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Two sessions: 24 May 2018, 25 July 2018
Total approximate duration: 3 hours 20 minutes
Interviewer: Tacey A. Rosolowski, Ph.D.
About the Interview Subject:
Michael S. Ewer (b. September, 1944, New York, New York) came to MD Anderson in 1978 as an Instructor in the Division of Medicine and advanced to assistant profession status in 1979. His clinical research has focused on the cardiotoxicity of chemotherapeutic agents. He was responsible for developing emergency care services at the institution, then expanded his range of expertise to ethics and conflict of interest assessment. Dr. Ewer was involved with the first Ethics Committee of MD Anderson, formed under President Charles LeMaistre. Dr. Ewer was a committee member from 1985 to 1997, when Dr. LeMaistre disbanded it. He served as committee chair from 1988-1993. Since 2005 he has served as Special Assistant to the Vice President of Medical Affairs. Dr. Ewer retired to part time status in 2013.
Major Topics Covered:
Education and personal background
Service as Medical Officer on a Princess Cruises ship
Intensive Care Services at MD Anderson; building the service
Views of cardiology versus onco-cardiology; medical education
Ethics Committee: formation; composition; evolution; purpose of ethical consults; developing an institutional philosophy of ethics; challenging cases; shifting institutional priorities and effect on ethics
Research: cardiotoxicity of chemotherapeutic agents
About transcription and the transcript
This interview had been transcribed according to oral history best practices to preserve the conversational quality of spoken language (rather than editing it to written standards).
The interview subject has been given the opportunity to review the transcript and make changes: any substantial departures from the audio file are indicated with brackets [ ].
In addition, the Archives may have redacted portions of the transcript and audio file in compliance with HIPAA and/or interview subject requests.
The views expressed in this interview are solely the perspective of the interview subject. They are not to be interpreted as the official view of any other individual or of The University of Texas MD Anderson Cancer Center.
Interview Session One: 24 May 2018
Education with a Strong Humanities Thread
Residency Training and Trials
Two Years on the "Love Boat" and Reflections on a Dissertation
A New Residency Program and Thoughts on Challenging the Status Quo
A Fellowship in Cardiology at Baylor University Medical Center, Dallas
Building Intensive Care at MD Anderson
A Shift in Philosophy and the Growth of Medical Ethics at MD Anderson
Session Two: 25 July 2018
The Ethics Committee at MD Anderson, Part I: an overview
The Ethics Committee at MD Anderson, Part II: Practicing Ethics in a Context of Innovation
Ethics after the Ethics Committee
Bringing a Legal Perspective into Ethics Work
Views on Changes at MD Anderson
Research on Cardiology
Interview Session One: 24 May 2018 (listen/read)
Interivew Identififer (listen/read)
Chapter 01 (Educational Path)
Education with a Strong Humanities Thread (listen/read)
Dr. Ewer begins this chapter by sketching his family background: German parents who met in England, a father who was a lawyer and a communist agitator in Nazi German, and a physician uncle who had a great influence on him.
Next, Dr. Ewer begins to recount his educational path, noting that he originally intended to be a violinist and attended the High School of Music and Art in New York. He explains his continued participation in music despite his decision not to continue with training in this area once he went to Hunter College [Bronx, New York; BA, 1964]. There he majored in chemistry and credits his father with solidifying his decision to go to medical school at the University of Basel in Basel, Switzerland [MD, 1969]. Dr. Ewer explains his choice to minor in theology to take a philosophical approach to human nature. He talks about features of Swiss medical education, which stressed the clinician's ability to take care of people. He comments on living overseas.
Next, Dr. Ewer explains the evolution of his interest in anatomy and the opportunity he had to work with the famous surgeon, Rudolph Nissen, then at the University of Basel. He tells an anecdote about recognizing the impact of medicine on patients.
Chapter 02 (Professional Path)
Residency Training and Trials (listen/read)
In this chapter, Dr. Ewer covers his post medical school experiences, beginning with his Rotating Clinical Internship at Norwalk Hospital in Norwalk, Connecticut (1970-1971). He talks about his work in internal medicine and pediatrics and tells anecdotes about medical education at that time.
Next, he notes that he undertook his Junior Residency at Norfolk General Hospital in Norfolk, Virginia (1972-1973). He then explains how he came to be fired from that position.
