Chapter 24: The Schwarz Rounds at MD Anderson and Mindful Medical Practice
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Description
Dr. Fisch talks about the Schwarz Rounds implemented at MD Anderson in 2007. He describes the focus on the experiences of the care providers and the emotions that come up for them while offering care to patients. He explains that the need for the Schwarz Rounds arose because the Medical Oncology fellows were experiencing fatigue and burnout. Dr. Fisch explains why the program stopped.
Next, Dr. Fisch talks about mindful medical practice, which helps reduce burnout and fatigue among. He gives examples of the stresses of an oncologist’s job. He notes that the value of awareness is increasingly recognized in medicine. He has worked to bring visibility to the issue at MD Anderson by drawing attention to research that shows how mindfulness can ensure delivery of high-quality care.
Identifier
FischMJ_03_20150218_C24
Publication Date
2-18-2015
City
Houston, Texas
Interview Session
Michael Fisch, MD, Oral History Interview, February 18, 2015
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Michael Fisch, MD:
One of the things we did at MD Anderson is something called the Schwartz Rounds, and these were rounds that were initiated in Boston through the Schwartz Center. There was a specific patient who had been very much touched by the compassionate care he received towards the end of his life as he died of lung cancer, and there was some money that was donated to found this initiative towards compassionate care. What they were doing is having these rounds where the providers, instead of focusing on the medical problem at hand, that sort of typical case conference where the patient’s problem becomes the issue, you know, “This is a patient with human papillomavirus-induced anal cancer who’s been treated with this and that, and this is what our outcomes are,” and blah, blah, blah, but the patient gets lost in this, and the emotions and the experience of the providers get lost. The Schwartz Rounds was more focused on the providers and their own experience and their own reactions and sometimes emotions in the course of the care. So, a very different kind of rounds, and almost hard to wrap your head around. So when this came up, the reason it came up is to solve a problem, and the problem was that the medical oncology fellowship, as we’re being evaluated by the Graduate Medical Education reviewers, the fellows indicated a certain amount of fatigue, too much fatigue and sort of burnout in their work. And then you have this gap, you know, you have this issue, and then you have to dream up what your action plan is going to be. So people were brainstorming on this action plan. And Dr. Bob Wolff, who’s actually now the ad interim chair of General Oncology, and who was also the head of the fellowship program, and at the time he’d heard somebody mention Schwartz Rounds, and he thought, “Maybe we’ll implement Schwartz Rounds as an action plan to address this gap and see whether our fellows—we’ll ask them to come and we’ll see if their fatigue and burnout would improve because they’d have a chance to talk about their own experience of care, and this would be healthy.”
Tacey Ann Rosolowski, PhD:
When did that happen?
Michael Fisch, MD:
I’m trying to remember. I’m thinking this might have been 2007 or so. That’s my guess, roughly that. So it’s a while ago. But anyway, so we ended up going to Boston to see the Schwartz Rounds in action, because it was hard to wrap our head around exactly what this would look like. But it’s one of those “See one, do one, teach one.” But once we saw it, we got what this was about, and then we started to do it here, and the audience would be our fellows. We’d divide everybody, the whole—anybody in the institution that wanted to come to Schwartz Rounds could come, but we focused on our fellows, made sure it would work on their schedule, made sure we got them to the table, and started to conduct these things. You needed to be able to moderate with not just a doctor, but a doctor and social workers. So Marlene Lockey, who is a social worker in Palliative Care, she co-facilitated it with me, and we started to do that and we had a lot of success. That is to say that we had interesting topics. It was very much appreciated by the fellows in the institution. The Schwartz Center was very careful about and very regimented about their evaluation process and how it was implemented, and they were happy with how it was going. In fact, they started to send other people who wanted to start Schwartz Rounds, would come and watch our Schwartz Rounds learn, just like we had in Boston. We became kind of like a regional place. If it was easier for you to get here, then you could come see us do it, and then you can do it.
Tacey Ann Rosolowski, PhD:
How quickly did it take the fellows—how quickly did they understand what it was about and really participate in it wholeheartedly?
Michael Fisch, MD:
It didn’t take them very long. I’d say within the first two Schwartz Rounds. Because the one thing about the fellows is, you know, they get to know each other and feel safer around each other. So once they kind of figure out what you’re doing and then became part of the woodwork, it’s easier to make it—it’s easier for them when it’s part of the woodwork, you know, because they come in tabula rasa. You know, training is whatever it is. If Schwartz Rounds is part of what you do here, you know, then it’s not that weird. The weird part’s for the rest of the world.
Tacey Ann Rosolowski, PhD:
Yeah, I was going to ask what about the faculty then.
Michael Fisch, MD:
Right. The faculty, harder. Fellows, you know, this is all they know if they’re getting started. It’s maybe a little harder for the fellows who had two years without Schwartz Rounds, but the ones that just come in and then Schwartz Rounds is part of the show, well, it’s part of the show. (laughs) So I thought it went very well, and they sort of became a guaranteed audience, you know, like a guaranteed number of ticket sales at an event or hotel bookings. We got a certain number of guaranteed bookings because we knew the fellows needed to come. And then there was a certain amount of energy in the room, and other people would come, and people seemed to really appreciate it. And then you think, well, are you still doing Schwartz Rounds? And the answer is we’re not. And what happened was there was sort of institutional financial crisis, like a cash crisis, for a while, and even though the Schwartz Rounds was paying for lunches—I mean, part of the way this worked is the Schwartz Center would pay for the lunches and you’d have a lunch conference, so people during their lunchtime would get to eat food and participate in this thing. But the institution was saving cash and said there was sort of no food allowed at conferences for a while, and even though the food was free, it still fell into the no food, like, “If we can’t have Schwartz-paid food, well, we’re not doing food anywhere else.” So it sort of screwed it up in that sense. And then when that cloud lifted, we sort of lost some energy. And the other thing that we lost was the institutional—like you need to prioritize the scheduling preference. That is, if the Schwartz Rounds was once a month in a different random place in the institution, it’s hard to want to go. Sometimes it’s far from your clinic. Sometimes it’s a little closer. At lunchtime, if you can’t get there on time and then get back to where you need to be, it doesn’t work. So for a clinically oriented thing, it needed to be situated closer to the clinical flow, but we didn’t have priority place in the scheduling, so we were very much left to random scheduling and often difficult scheduling. So I just became kind of weary of fighting that fight, and it had already sort of served its purpose. That is to say, it was born of a certain need and then that need came and went, and even though it was a good thing, it had no owner. Nobody institutionally said, “This is important. Let’s keep doing it, and if it needs to be prioritized space-wise, then we’ll do that.” There was sort of no overarching caretaker of that, and so we let it go. Now we’re trying to invent it again.
