Robert Lee Fine, MD: a conversation with the editor

Bob Fine (Figure 1) was born in Denver, Colorado, on December 21, 1952, and grew up mainly in Kansas City, Dallas, and Fairfax. He graduated from the University of Texas (UT) at Austin in 1973 in 3 years with highest honors and Phi Beta Kappa. He majored in English. After working a year in Austin, he entered the UT Health Science Center at Dallas (Southwestern Medical School), graduating in 1978. During that time, he was editor of Borborygmi, the student literary magazine. His internship and 2-year residency in internal medicine were at Baylor University Medical Center (BUMC). After finishing in 1981, he entered the private practice of internal medicine and became an active member of the BUMC medical staff.

Figure 1.

Robert L. Fine, MD.

Within 2 years of completing his training, he became very involved with the hospital ethics committee, which at the time consisted of physicians, one administrator, one chaplain, and the hospital's general counsel. By 1985 he had helped transform this committee into a true multidisciplinary clinical ethics committee responsible for developing hospital ethics guidelines, ethics education for all staff, and clinical ethics consultation. Under his leadership, the Baylor Institutional Ethics Committee became one of the most experienced and active ethics consultation services in the country. While continuing to chair the BUMC ethics committee, Dr. Fine went on to become director of the Office of Clinical Ethics for Baylor Health Care System. At Baylor he has directed over 1000 clinical ethics consultations over 20 years. His clinical ethics work at BUMC led him to help establish and become co-chair of the Corporate Ethics Committee for VITAS Hospice, a national hospice based in Miami, Florida. This was one of the first ethics committees at any hospice organization in the country.

Dr. Fine is a leader of the Texas Advanced Directives Coalition and one of the primary authors of the Texas Advanced Directives Act. This state law has been widely recognized as the first law to provide a legislatively sanctioned mechanism for resolving medical futility disputes between physicians and patients' families. In 2004, he initiated the Palliative Care Consultation Service at Baylor. He became board certified in internal medicine (1981), geriatrics (1988), and palliative care (2004).

Dr. Fine's commitment to improving care at the end of life extends well beyond Baylor Health Care System. In 2001, Dr. Fine led the development of a program of scripted conversations in nursing homes to improve advanced care planning in long-term care. He has provided clinical ethics and palliative care training for physicians and nurses across the state, for those in the nursing home industry, and for state inspectors responsible for improving the quality of care in Texas nursing homes. Dr. Fine serves on the board of directors and chairs the public policy committee of the Texas Partnership for End of Life Care, an organization dedicated to improving care at the end of life for all Texans.

In 1998, he helped establish the Interfaith Task Force at BUMC with a goal of promoting interfaith understanding and enhancing the role of spirituality in healing. His work with many colleagues in this area culminated in the development of the Bradley Wayne Interfaith Garden of Prayer in the center of the BUMC campus in 2003. In 1989 he was selected by the Texas Junior Chamber of Commerce as a recipient of the “Five Outstanding Young Texans” award for his community service work, largely related to his work with indigent patients and AIDS patients. He and his wife, Nina, a partner in the law firm of Haynes and Boone, are the proud parents of three girls, one of whom is presently in medical school, another in college, and another in high school. He is also a nice guy and fun to be around.

William Clifford Roberts, MD (hereafter, WCR): Dr. Fine, I appreciate your willingness to talk to me and therefore to the readers of BUMC Proceedings. To start, could you talk about your early life, some of your earlier memories, and your parents and siblings?

Robert Lee Fine, MD (hereafter, RLF): I was born in Denver, Colorado, to Samuel Davis and Mary Jones Fine. My dad started with the Food and Drug Administration (FDA), initially working as a chemist. By the time I was born (1952), he had moved into the administrative wing at the FDA and ran the FDA's office in Denver. Government employees moved periodically, especially those on the administrative track. When I was 2 or 3 years old, we left Denver for Kansas City and stayed there for about 4 years. I went to kindergarten through the second grade there. We then moved to Dallas, where my father ran the regional office for the FDA, located on Bryan Avenue very near BUMC.

WCR: What year did you come to Dallas?

RLF: We came in 1960, so I would have been 7 or 8 years old (Figure 2). My mother was a music teacher. I was the third of four children. She raised children nearly full-time. She gave some music lessons on the side. We were all raised to be engaged in music. I completed the first year of high school in Dallas and then my dad was relocated to the Washington, DC, area. I had two of the best years of my youth there. Although we lived in Fairfax, Virginia, we went into Washington, DC, often. Throughout my schooling I enjoyed science projects, writing, and music. In high school, I had a folk band. I had a wonderful youth.

Figure 2.

In elementary school.

WCR: Where was your father born?