Chapter 03 (Professional Path)
Two Years on the "Love Boat" and Reflections on a Dissertation (listen/read)
Dr. Ewer begins this chapter by noting that he needed a job in a hurry after being let go and found a position as a staff physician (1972 – 1974) on a Princess Cruises ship (which served as a model for the ship in the television series, the Love Boat). He tells several stories from his work on the ship and also comments on how this position expanded his medical practice: he set up a water potability testing lab and an ICU on board the ship. He talks about the success of these ventures and notes that the water potability studies were his first bona fide academic pursuit. He explains that he technically received both and MD and a PhD in medical school, he does not count his brief dissertation as true research, even though he made a discovery considered significant. He also notes that the ICU was established primarily to treat older patients and explains that he had worked in a nursing home earlier in his career to pay for flying lessons.
Chapter 04 (Professional Path)
A New Residency Program and Thoughts on Challenging the Status Quo (listen/read)
In this chapter, Dr. Ewer explains why he left his job with Princess Cruises returning to his medical education with a Senior Residency at Pawtucket Memorial Hospital at Pawtucket, Rhode Island, where he also served as chief resident (1974-1975). To demonstrate his belief in questioning the status quo and conventional ways of operating, he tells an anecdote about a choosing a controversial and unorthodox stress test he applied to assess cyanosis in his own son. He goes on to talk about the importance of assessing how much of medical treatment actually benefits the patient.
Chapter 05 (Professional Path)
A Fellowship in Cardiology at Baylor University Medical Center, Dallas (listen/read)
In this chapter, Dr. Ewer discusses his fellowship in Cardiology at the Baylor University Medical Center (Dallas, Texas, 1975-1977). [The recorder is briefly paused near the beginning of this chapter.] He notes that he was very intrigued by the new cardiac ultrasound capabilities being developed (and set up the first echocardiogram progam? At MD Anderson). He explains that during his fellowship period, he was very focused on assessing the value of cardiac interventions, given that there was no data about how various interventions effected outcomes.
Chapter 06 (Building the Institution)
Building Intensive Care at MD Anderson (listen/read)
Dr. Ewer begins this chapter by explaining how he found out about an opening at MD Anderson and the interview and selection process. He joined the institution in 1978 and notes that he only expected to be at MD Anderson for six months to work on the cardiotoxicity of chemotherapeutic agents. He then talks about how he assumed the de facto leadership of the intensive care unit, a role he served until the early 1990s. He talks about a prevailing attitude that had an impact on the perceived value of intensive care: that cancer is more interesting in the early stages, when medicine could have more impact than at the end of life. He talks about the growing acceptance of critical care at the institution and also recounts advice he received from Robert Benjamin, MD [oral history interview], who told him never to get tunnel vision about medicine. He talks about working with Dr. Benjamin on a heart biopsy program and conducting two thousand procedures with no deaths.
Chapter 07 (Building the Institution)
A Shift in Philosophy and the Growth of Medical Ethics at MD Anderson (listen/read)
Dr. Ewer begins this chapter by explaining that in the early eighties, as a result of his work in intensive and critical care, he began to develop the philosophy that clinicians shouldn't assume that anyone wants to be in intensive care on a ventilator to die. He speculates that intensive care at MD Anderson may have been the first setting to develop a process of "terminal weaning." He notes how controversial the practice was, but that his group prevailed in gaining acceptance for it. He next talks about two important figures in ethical care at the institution: the head of the chaplaincy program, Sister Alice Potts, and Jan Van Eys, MD, a former head of the Ethics Committee. Next he talks about his own role on the Ethics Committee (formed in the early 80s prior to the national mandate for academic institutions to have such a body). CLIPS He gives examples to demonstrate the conventional approach to ethical issues at the time and his new approach that considered ethical cases as an appeals court. One of these cases highlights MD Anderson's relationship with drug companies and how these contextual factors can influence ethical decisions.
Next, Dr. Ewer explains his view of why the Ethics Committee was disbanded and how this indicates the relationship between the practice of ethics and the administration of healthcare in the institution.
