual restraints about how to value oncologists ultimately. I was sharing with the thoracic expert a nurse and we were sharing one secretary, so I had a half nurse and a half secretary. And then our nurse started to be asked by the administrators to do certain night shifts so that she wasn’t always available to us in clinic, so it was really less than half a nurse. And then our secretary took another job somewhere else in the institution, and they decided not to replace this secretary. And I thought, you know, if I can’t have a half nurse and a half secretary—I mean, we were borrowing other people’s secretary with no intent to fill that. I thought, “This is not going to work. This is not possible.”
Tacey Ann Rosolowski, PhD:
Was that some weird political vote on—
Michael Fisch, MD:
You know, I think it had to do with the attribution of value of oncologists, because if you look at oncologists and only credit them for the evaluation and management of the patients and the billing that goes with that, then they’re just like expensive, needy rheumatologists. They need a lot of resources and support to do a cognitive discipline. But in truth, oncology was lucrative because lab and path and imaging and chemotherapy was driving lots of revenue, and so that’s true here and it was true there. But the revenue was not being attributed to the oncologists; it was being attributed to the Cancer Center. So if you didn’t really know the business of oncology, you might have the misperception that the pharmacist in the Cancer Center is the world’s most valuable individual who should have gold-lined walls and marble sink, and the oncologists are worthless and you can’t even afford a half secretary for those worthless individuals. So I think it just got misunderstood, and in a matrix hospital like that, it seemed to me—this is just my naïve view at that time, but it seemed like they understood the business of how do you make a Heart Center work and what’s the business of cardiovascular care and what’s the business of orthopedics care, but the business of cancer care was different, the model was different, and it was conceptually not well understood by everybody. It was understood by some people. But it was possible to kind of get off kilter in how you thought about how to attribute value. They were paying me $91,000 a year to work very, very hard, and I probably would still be there if they would give me, you know, a half secretary, a half nurse, and about 2 percent increase per year, but they didn’t. (laughs) So I became open-minded to what other options there might be, and that’s where MD Anderson came in because I presented a poster about some of this depression work, some other depression project that I had going on at UVA that I’d started in those two years in my health evaluation sciences realm. And I presented at ASCO in the spring of ’99, and Dr. Bruera, who was in Edmonton at the time, but he’d been recruited to start Palliative Care at MD Anderson, and he was looking to build his faculty, he saw my work and talked to me at ASCO and basically offered me a chance to come work for him. It turned out that that would be a chance to work with a very famous, brilliant guy who’s a specialist in palliative care. I had nobody to sort of teach me quality-of-life stuff at UVA, and was just a self-declared interest guy, but I didn’t have a way to learn it other than by myself. But here’s somebody who was established in that field, could teach me, who’d build a department. And I’d get an 80 percent raise and I’d get some basic resources. I thought, “I’ll try that.” There’s no fellowships in Palliative Care at the time, right? So you could just declare yourself Palliative Care faculty, self-declared, “All right, I’m that now,” and I’ll learn on the job, and they’ll pay me on the job to learn palliative care. I remember telling my family, who were very upset to leave central Virginia, because Charlottesville is kind of right in between where my parents and my wife’s parents were, so it was a perfect situation for us, but professionally it wasn’t perfect. So go all the way to Texas for what? But I thought, “You know, I’ll come here for a few years, and I’m very interested in learning this stuff, and if I don’t like it, I’ll go back and do what I do. But, you know, nothing bad could happen here. I don’t see what bad comes out of coming to MD Anderson, working with this kind of person in this environment. The narrative of my career will not be ruined by this move.” (laughs)
Fisch, Michael J. MD, MPH and Rosolowski, Tacey A. PhD, "Chapter 07: Coming to MD Anderson to Learn Palliative Care on the Job" (2015). Interview Chapters. 830.
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