RLF: He was born in Missouri, the offspring of a woman from a wealthy Missouri land-owning family that once owned plantations before the Civil War and a poor man without a college education. My father's father died in World War I. He had wanted to make something of himself and saw the war as an opportunity! I saw a letter from him that stated something like, “I will go to serve the country in the war. I shall go to France. I shall come home an officer, or I shall come home dead.” He came home dead. Actually, he didn't even come home because he's buried in one of the battlefield graveyards in France. My dad's mother was considered the “black sheep” of her family. Her father, who was well-to-do, had not approved of the man she married, my grandfather.

WCR: What kind of man was your father, Samuel Davis Fine (1914–1997)?

RLF: My sisters and I thought my father was an extraordinary father and an extraordinary man. During his youth he was moved around by his mother periodically, but nevertheless he did very well in school. He was the first person in his family to go to college. He did graduate work in chemistry at the University of Missouri in Columbia, then went to work for the FDA, and then went into World War II. He had to fight to get into the war. As a chemist, he was considered “essential civilian personnel” and not allowed initially to join the US Armed Forces. He got frustrated after about a year of civilian life, resigned from the FDA, and was sent to officer training school at Princeton and then into the navy.

WCR: How many siblings did your father's mother have?

RLF: Eight or nine. When my dad was on his deathbed at BUMC, I told him how amazed I was that he was such an extraordinary father given that he never really knew his own father. He said, “I had many parents.” I believe his aunts and uncles were very attentive to him. They realized that he was a very bright young man. They bought him books and encouraged him to go to school. I think they realized that their sister, his mom, was a little bit crazy, frankly, so they really watched after him. The only thing my father remembered about his own father was being spanked for a sin of some sort. My dad was only 2 or 3 years old when his father died.

WCR: Did your father have enough money to go to college easily?

RLF: I think some of his aunts and uncles loaned him money. After graduating from college with a teaching degree, he taught, saved money, and worked during graduate school. When we were young we had a comfortable government bureaucrat's middle-class existence. We had a small house but always food and nice toys at Christmastime. Our family vacations were usually camping trips. After growing up, I said to my parents, “You must have really loved to camp.” And my mother said, “That's all we could afford to do with four mouths to feed on a government salary.”

WCR: Where are you in the hierarchy?

RLF: I am number three of four. I have two older sisters and one younger sister.

WCR: You said your father, even though he never really knew his father, was a wonderful father. What do you mean by that?

RLF: Even though he kept very long hours, especially in Washington, DC, and always worked very hard at his job, he made it his business, as much as possible, to be home at dinnertime. Often after dinner he would go off and work in his study long into the night. He was always very engaged with each of us in our lives. For me as the only boy, that meant helping to coach my Little League baseball team, helping run the Boy Scout troop that I was in, and teaching me to sail.

My father was a quietly religious man. He was always very active in various churches, and that meant that we children were active in church. I spent more hours than I can remember mowing church lawns and painting small church buildings. I kidded him when I converted from Christianity to Judaism. I said, “Dad, Jews don't mow lawns.” I had spent so many hours on weekends doing that. After we mowed the church lawn and repaired the church property, we pursued various hobbies. My father was a great amateur everything—photographer, sailor, carpenter, gardener. If he didn't know how to do something, he studied and learned how to do it. After we completed our chores we often sailed together. Sailing was one of my father's great passions.

WCR: What church did your father belong to?

RLF: He was raised in a Methodist family, and in each city he lived in as a younger man he helped organize new Methodist congregations. When we moved to Dallas, we joined a Methodist church, a lovely historic church in town. However, in about 1962 or 1963, my father led us out of that church, and we never went back. The next thing I knew I was mowing lawns at a little Presbyterian church down the road. Years later I asked my dad, “Why did we leave the Methodist church and become Presbyterians? What happened?” Apparently, the minister at the time had given a sermon saying “Negroes” would not be welcome in the church. This was intolerable to my father. One of his father figures had been an African American man who had been born into slavery on my father's great-grandfather's plantation. My father would not tolerate any kind of racism.

WCR: Is Robert E. Lee in your family?

RLF: Not Robert E. Lee, but there's a southern background in the family, yes. I have a cousin named Dixie, an uncle Beauregard, and so on. My dad, Samuel Davis, was named after a Confederate spy. One relative on my father's side, Camden Riley, was a Confederate colonel and was killed in the war. Another Riley relative was captured at the battle of Vicksburg by the Union, swore an oath that he would not take up arms against the Union again, and was set free on his honor. He went to Virginia, joined the Army of Northern Virginia, was captured again in the Battle of the Wilderness, and was executed because he had broken his oath. I credit my parents with being able to leave all the racism behind, even though they were raised in old deep-racist South with all that Confederate history in the family background. I think it's remarkable.

WCR: What was your mother (1917–2000) like?

