Recently by Michael Fisch M.D.

Sitting with the boys from Little League and their parents on Saturday night, a parent (and friend) surprised me when he said, "I know a lot about your Dad." He told me my Dad's name and he knew that his birthday was on Valentine's Day. It turns out that he had met the spouse of a former patient of mine, and she remembered me fondly and recalled this information that I had shared. I wondered ... what was the context for me sharing this about my Dad and was that appropriate?

The next morning, I read the front page article in the New York Times about M. D. Anderson Cancer Center. The question on my mind after reading this article is whether or not the story captured the essence of our top-ranked institution. 

There are many perspectives on the story, depending on whether you talk to faculty and staff or patients familiar with M. D. Anderson, or other people who are mesmerized by the story but unfamiliar with our center. To me, of the images and various vignettes in the story, the most striking was that of a singular mission -- to eliminate cancer in Texas, the nation and the world -- and an ambitious and compassionate approach.

What I noticed the First Time I Saw Patients on Rounds as a Medical Student

On a rainy weekend, I spent a few minutes looking through an old photo album with my kids. Tucked away in a folder within one album were letters that I shared with my parents during medical school. My mom, who died of lung cancer in 2006, had saved these letters.

One letter was written to a wonderful physician and mentor who allowed me to go on infectious disease rounds with him on a Saturday morning for the very first time, during my first month in medical school when everything was about book learning. I found a "thank you" letter to my mentor, Dr. Barry Farr, dated Oct. 27, 1986. In the second paragraph of my letter, I wrote:

I want to share with you some of the things that I learned on Saturday that I otherwise would not have known. I think that this may be interesting for you because it seems that physicians (and other medical students) do not always remember exactly what they did and didn't know when they were first-year students.

In the ensuing paragraphs, I listed seven categories of my observations. Topic six was about vocabulary:

I realized that my ability to understand what was going on hinged on my familiarity with the vocabulary. One way to categorize the vocabulary might be as follows:
a) Anatomical vocabulary (i.e. fourth metatarsal)
b) Vocabulary of disease (i.e. osteomyelitis)
c) Vocabulary of clinical medicine (i.e. nosocomial, iatrogenic)
d) Current jargon (i.e. "LCM," "PTC")

As you may recall, I think that one of Yogi Berra's quotes may apply here (if adapted to medicine). He said something to the effect that "Half of baseball is 50% mental." This can be adapted to read "Half of medicine is 50% vocabulary."

The following week after finding this old letter, a colleague, Dr. Daniel Epner, shared with me his correspondence with Dr. John Mendelsohn, M. D. Anderson's president, regarding his reflections on health care reform. Dr. Epner wrote:

... Many challenges that we face on a daily basis that we think of as biomedical, technical or logistical issues are essentially communication issues. For instance, I hypothesize that we can improve care tremendously and avoid uncomfortable and futile interventions at the end of life by implementing improved communication protocols and procedures that focus on discussions of goals of care throughout the spectrum of illness. ...

The key point from Dr. Epner is the focus on goals of care and attention to the topic of physician-patient communication. Nevertheless, the vocabulary of medicine itself is one part of the challenge in communication, and it is all too easy to forget when we, in health care, didn't understand all of these words (as I noted to Dr. Farr after my very first rounds).

For some reason, I have a track record for working in areas of cancer medicine that are fundamentally patient-centered, difficult to understand based on their labels and challenging to briefly explain. Three examples: palliative care, general oncology and integrative medicine. What do these topic areas mean to you? 

I arrived at M. D. Anderson in November 1999. I had been trained in internal medicine and hematology/oncology, and had spent the first two years of my career as an academic oncologist focusing on the care of genitourinary malignancies. But I had decided to pursue my interests in issues related to symptom management and quality of life, so my job position here was in the Department of Palliative Care and Rehabilitation.

The department was new, and I would be asked by faculty and staff on a frequent basis, "what is palliative care, anyway?" I would babble something about quality of life and helping people live better, but I couldn't explain it coherently before the questioning colleague got off the elevator or veered in a different direction. So I decided to find a succinct definition that I liked, and rehearse and memorize a version of it. Here's what I memorized:

"Palliative care is comprehensive, interdisciplinary care for patients with life-limiting illness, where the focus of care is enhancing quality of life and reducing suffering for the patient and family."