Interview Identifier (listen/read)
Chapter 08 (Building the Institution)
The Ethics Committee at MD Anderson, Part I: an overview (listen/read)
Dr. Ewer begins this chapter by stressing that MD Anderson has always been interested in 'doing the right thing for patients.' He goes on to sketch how that desire was first formalized when the Ethics Committee was formed under President Charles. A. LeMaistre [oral history interview]. Dr. Ewer sketches the membership of the committee. He then talks about the main types of policy issues the Committee worked on during the period when he was a member and chair (1985-1993; 1988-1993). First he discusses the committee's development of a "decision triangle" to determine the weight that patient/family input should have in medical decision making. Next he talks about how MD Anderson stopped the current (in the 80s) "go slow" code in use at many institutions. Next he explains why the Ethics Committee decided not to become involved in the IRBs and examine issues in research protocols, but focused on clinical situations. Dr. Ewer notes that the Committee made many controversial decisions, which eventually led to its disbanding (as sketched in the last session). He discusses two cases of controversy.
Chapter 09 (Building the Institution)
The Ethics Committee at MD Anderson, Part II: Practicing Ethics in a Context of Innovation (listen/read)
Dr. Ewer begins this chapter by discussing some political infighting in the Ethics Committee. He then goes on to describe how much of the committee's work was conflict resolution. He gives an example to demonstrate.
Next, Dr. Ewer explains how pushback against Ethics Committee recommendations was often philosophical and rooted in the prevailing mindset that "a patient who doesn't survive is a failure." He explains that that mindset cannot serve the institution as cancer care and healthcare environment has evolved over the last 40 years. CLIP He also talks about the challenges of balancing ethical concerns with the creative impulse to push the research envelop that is also so important to the institution. At the end of this chapter, he expresses concerns for the institution, its financial health, and how MD Anderson might be positioned for a takeover, which would destroy its research identity.
Chapter 10 (Overview)
Ethics after the Ethics Committee (listen/read)
In this chapter, Dr. Ewer sketches how ethics evolved at the institution after the Ethics Committee was disbanded in 1993. He explains that Rebecca Pentz, PhD, was appointed head of ethics (though was uncertain if it had been formalized as a department at that time) and recounts a story to demonstrate how her perspective on handling ethical situations differed from his own. He notes that some of the original members of the disbanded ethics committee joined Dr. Pentz's group. Next he talks about Colleen Gallagher, PhD, who came to MD Anderson in XXX to head the Department of Integrated Ethics. He describes the leadership she has built and notes similarities in their perspectives. He talks about their collaboration on a book.
Next, Dr. Ewer explains his terms, "macro ethics and micro ethics."
Chapter 11 (Overview)
Bringing a Legal Perspective into Ethics Work (listen/read)
In this chapter, Dr. Ewer explains why he earned a legal degree (JD 2001, Advanced degree in Health Law) and the impact it has had on his thinking about ethics. He begins by how he first thought of law school when he worked for Princess Cruises because of a chance encounter with Earl Warren, former Chief Justice of the Supreme Court. He sketches the process of getting into law school at the University of Houston then gives examples to demonstrate how this perspective has shaped his thought. Next, Dr. Ewer talks about his roles as Special Assistant to the David Callendar (1994-1997), the VP of Patient Care. The recorder is paused.
Chapter 12 (Institutional Change)
Views on Changes at MD Anderson (listen/read)
In this chapter, Dr. Ewer offers his perspective on how the institution has changed since 2011. He offers his view of Dr. Ronald DePinho's vision for developing MD Anderson's research capacity and the struggles the institution had implementing this during a period of financial change in healthcare. He then talks about offering his services to Dr. Peter Pisters, the new president of MD Anderson.
Chapter 13 (The Researcher)
Research on Cardiology (listen/read)
In this chapter, Dr. Ewer sketches his research on the cardio-toxic effects of chemotherapy. He tells the story of one set of trials focused on Herceptin. He talks about formulating a controversial theory of Type 1 and Type 2 cardiotoxicity. At the end of the chapter, he sketches his formal retirement in 2013 and changes to his partial appointment thereafter.
Chapter 14 (Overview)
Final Comments (listen/read)
Dr. Ewer begins this chapter by looking back at the impact he feels he has had on the institution. He notes that he wishes he could have had more of an impact on young faculty in cardiology, helping them to think outside of the box in the ways that are essential to address cardiac issues in cancer patients. He notes that he is currently working on a case study of basal cell carcinoma. At the end of the session, he comments on the profession of oncology.