RLF: She was one of five children of a country doctor in Missouri. Although she had a teaching degree from college, she was raised to be a traditional housewife. She majored in music and English in college.

WCR: Where did she go to college?

RLF: She went to Southeast Missouri State in Cape Girardeau and pursued a variety of interests, even some athletics, which I did not know about until she was rather elderly. One day when my mother was over 70 years old, I was in the backyard shooting basketball hoops with one of my daughters. My mom came out and calmly sank a free throw and then another couple of shots. I said, “Mom, where did you learn to play basketball?” She said, “Oh, I played basketball as a young girl and was a good athlete, but my father thought it unbecoming of a woman to play sports.” So, she quit playing sports. Her father was a country doctor and a rather traditional, conservative man.

She was a wonderful mother. She raised all four children to love reading books and playing music. It was required in my family that every child play a musical instrument. Later, when my mother met Nina, my wife, one of the first things my mother said was, “Nina, it's so nice to meet you. What instrument do you play?” (Nina doesn't play any musical instrument.) My high school girlfriend had been a gifted piano player, and so my mother had assumed that since I sang and played music, a girlfriend serious enough to bring home must also play music.

WCR: What instrument did you play?

RLF: I started off at a young age on the piano and played that through the third grade. Then I rebelled, wanting to be out playing sports with the other guys and not playing piano. The deal my mother made with me was that I could quit playing the piano but I must take up another instrument. I took up the trumpet and became a very accomplished trumpet player, being in all regional bands and first chair in the band. In fact, I had every intention of becoming a professional musician. If you'd asked me in junior high or high school what I was going to be when I grew up, I would have said a musician. I was deaf in one ear, however, and the otologists always advised me against being around loud music.

As I entered my senior year of high school, I took up soccer, had a bad collision with a bigger guy, and knocked out a front tooth. This event happened 2 days after I had gotten my braces off. The tooth was reimplanted, but as a consequence I could not play my horn for about 2 years. I went off to college, and by the time I could play again I realized that the 2 years of downtime plus the hearing deficiency made music an unwise career choice.

WCR: So the soccer accident changed your career?

RLF: It did.

WCR: You mentioned that you were deaf in one ear. How did that come about?

RLF: Possibly, a failure of maternal immunity from lack of adequate breastfeeding allowed measles to damage my auditory nerves when I was 1 or 2 years old. My hearing loss was not discovered until second grade, when I was getting into trouble for not paying attention both at school and at home. My mother would call me and I would apparently not answer. My hearing was tested and I was totally deaf in my right ear.

WCR: Did you ever follow your mother's father, a physician, around?

RLF: No. He died when I was about 6 years old. I have his medicine bag, however, and his Osler's Textbook of Medicine. He went to Washington University School of Medicine. I was disappointed when I became a doctor to find out that his diplomas and most of his medical equipment were lost. He was a doctor in the little town of Lilbourn, Missouri. His office was in his home. He treated many people for free and was often paid in produce. I remember visiting him when I was a young boy. A patient came to the front door and said, “Is Dr. Jones in?” My grandmother said, “You know better than to come to the front door. You go around to the back door.” He did minor office surgeries in his home office. He carried all of his medicines in his black bag. He made horse-and-buggy house calls. He was one of the earlier people in his county to have a Model T and then made house calls that way. My mother often accompanied him on house calls. I asked her, “What did Grandpa do when he saw people who were so sick that they were dying? Did that ever happen?” She said, “Yes, it happened all the time. We held vigils and we prayed.” It's a real reminder of what medicine was like before the modern high-tech medical industrial complex that we now work in.

WCR: Your mother and your father met during college?

RLF: They might have briefly met in high school, but they really established their relationship in college. He was 2 or 3 years older.

WCR: What was your home like growing up?

RLF: It was busy. In addition to his professional work, my dad was a Boy Scout troop leader, a church deacon, a church maintenance man, and a sailor. My mother was a music teacher and the church organist and was forever driving us to lessons and school activities. She was a den mother for my Cub Scout troop. We were all encouraged to do school projects and science projects, and I enrolled in science fairs every year. Looking back, I think our home was a sort of “controlled chaos.” My mom raised four children, cooked, and did all the interior housecleaning. She would not have a maid. Even once it became affordable she wouldn't do it.

WCR: Was dinner at night a big deal? You said your father was usually home.

RLF: Yes. He would make every effort. We would often watch the news together—eat dinner in the breakfast room and watch Walter Cronkite. For example, I remember Marshall McLuhan's ideas about the “global village” being discussed at the dinner table. Part of my parents' household rules was to discuss what was going on in the world and discuss the news. It was an intellectual conversation.

WCR: Was there alcohol in your home growing up?

RLF: My dad enjoyed a cocktail, typically on the weekends. Alcohol was not locked up. They didn't drink on a daily basis, but I probably drink a glass of wine five nights a week.