OK, so what's general oncology? It's the ultimate paradox at our institution, which is well known for incredible subspecialty expertise in so many areas. Why would M. D. Anderson want "general oncology?"

On our main campus, general oncologists have a role in the initial evaluation of complex international patients as they're evaluated and cared for in preparation for the appropriate subspecialty, multidisciplinary team. Moreover, they're often called upon to help navigate complex care when multiple specialty teams are involved. General oncologists provide care in our Integrative Medicine Clinic as well.

Our Department of General Oncology leads the medical oncology care at Lyndon B. Johnson General Hospital and at our community-based clinical care centers. Also, general oncologists often lead and participate in patient-oriented research projects and clinical trials that address issues cutting across different diseases, and collaborate on other projects and clinical trials that are led by subspecialists.

Finally, if general oncologists evaluate patients in the Integrative Medicine Clinic, what exactly is integrative medicine? According to the Consortium of Academic Centers in Integrative Medicine, it's "the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals and disciplines to achieve optimal health and healing."

To me, that sounds exactly like good medical care -- just the kind of patient-centered care that people expect. The thrust of the care in integrative medicine is tailoring to each individual patient a program that improves his or her health and well-being, above and beyond the disease-focused expert care provided by other care teams.

My aunt left me a message last night while I was umpiring a Little League Baseball game. While I was enjoying watching 8-year-old boys show their skills on the ballfield, she was calling to let me know that her cancer has returned. She wanted to know about her treatment options for the difficult disease that has come back, despite her previous surgery and radiation therapy.  

She lives in another city, and her excellent team of cancer specialists discussed with her the choice of a standard treatment regimen of chemotherapy compared to a clinical trial. The trial option involves allowing the treatment choice to be randomly assigned (by a computer) to a new cancer treatment pill (taken alone) versus a combination of the new agent and some other commonly used medications.

So what help could I offer her in making this decision? What is the formula going through my mind?

clinical trials = discovery = hope = quality care in medical oncology

While this isn't the key equation in all other disciplines (such as pathology, surgery, family medicine, etc.), the discipline of medical oncology is different in this regard. Clinical trials are what nourish medical oncologists and patients in the research-driven patient care model.

Clinical trials are critical to the international patients we care for at M. D. Anderson and to our patients who choose to receive care at our satellite centers in the community, much in the same way as they're important to patients who we care for at our main campus in the Texas Medical Center in Houston, Texas. All of these groups are more similar than different.

Even if only a portion of patients choose to enroll in our trials, it's the HOPE that emanates from the trial menu and related discussions about discovery that sustains the magic of M. D. Anderson Cancer Center and the power of change in outcomes related to cancer care.
 

Michael Fisch, M.D., chair of M. D. Anderson's Department of General Oncology, was asked in a recent WebMD article on Farrah Fawcett's choice to seek cancer care in Germany to provide suggestions to patients considering leaving the country for cancer care. In the article he recommends that patients:

•    Define and prioritize goals
•    Discuss those goals with a doctor
•    Don't take good care for granted
•    Consider their own backyard
•    Recognize their vulnerability



In this video, Dr. Fisch expands on his thoughts about making the choice to explore alternative care outside of the United States. .

Source: WebMD http://www.webmd.com/news/20090515/farrah-fawcetts-german-cancer-care

The patient had been perfectly healthy and now he had this new diagnosis of cancer. Now he is just miserable. And I reflect not only on the details about the disease and treatment, and the facts about treatment goals and prognosis, but I wonder how he can restore a sense of "buoyancy" (that force that keeps one afloat as opposed to sinking)?

I'm a cancer physician, not a pop-psychologist, but nevertheless I find it useful to get my own clear sense of buoyancy -- to understand my patients and to understand myself, too. I've decided that these 10 parameters (specific "floaties") are most important. They're in no particular order, they don't have equal importance, and their contributions to my overall buoyancy vary over time.

