Chapter 08: Building a Palliative Care Program at MD Anderson
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Description
In this chapter, Dr. Fisch talks about the challenges faced as he and others set up palliative care program at MD Anderson from scratch. He defines palliative care, which he stresses is much broader than pain management. He also explains how the culture of MD Anderson worked against acceptance of palliative care. Dr. Fisch notes that the palliative care program stressed quality of life and that a decision was made to change the name to the Supportive Care Center to help overcome resistance . He gives examples of how he and other palliative care providers would figure out how to “create an interface” with treating oncologists, so they would integrate a palliative care provider into the team.
Identifier
FischMJ_01_20150205_C08
Publication Date
2-5-2015
City
Houston, Texas
Interview Session
Michael Fisch, MD, Oral History Interview, February 05, 2015
Topics Covered
Building the Institution; MD Anderson History; MD Anderson Culture; Overview; Definitions, Explanations, Translations; Building/Transforming the Institution; Multi-disciplinary Approaches; Growth and/or Change; Obstacles, Challenges; Professional Practice; The Professional at Work
Transcript
Michael Fisch, MD:
So I came, and it was the most strange experience, because I leave the common world of Internal Medicine Division and Department of Hematology/Oncology, and then I come here, and Tom Feeley was my first chair. He’s the head of Critical Care and Anesthesia. So I’m in the Division of Critical Care and Anesthesia. That’s where Palliative Care and Rehab sat. Eduardo [Bruera] had come in July, by July he showed up, so it was July of ’99 he starts. By November of ’99 I’m here. I gave them seven weeks’ notice at UVA. In hindsight, I should have given them longer. I didn’t know how to properly transition from one place to another. But they seemed to want me to come here fast, and so I did. (laughs) But then I’m working. The initial sort of culture, the natives who are already here were anesthesiology-trained cancer specialists, so these were not Internal Medicine. These were people who were not acculturated the way I am. They’re not from my tribe. (laughs) They’re not oncologists. They’re not even internists. They’re anesthesia pain people who do a lot of procedures. Dr. Bruera’s goal was to recruit medical experts like me and other palliative care experts, and he recruited Donna Zukhovsky and Paul Walker [phonetic]. Suresh Reddy [phonetic] was an anesthesia-trained person who was there at the time. Larry Driver [phonetic] was there at the time. So those faculty, Suresh Reddy, Larry Driver, Donna Zukhovsky, Paul Walker, were already professionalized in this realm, and they were not tabula rasa, learning on the job. They were recruited because they know what they’re doing. I was recruited because I was willing to learn. (laughs) But anyway, they were great people and I was able to learn from them. And as we were building from scratch, we weren’t super busy at first, right? We had to sort of show up, and people had to figure out how to ask us to do anything. So it was very disconcerting at first, it was so unusual.
Tacey Ann Rosolowski, PhD:
What was going on at the institution at that time that motivated the creation of this department, Palliative Care?
Michael Fisch, MD:
Yeah, that’s a good question, because that’s a backstory that I—you know, the part of the frontstory was Eduardo had a job to give and had a lot of charisma and had a lot of ability and—
Tacey Ann Rosolowski, PhD:
And Eduardo is Dr. Bruera?
Michael Fisch, MD:
Yeah, Dr. Eduardo Bruera, the chair of that department. He’s the most famous person in the field now, and he was pretty much the most famous person in the field then, prolific and brilliant. So it was easy to want to come work for him. He has since built an incredible department that has twenty-plus faculty, but I was one of the very first. I think I was the first externally recruited person to arrive, at least to show up and be in the office. It was a fabulous, interesting experience. But what was happening in the institution at the time is hard for me to know, because, in a sense, I was not privy to all that. But I think there was interest in pain—I think they’d had a pain team. They’d had some other people before Eduardo who were more like pain specialists.
Tacey Ann Rosolowski, PhD:
Yeah, like C. Stratton Hill had—
Michael Fisch, MD:
C. Stratton Hill and—
Tacey Ann Rosolowski, PhD:
—who I interviewed.