WCR: Did your mother or father smoke?

RLF: No. My dad briefly smoked cigars and then gave that up when I was still in elementary school.

WCR: You mentioned that your sisters always made good grades and obviously you did. Did your parents push you in school or was it just expected?

RLF: I think it was expected, and Nina and I have raised our children with the same expectations. I once marveled to one of my daughters that she was an amazing student. I told her, “It's okay to slack off now and then.” And she said, “You would never let me do that.” I said, “We have never told you that you had to do A, B, C, or D.” And she said, “But it's expected.” I said, “Well, you're right.” Somehow, my sisters and I were raised with the expectation that we would do well in school. One sister has a doctorate and is chair of a department at Virginia Tech University; one is a lawyer; and another has a master's degree in social work.

WCR: What department does the university professor lead?

RLF: She is the chairperson of a division of humanities, the Center for Interdisciplinary Studies. She is probably one of the pioneering folklore historians of this country. Her doctoral dissertation and first book concerned preserving the oral tradition. Her most recent book was on step dancing, which is a type of dance done often in African American sororities and fraternities. My sister has traced many of the step dance moves back to tribal Africa.

WCR: Were you an athlete in high school?

RLF: No. As a young boy, however, I was a good athlete. I was a wiry, very quick kid. I played tennis and basketball very well. In junior high in Dallas, I was a very good shot in basketball. My father put a basketball hoop in our backyard, and we played lots of basketball. I went to a junior high and high school that focused on basketball as opposed to football. The junior high coach tried to recruit me to be on the basketball team, but at that time you couldn't play a sport and be in music. I chose music. Many of my friends that I played with in elementary school and in physical education in junior high went on to play on a state championship team in high school.

WCR: You mentioned that your last 2 years of high school were in the Washington, DC, area.

RLF: Yes. It was very cosmopolitan compared with Dallas at that time. Dallas now is dramatically different than the Dallas I grew up in. Going to Fairfax, Virginia, seeing the District of Columbia, and going to school with kids who had grown up in the foreign service with many interesting stories to tell was just plain fun. My teachers were in a totally different class. I had a high school Spanish teacher who had a doctorate in philosophy from the University of Madrid. He was a Cuban refugee who talked about the evils of Castro rather than teach us Spanish. My physics teacher had a doctorate in physics and had been in the navy and worked with nuclear submarines.

WCR: This was a public high school?

RLF: Yes. I went through public schools all the way, and Fairfax was a wonderful place. I met many new friends and furthered my singing career. I was in a three-person band. I was a Bob Dylan wannabe. Another guy and I played our guitars and bass fiddle. A girl sang harmony. I started the guitar in the seventh grade when I was grounded for misbehavior in school. During science class I managed to put some frog eyeballs in a girl's purse and then hid some fermented beans elsewhere in the class and stunk up the classroom. I think this behavior was not unusual for me in my youth. Although my academic grades were A's, I would come home with what were called “X's” for behavior. That was a recurrent thing in my youth. Being grounded in the seventh grade meant that I came home from school and was sent to my room. After a while, the trumpet got a little old. My oldest sister had learned guitar, and she left her guitar with me while she was studying in Spain. I taught myself to play the guitar. I fell in love with it, and when I knocked my tooth out playing soccer I took off.

WCR: Do you still play the guitar?

RLF: Yes. It's one of my escapes and ways to relax.

WCR: Do you do it every day?

RLF: No. It goes in spurts, but I play a couple of times a week.

WCR: You mentioned that both you and your mother sang. Did you have sing-alongs at home?

RLF: Yes. On our camping trips to Colorado or the Grand Canyon, we would sing along the way. My oldest sister and I sing when we get together. She plays piano and I play guitar. My children sing, and all three play the guitar to some extent. One, the medical student, is a good singer-songwriter. We enjoy singing together and making harmony.

WCR: What about your wife?

RLF: She actually has a lovely voice, but she claims that I intimidated her years ago musically and so that's that.

WCR: Did your parents work well together?

RLF: Yes. They were ahead of their time in terms of being very egalitarian about roles within the family and discussing things. We children were aware that they would have quiet discussions in their bedroom after which decisions would be made. My father was a feminist before his time. He encouraged my sisters to go to college, do well, and have a career. My mother was almost a radical feminist, ardently pro-choice. She remembered the tragic outcome of women who died following back-alley abortions before abortions were legal. My father was a Franklin D. Roosevelt Democrat and politically very liberal. I used to kid him that he was to the left of Mao Tse-Tung. He used to say, “Well, you know, all the Chinese get fed. Maybe it's okay.” Here was a man defending the Chinese communists, and yet he saw combat in the US Navy in World War II and served in the naval reserves until he was kicked out for being “a valued civil servant.” McNamara, the secretary of defense, determined that such civil servants couldn't be in two places at once, and, if we went to war, my father was needed for assuring the safety of foods and drugs; thus, he was kicked out of the reserves. My dad had defense drills in which he would disappear. These were nuclear war drills. There used to be a bunker in Denton, Texas, where valued civil servants would be sent to ride out the nuclear war drills. Their families would be left behind.