1. Autonomy (freedom to choose). It's good not to be told how to act, dress or do every little thing at work.
2. Exercise my skill (do my thing). I love being a cancer physician.
3. Establish and maintain meaningful relationships. This applies for all aspects of my life (work, family, other activities).
4. Being awake to my present reality. That means knowing that I'm not an astronaut, but also being able to tell when I'm tired or hungry or angry.
5. Gratitude. The glass must be half full, at some level.  
6. Courage (managing fear). There's no avoiding fear and doubt.
7. Appreciation of impermanence. This just means that I "get it," that all things change. I may not relish change in all instances (like my aging body or my changing bank account in this economy), but I can see this truth.
8. Compassionate mind frame. Empathy with benevolent intent.
9. Finding and keeping my safety and security. This varies for each person. It might be a religious thing for some, or it could be related to having enough money or living close to family. It's that grab bag of individual stuff.
10. Answering the question "do I matter?" This could be the ultimate existential question at some level, or it may apply in smaller situations (like "do I matter" on this project, or coaching this kids' soccer team, etc.).

Another close call -- just made it onto the early flight. The research meetings at the National Cancer Institute were lively, useful and inspiring. But getting onto this flight means that I may catch part of my son's Little League baseball game.

Having spent a few days at a recent Texas A&M baseball camp with my son, I cannot help but think of how so much of what was taught there applies to my work as a physician, educator and researcher.

The college coach at the camp stressed the importance of four attributes:

• Attitude
• Approach
• Intensity
• Toughness

For them, attitude involves having confidence in one's ability and preparation, and understanding the goal is to win as a team. For me, attitude involves a similar confidence -- knowing that I can apply my knowledge and skills with integrity and compassion to contribute to the care of individuals, or to teaching or research, that has that same ultimate aim.

Approach is your willingness to do your job, at any given time, within the confines of the "pack" (if you're an Aggie ballplayer) or confines of the medical system and highest professional standards (if you are me).

Intensity is the passion for the activity. Ballplayers love to play baseball and I love to care for patients, teach colleagues and learn from them, discover and apply new knowledge. The flame burns intensely bright.

And what about toughness? Toughness is the ability to maintain your attitude, approach and intensity in the face of adversity. Baseball is full of failures -- players must have resilience. And failure is part of cancer medicine, too. Well-planned and executed treatments do not always succeed. Clinical trials do not always succeed or lead to useful new approaches. Toughness is critical.

As a cancer physician, I found this quote in the Aggies' clubhouse inspiring for my line of work: "Don't ever forget how close we were, or how close we are ... earn it every day."

The e-mail subject line said "homework assignment." The message was from a colleague trying to prepare me for an upcoming media workshop. The trainer wants me to think about my department and talk about the "human element" in our programs and activities.

It occurs to me that this homework assignment is appropriate to any endeavor. It's no different than the starting point for the Texas A&M Aggies baseball team, at least the way they taught their philosophy of baseball to my son and his teammates at their weekend baseball camp in January. I know, because I was there ... taking notes like I was in medical school ... like I was a student and ready for a homework assignment.  

The very first question the Aggies' coach asked these 10-year-old campers: "Who do you play for?" The coach explained that they're not playing to impress their parents or friends, or to get on the all-star team. The answer for the Aggies is that they play for their team, and the goal is to win championships.

At M. D. Anderson Cancer Center, the goal is different, but the question "who are these programs and activities for" is no less critical. It's all for the patient -- the individual patient who is facing illness or a threat of illness. The focus is on how do we, working together with other health care providers as a team, identify appropriate goals for that person and his/her family, and make it happen.

It's no war on cancer and not even about being the best cancer hospital on the planet. It's about caring deeply for individuals and finding ways to help them live fully. Whether I'm evaluating a patient with a newly diagnosed malignancy, helping a cancer survivor understand his/her children's risk for developing the same cancer, or discussing the issue of recruitment of minority/underserved patients to clinical trials with research colleagues at the National Cancer Institute, it all boils down to the same thing.

It's the human element -- how to care for patients, applying everything we know about science, about compassion, about communication and negotiating goals of care. It's about human systems and teamwork, to get the job done for each individual