Michael Fisch, MD:
So they had sort of a Pain Clinic story. But Eduardo was being recruited to get beyond pain, a bigger model, and Palliative Care was not nonexistent. It was existent at that time, but nascent and not really integral to oncology thinking.
Tacey Ann Rosolowski, PhD:
Could you define for me “palliative care”?
Michael Fisch, MD:
That’s a fabulous question. One of my earliest experiences coming here was—so I show up here, and I’ve got “Palliative Care and Rehab” on my name badge, and I’m on the elevator, and you can tell that people are looking at you, trying to figure out—you’re a new face, and looking at your name badge. I remember on one elevator ride, one of the faculty there—I can’t remember who it was, but an older established MD Anderson faculty, goes, “Oh, you’re with the body bag service.” And I was taken aback by that, and I started to try to explain what palliative care was, and I don’t remember what I was saying, but it sounded a lot like a lot of babble. This was the classic elevator speech, right? Ether you’ve got something ready to explain about what is palliative care on an elevator, because you’re on an elevator, or you don’t. And it’s the body bag service until you explain otherwise. And my first experience with that was a fail of some sort. So I went back to my office and I found a definition that I was going to be able to use, and it was one written by Andrew Billings, who was at, I think, Mass General at the time. So palliative care, the way I decided I was going to explain it, is comprehensive interdisciplinary care focused on patients and their families when the patient’s living with a serious chronic illness, and the goals of care include improving quality of life and reducing suffering. So more or less those kind of five bullet points kind of come to mind for the elevator spiel. At least that made me feel like I was qualified to have that on my name badge. And then I found that very useful, right, because referring doctors wanted to know. Patients and families, “Why am I being referred to—why am I seeing you? You’re what? What’s palliative care?” So that question was a quite useful question. If you can’t make any sense out of that, things aren’t going to work.
Tacey Ann Rosolowski, PhD:
It’s interesting, when I was interviewing, I think it was C. Stratton Hill who told me this, because there was the whole issue of when or how did MD Anderson get connected up with Hospice, and apparently there was a resistance when, I mean, R. Lee Clark was, like, adamant, “No, we’re not going to get connected up with Hospice, because Hospice is about dying, and MD Anderson is not about dying.”
Michael Fisch, MD:
Well, that’s exactly right, and that actual reluctance has been present here and present everywhere in cancer medicine, you know, globally, that avoidance of the association. You’re either coming to our Cancer Center for hope and life and cure. Nobody comes here so they can die better. If we make dying better, dying easier, quality of life our emphasis, then people are going to reject us and they’re going to go to our more hopeful competition. So it’s been hard. I mean, it’s been a fear fest in that sense. The question is how do you bring both? How do you strive for novel treatments, hope, curative therapy, aggressive care, if that’s what people want and when it’s appropriate, you know, how do you pull that off without enhancing the suffering or reducing opportunities to mitigate suffering, and how do you do that. So it’s been puzzling, and we struggle with that. So we found that talking about palliative care was always associated with Hospice. It’s sort of just a mental association, and palliative care linked to Hospice, linked to dying. “I don’t want that.” So we started to talk about our work as emphasizing the quality-of-life stuff. We’re the quality-of-life guys, you know, like the car guys. We’re the quality-of-life guys. Then we started talking about we probably should change our name badge. We should call ourselves something else. (laughs) And that was debated for a number of years and eventually—this is after I left Palliative Care to get into General Oncology, but eventually they did that and changed the name from Palliative Care Center to the Supportive Care Center and have actually published about what that name change has meant. So that work has been done, but before that change and the subsequent publications was a lot of dialogue and a lot of resistance, because in the field the issue was—and I always felt that our department was more or less palliative care centrists, so true palliative care, and what they wanted to do is just get everybody on the right page about what true palliative care is, why it’s important, what people need, and how to understand it properly. And they were seemingly a little bit more suspicious of things on the edge of palliative care, like, to me, sort of a bubble of palliative care in oncology and at the interface is what I was interested in. But at the interface is where things are most different from centrist palliative care. So the centrists were not always happy with the palliative care at the edge of oncology.