WCR: What did he actually do in World War II?

RLF: He was second in command on a PT boat tender, the USS Willoughby. It was a larger boat that tended the speedboats. He was the gunnery officer.

WCR: How was it that you went to college at UT?

RLF: During high school, my parents gave me little direction. Apparently, they thought I didn't need any. I attended a big public high school, and college counseling was almost nonexistent. I visited a college counselor who said, “Where would you like to go to college?” I said, “I would like to go to Georgetown or Princeton University.” I had no particular reason to know much about Princeton other than my father had gone to officer training school there. Georgetown University represented nirvana to me as a kid in the Washington, DC, suburbs. My counselor said, “That sounds fine. That will be okay. Tell your parents about it.” I told my parents, who said that both colleges were too expensive. No alternatives were suggested to me, and I wasn't on the ball enough to pursue a scholarship.

In late July or early August, my mom said to me, “By the way, where are you going to college this fall?” I said, “I haven't applied.” Both of my older sisters had gone to UT Austin. My mother picked up the phone, called the registrar at UT, and said, “Is it too late to apply?” And they said, “No.” We sent the transcripts down, and a few weeks later I was on a plane to Austin. It was not a well-thought-out decision, but it was a wonderful place to go to college and it was relatively inexpensive.

WCR: In 1970, how many students were at UT Austin?

RLF: Probably 40,000.

WCR: How did college in Austin strike you?

RLF: For me it was just fun (Figure 3). I majored in English. My mother had been an English teacher, and both my two older sisters had undergraduate degrees in English. It seemed to be the thing to do. I often joke with people that an English major is really philosophy for people who like to plot. What do you do in an English class? You discuss ideas. But, along with the ideas you discuss character development and plot. The size of UT didn't bother me. I had many English classes with only 10 to 12 students in the class. It was wonderful, a great experience. I also had a great interest in science, but science classes were a different deal. My organic chemistry class probably had 300 kids in it. That was okay because I didn't need much help or input from the teacher.

Figure 3.

College days.

WCR: Science came easy to you?

RLF: Yes.

WCR: So did English?

RLF: Yes. But in English, dialogue with the professor is important, and I was able to do that very well there.

WCR: When did the idea of being a physician cross your mind?

RLF: That was one place where my parents had an impact. My father had great respect for physicians. He worked with a lot of physicians at the FDA. He very much wanted me to become a physician. It was not an intellectual problem for me because I really loved biology, microbiology, and virology and had taken courses like that just for fun. However, I had actually come to the conclusion that I wanted to get a PhD in English. One of the only times I was at cross purposes with my father in my life was when he sat me down and said, “You need to understand the difference between a vocation and an avocation. A vocation as an English professor is okay, but you won't be very secure.” Both my father and my mother were children of the Depression, and my father in particular remembered some hard times. He was fiscally very conservative. He was politically liberal but conservative in life. “Know how to take care of yourself, how to take care of your family, and how to make ends meet.” He saw an English degree as a foolish pastime and put a lot of emotional pressure on me to pursue something that he considered more practical.

By the time I succumbed to that notion and decided to apply to medical school after all, it was too late. I had missed the application deadline for the year. I graduated from college in 3 years and then spent a year in Austin working for UT Press as a laborer shipping books. Nina had also gone through college in 3 years—we were boyfriend and girlfriend by that time—and enrolled in law school. So while she was in law school, my job was shipping books, and once the orders for the day had been shipped and the floor swept, I was off!

WCR: Had the music scene hit Austin by that time?

RLF: Not really. My singing partner in college and I sang in the campus coffeehouse periodically, once or twice at a place in Austin called the Checkered Flag and once or twice at a place in Dallas called the Rubaiyat. These were old coffeehouses that would bring in touring national artists, and we opened for them. Our problem was that we couldn't write music very well. We could sing well but we sang and played other people's songs. We weren't very creative in our own right.

WCR: How did you and your future wife, Nina, meet?

RLF: We first met in junior high school in Dallas. Her parents were Jewish refugees from Germany, and she was born in Dallas. In our sophomore year in high school, we had an honors English class together, and I developed a crush on her. I thought she was beautiful, smart, and wonderful. I was a shy kid at that point and never quite got the courage to ask her out on a date. The summer after the tenth grade, I took a class in computer programming at Thomas Jefferson High School. I walked by her house every day—between my house and the high school—hoping to catch a glimpse of her. Every day I'd see the dog in the yard. I'd see the front door open, but I was never brave enough to go knock on the door.