Tacey Ann Rosolowski, PhD:
Yeah. I was seeing the whole mindful medical practice, but is that where you were—
Michael Fisch, MD:
Yeah. So the mindfulness is can you notice what’s happening to you, what your thought process is? Can you get your head on around what’s about to happen? I’m about to break bad news. I’m going to go in and tell this woman that her cancer’s relapsed, which is going to be very hard for her because her son’s in the ICU with relapsed cancer right now, and her other son is very upset and needs her, and her husband is taking off too much time from work, and they’re not going to have enough money. And, you know, you start to realize this is really bad and this woman is—her son’s my son’s age, and just noticing what you’re dealing with and how it’s affecting you and—
Tacey Ann Rosolowski, PhD:
There’s that idea of vicarious traumatizations, you know, that people have, I guess, in working in emergency sites where you just take on and take on the emotions of the people around you as they’re suffering.
Michael Fisch, MD:
Yes. So can you notice what’s happening within you? Let’s say bad news breaking. Bad news breaking goes particularly bad when you don’t know that’s what you’re doing, where you haven’t thought about it as a procedure. If I’m going to go have a family conference, that’s a certain kind of procedure. How do I want that to go? What’s going to happen here? What are the best practices around that? What’s a skillful way to do that? If I’m breaking bad news, noticing my own reactions, knowing what I’m trying to do, knowing how skillful people do that.
Tacey Ann Rosolowski, PhD:
Now, aside from becoming more functional, I mean, obviously what you’re saying, getting your head around it, learning how to perform better, what are the other advantages of mindful medical practice for the clinician?
Michael Fisch, MD:
Well, I think it helps clinicians reduce their own burnout and fatigue, that once they notice what their own experience is and have a game plan, that they tolerate it better. It’s sort of like maybe there’s still rain, but they have a bit of an umbrella and they don’t get quite as wet, so the mindfulness umbrella, partial protection, a little drier, a little bit better able to sustain the work. One of the real connections around this stuff is also being willing and able to get support from your own colleagues, to talk about what you’re doing. “I’m about to break bad news. How can I do that better?” Or, “I feel very frustrated now. I’m going to take a very short break before I get ready to go back and see my next patient.” If you don’t know that that’s what’s happening, and you just keep going into the rain, things go worse. But if you can notice it and you can verbalize it, or maybe somebody—you can verbalize it and notice it and then somebody could say, “Why don’t you take a short break, and we’ll help you and we’ll do this or that while you go gather yourself for a few minutes.” Or maybe somebody needed to go cry or whatever, but then come. But you can’t begin to make anything work out if you don’t notice what’s happening. So you make that more part of the culture of being a doctor and being a team member. And there’s quite a lot of progress in that regard in medicine overall, but trying to let some of that progress take shape for us personally and for our trainees and make sure our trainees become affected by the growth in that work and notice it when it’s being published in our own journals and notice the world around us, because we can get into our own little cocoon where we notice a specific subset of that which is happening around us scientifically and medically, but ignore another set of progress and not know how to pipe it all in. It’d almost be like the world of cardio-oncology making progress and somehow that being off the radar, so we would just become indifferent or just late to the show. You don’t want that, right? When cardio-oncology techniques start to be known, you want to be able to apply them to our patients as soon as there’s knowledge to be applied. And if there’s research questions to be asked, we want to be able to participate or innovate in that regard. And I’d say the same about compassionate care, palliative care, mindful practice. We want the best for our patients and for the science, and this is part of it. But again, I think it requires not just a set of people who know this, but they’re a little bit marginalized and don’t interact with others, so it could be that the psychiatry nurse liaisons know all about that, but the oncology fellows don’t. So if you can’t connect them, then it’s not going to do us as much good. So how do you bring these people into interaction in an inter-disciplinary sense? Again, that’s where this onco-palliative intersection has been so valuable, because some things you can’t connect unless you’re part of these groups. You can’t connect to cardiology if you don’t have at least some people who are in the cardiology group. They won’t all do it by strangers. They need some people to grow up within them who are connecting to oncology. You know what I mean?
Tacey Ann Rosolowski, PhD:
Mm-hmm.
Michael Fisch, MD:
And if Palliative Care has no oncologists, then that doesn’t work. So our Palliative Care group has some oncologists, and then our Oncology group has some Palliative Care people, and that allows for a much more robust way of staying attuned to and applying the new knowledge at that interface of different disciplines.
Recommended Citation
Fisch, Michael J. MD, MPH and Rosolowski, Tacey A. PhD, "Chapter 24: The Schwarz Rounds at MD Anderson and Mindful Medical Practice" (2015). Interview Chapters. 847.
https://openworks.mdanderson.org/mchv_interviewchapters/847
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