Tacey Ann Rosolowski, PhD:
And what are some of those things at the edge?
Michael Fisch, MD:
Well, one might describe it as the sort of things where you sort of holding your nose while people do things that you might not want to see them doing, you know, giving extra chemotherapy while you’re trying to work on symptom management, or, you know, it’s basically a negotiated version. Like in order to have the privilege to get involved with care, you can’t have a non-negotiable style about what’s going to happen. Who’s going to be talking about prognosis and what’s the story? You can’t have a counterstory to the treating oncologist, because that doesn’t have a favorable effect on patients and families. They just realize, “These people aren’t on the same page. They’re confusing me. Which is it?” So unless you want to make people suffer, you’ve got to figure out how to influence care by harmonizing with the treating oncologist, and that means they might do things that you might not always agree with. Or, for example, if you want to start morphine or if you want to use methadone because the morphine that’s being given to the patient is not being well metabolized and it’s making them confused or twitchy or delirious, and you want to switch the patient to methadone, which you think in a sense will burn cleaner and be a better way of achieving the goals, well, what if the oncologist doesn’t want to do that because they don’t like methadone, because they associate that with addicts or they think it’s dangerous or they’re just unfamiliar, they’re just not going to do it? Well, you need to come up with some other idea. You’ve got to switch to something else that they’re willing to do, or maybe you’ll get involved with helping in ways that they’re willing to let you help. So maybe they don’t want to switch the morphine at all, even though you think it’s a good idea, but maybe you can talk to the patient about working on their bowels or helping them get hydrated. So in a sense, if the clinical problem is opioid toxicity and you actually feel like you can solve it by switching the opioid but that’s not comfortable enough for the treating oncologist, then try to switch it by improving the patient’s renal function by hydrating them, by solving their constipation problem, by making yourself useful in some other ways. Do something useful that you’re allowed to do, and over time you’ll gain some credibility, and maybe they’ll see some other people get opioid rotations or get switched to methadone, have things go nifty, and begin to have more confidence in you. But you’ve got to be willing to sort of start with whatever role you’re given, being the water boy, being sort of the water boy on the team. You have to be very humble and, of course, it’s easy for me to be humble because I was just learning this stuff anyway. But I think it’s harder if you’re a palliative care centrist and you know how to do things, and you come to a place where people are not respecting what you know how to do or even let you exercise your skills to help patients. It takes a certain resilience to put up with that.
Tacey Ann Rosolowski, PhD:
But I tell you I’ve had so many conversations with people along these same lines, you know, basically have come up with a new idea, and basically having to prove literally case by case that what they have to offer is legitimate, and then building a constituency and a demand for their services through that step-by-step process.
Michael Fisch, MD:
Yes. So probably this entire story of the seeding of Palliative Care at MD Anderson is not very different than the seeding of any innovative new thing.
Tacey Ann Rosolowski, PhD:
Basically.
Michael Fisch, MD:
It’s the same formula.
Tacey Ann Rosolowski, PhD:
Particularly when it involves multidisciplinary interactions like that.
Michael Fisch, MD:
Yeah, it’s the same on the—
Tacey Ann Rosolowski, PhD:
Not to diminish your pain. (laughs)
Michael Fisch, MD:
No, but, I mean, we only live one story, so it’s the only story we know. But I think probably true that it’s a very general thing.
Recommended Citation
Fisch, Michael J. MD, MPH and Rosolowski, Tacey A. PhD, "Chapter 08: Building a Palliative Care Program at MD Anderson" (2015). Interview Chapters. 831.
https://openworks.mdanderson.org/mchv_interviewchapters/831
Conditions Governing Access
Open