At the end of that summer my dad said, “We're moving to Washington, DC.” It was very short notice. We moved, I came back to attend UT Austin, I met her in the dorm, and we struck up a platonic relationship that by the end of our freshman year had become romantic. Actually, in our high school yearbook from our sophomore year, we were both very interested in debate, and she had written in my yearbook, “Hope to get to know you next year better in debate.” I suspect we might have gotten together had I stayed in Dallas, but we had to delay it. We maintained our relationship through college and then the year when she was in law school and I was working and playing in Austin. Then, I came up to Dallas to attend medical school, and we carried on a long-term commuting relationship while she finished her legal training. We got married in 1976. Thus, we dated for 6 years and only married once she graduated from law school.

WCR: What were the characteristics of Nina that attracted you to her?

RLF: I thought she was beautiful, and I still do. We are middle-aged, and I still think her eyes are the prettiest eyes to look at. And, she is a brilliant woman. I grew up in a house where we enjoyed ideas and Nina is the same way, and so we just found ourselves debating and talking and arguing on philosophy and politics. When she went to law school, I found myself loving discussions of her legal cases and the ideas behind them. We have, like any successful marriage, had our times when we've had to work harder than others to make it work. I think that's true of any long-term relationship (Figure 4).

Figure 4.

With wife Nina and three daughters in 2004.

WCR: You had taken all the required science courses for medical school during those 3 years while you were majoring in English?

RLF: Yes. At that time I don't think you could have a double major at UT Austin, but I had the equivalent of a minor in microbiology, a subject that I really enjoyed.

WCR: Which medical schools did you apply to?

RLF: I applied to Southwestern, Baylor, Galveston, Houston, and San Antonio. My home state was Virginia, so I applied to the University of Virginia. When I went for that interview, I was somewhat of a free spirit. I had long hair and had written a crazy essay on why I wanted to be a doctor. The surgeon who interviewed me at the University of Virginia was a really stiff white-coat kind of guy. He was clearly put off. He said, “What kind of major is English? What are you going to do with that in medicine?” At Baylor College of Medicine, I was interviewed by a psychiatrist who probably thought I was a bit loony, and I didn't get an offer from them.

WCR: How did you wind up at Southwestern?

RLF: My favorite medical school, based upon interviews, was the UT Medical Branch at Galveston, but there weren't many good legal jobs in Galveston at the time and Nina thought Dallas might be a better place for her. Nina's mother also lived in Dallas.

I was very close to her mother. Her mother was a breast cancer survivor, and her father had died at the beginning of her sophomore year of college. I knew that Nina would like to be back in Dallas to be close to her mom, and Southwestern was obviously a great school so I went to UT Southwestern. When I looked for a residency, a part of me wanted to leave Texas. I remember requesting information on residencies in Hawaii, at the University of Washington in Seattle, and at Cedars-Sinai in Los Angeles, and a part of me really wanted to go back to Washington, DC. At that point, when I was looking for residencies, Nina had spent 2 years at a small law firm, and she said, “I don't know if I can duplicate this kind of legal practice elsewhere.” I had loved BUMC during medical school so I said, “Fine. I'll stay in town.”

WCR: Tell me more about your time in medical school.

RLF: I almost dropped out of medical school and even took the Law School Admission Test during medical school because I was just not very happy there. I didn't seem to fit in well at first. I was the long-haired hippy type, one of 12 nonscience majors in my class of 200. At that time, medical school and in particular UT Southwestern really favored science majors. I found Southwestern kind of stifling. Students were very competitive about grades. They would steal books from the library to keep other students from using them. It was not pleasant. As an outlet for my creative energy and frustrations, I became one of the coeditors of Borborygmi (bowel sounds), the literary magazine for Southwestern.

Towards the end of my freshman year of medical school, we had neuroanatomy and the student body seemed especially uptight. My roommates and I built an effigy of one of the professors, Dr. Liebowitz, a wonderful balding professor, a funny guy with a large nose (Figure 5). We hung this effigy from the rafters in the freshman lecture hall where the neuroanatomy final exam was given. Dr. Liebowitz walked in, laughed, and walked out. Students took their exam, but during the exam, the chair of one of the other academic departments walked in and did not think the effigy was funny. Word got out that it was Fisher, Fine, and Whitney who hung the effigy. Later that day we got a call from Dr. Moss, one of the physiology professors. He said, “Listen, they're holding a disciplinary hearing, and you all may be kicked out of school for unacceptable behavior.” I think they viewed this as a threatening gesture, but we didn't mean it that way. Drs. Moss and Bryan Williams came to our rescue. Bryan, I am told, went and said something like, “These are good guys and you don't kick

Figure 5.

In medical school with “Dr. Neuro,” the effigy he was almost kicked out of school for making.

them out of school for this.” And, Liebowitz said he was not offended. This was a huge relief, as for a day or two I was terrified that I would have to call my dad and tell him I had been kicked out of medical school.

WCR: Did studies always come easy for you? Did you have to work hard in college and medical school to do well?

RLF: What I realized later in life, especially watching my children, is that things sometimes came too easily for me and I was not as disciplined as I wish I would have been. My wife was more disciplined. I did work, but not as hard as I could have. I had some bad study habits as a kid and as a medical student, which I attribute to emotional immaturity. I didn't hesitate to play bridge and Frisbee regularly, and I never missed an episode of Star Trek all the way through medical school.

WCR: Do you sleep much, or, did you then?

RLF: Six to 7 hours does me well. I can get by on less, but I'm not as tolerant of sleep deprivation now as I was as a medical student or as an intern.

WCR: You made Alpha Omega Alpha (AOA) in medicals chool?

RLF: No, I did not make AOA in medical school. I was inducted into AOA years later. In medical school, I either got A's or C's. If I liked the subject, like anatomy or internal medicine or pediatrics, I got A's and wonderful recommendations. If I did not enjoy the subject, I did not do as well. I didn't want to be there, and I wasn't very mature.

WCR: Do you think you were rebelling a bit against your father?

RLF: Yes. I've often thought that. I would have been a much better student had I been older and wiser.

WCR: But you enjoyed college and medical school?

RLF: Overall, yes. I particularly enjoyed the junior and senior years of medical school (Figure 6). I attribute part of that to coming to BUMC. When I came to Baylor and saw doctors and patients interacting with respect and saw the wide variety of illness that we see at BUMC, I took on a different attitude. If I had not come to BUMC, I wonder if I would have even become an internist. I just fell in love with medicine at Baylor. Paul Thomas, John Bagwell, Sr., Ellwood Jones, and Howard McClure were some of the physicians who seemed extraordinary to me. They were an inspiration and helped me to discover how wonderful medical practice and internal medicine in particular could be.

Figure 6.

At medical school graduation with parents, Sam and Mary Fine; wife, Nina; and Nina's mother, Anne.

WCR: When you were rotating through the various services in medical school, did you give pediatrics or surgery or some of these other specialties a major look, or was internal medicine your clear choice from the beginning?

RLF: My first clinical rotation was pediatrics, and I loved it. I did well in it. My attending physician and residents said, “If you want to be a pediatrician, we want you at Children's.” I took a pediatric elective because that was the first thing I thought I'd be. I thought the kids were great and pediatric medicine was great, but the elective presented two issues for me. One was that I spent a bit of time in pediatric oncology, and I had a very hard time emotionally with dying children. Then, I did a pediatric outpatient clinic (with Dr. Ginsburg, who later became the chief of pediatrics there) and found myself getting very frustrated with the parents for not taking good care of their children. I also thought delivering babies was a lot of fun at Parkland, so I took a gynecology elective at BUMC. I've always enjoyed radiology and I thought very hard about becoming a radiologist while in medical school, briefly after my internship and briefly again after my medical residency. However, internal medicine became my home. In medicine I thought about subspecialties but decided against a 2- to 3-year fellowship with a full-time lawyer wife and a recently born child at home during my third year of residency.

WCR: So you had 3 years of medical training in total?

RLF: Yes.

WCR: As you look back on grammar school, junior high, high school, college, and medical school, did certain teachers have a major impact on you?

RLF: Yes. The first was an English teacher, Robert Parish, during my sophomore year in high school. He was an extraordinary man who had a way of inspiring students to think outside the box and to be creative in their approaches to both analyzing literature and to writing. He also was demanding for a high school teacher in Dallas at that time. He expected a lot from his students. He helped me see the joy of literature and what one could do with it. About 10 years into my medical practice, he became a patient. Sadly, he is my only patient to die during a surgical procedure. I will never forget his death among all the patients I have cared for and who have died. His wife, who is also my patient, gave me his personal copy of Walt Whitman's Leaves of Grass, which I read from time to time.

A college teacher who influenced me was David Kuryk, an English teacher who also taught about life, something that a really good teacher does.

I don't think any of my science teachers had a great impact on me. Courses like biochemistry and organic chemistry in college had 300 kids in the class, and in my case that was not conducive to a close relationship with the teacher. I think because of my deafness, I've always learned mainly by reading. I'm not very good at listening to a lecture. I really have to force myself to concentrate, whereas if I read something I get it quickly.

WCR: What about medical school? Did any of the professors at UT Southwestern inspire you?

RLF: Yes, I had some wonderful professors. My ward attending at Parkland in internal medicine was Juha Kokko, a specialist in renal physiology. He was absolutely brilliant, charming, and debonair. I found him fascinating in his demeanor and approach to life. He encouraged me to go into medicine. He said, “If you want a place at Parkland Hospital, I would love to have you come here.” Although I didn't have a working relationship with him, Don Seldin was also very inspiring. I thought the world of him. Like many students I was a little afraid of him. He could sometimes make students feel bad. Luckily that never happened to me. John Fordtran was an extraordinary physician and person. I think he also taught life as well as medicine. I don't think John would remember me as a medical student, but I had done an outpatient clinical elective through Parkland, and the two most memorable teachers from that process are John Fordtran and Ron Anderson. Those physicians at the medical school had a definite impact on me and on my life.

I was hired by Mike Reese to be an intern at BUMC. Ralph Tompsett was the chief of medicine then, and BUMC had a reputation for being a humane and interesting place to train with a high quality of academic medicine.

WCR: How did the BUMC internship and the 2-year residency strike you? Were you happy during that period? Was it what you expected it would be?

RLF: Yes. It was a nice mix of academics and a respectful place to be. It was everything I wanted. I remember meeting Mike Emmett for the first time and thinking, “What are you doing here? Why aren't you at the medical school? I can't believe I'm talking to you!” To train under people like Ralph Tompsett, John Fordtran, Mike Emmett, and Marvin Stone, in a place like BUMC, was extraordinary. I don't think I could have obtained better training at Parkland. To have these role models who kept up academically and tried to be the best internists they could be made BUMC a unique place.

WCR: How did it happen that you went into practice at BUMC when you finished your training?

RLF: During my third year, I looked at BUMC, Presbyterian Hospital, and at a private practice in Plano, where a well-known internist was seeking a young internal medicine trainee to join the practice. I would have been given a guaranteed salary and stepped into a ready-made practice situation. But I wanted to be in a more academic setting, fearing that if I practiced in a suburb my academic standards would begin to slip. I tell people that if you work in a good teaching hospital, you don't want to be embarrassed by the residents and interns, so it helps you to keep up. I decided that I wanted to stay at BUMC.

Several doctors I had trained with, a year or two ahead of me, had open space in their offices. One was Bob Rosen. Bob and I were friends. Bob was also a musician, played a mean bass guitar, and we were philosophically and emotionally very simpatico. I moved into his office. Bob's practice was only a year old, so it wasn't as if there was any overflow business. I did what young internists at the time did: I hustled cases where I could get them. I left my cards in the emergency room and said, “Please call me. Anybody who needs to be admitted, I will admit them.” For a number of years, we took our own calls every weeknight, and many nights I went to the emergency room to admit patients to the hospital. This was before interventional cardiology. Internists admitted many patients with acute coronary syndromes. We also admitted many patients with acute gastrointestinal bleeds. This was before emergency endoscopy. I used to really know what I was doing in an intensive care unit. I'm afraid I don't anymore.

WCR: You mentioned that you might have gone into a subspecialty in internal medicine if your family situation had been different. If you had gone into a subspecialty, which one would you have chosen?

RLF: Two interested me. One was rheumatology. I had done an extra rotation with Drs. Merriman and Chubick and had really enjoyed that. The other was cardiology. John Schumacher and I had gone through residency together, and he was pursuing cardiology. I had also really liked Chuck Gottlich and others in his group. These were physicians that I wanted to be like and to practice like, but ultimately I made the decision not to pursue a fellowship.

WCR: How did your practice build?

RLF: Because I had trained at BUMC, a lot of the subspecialists referred patients. John Fordtran sent me a number of lovely patients, some of whom I still take care of today. Many cardiologists and gastroenterologists would treat a patient and then tell them that they needed a good general internist and send them to me. That was one way it grew. Another way was the emergency room, where I would leave my cards. I built a lot of my practice out of the emergency room. Many of my best patients came from referrals from other patients. General internists take care of communities of people. I have several communities of people that I take care of. Some are individuals who belong to my synagogue, and one member would refer another member who would refer another member. Another would be the legal community. People would ask my wife if her doctor husband was any good. What was she to say? I take care of many judges and many attorneys in this town.

I used to joke that it would be hard for me to get sued because at one point I took care of several of the leading plaintiff's attorneys in town. This was sometimes awkward. One of these plaintiff's attorneys needed a good gastroenterologist and I referred him to “Dr. A.” He said, “I can't do that; I sued him.” So I suggested “Dr. B.” He said, “I can't do that; I sued him too.” I literally went through just about every gastroenterologist on our staff at BUMC, and this guy had sued every one of them. I said, “I don't know what else to tell you because these are all good doctors, and I don't like referring you to a doctor I don't know.”

WCR: From the very beginning I gather you participated in BUMC's teaching program.

RLF: Yes.

WCR: That meant initially that you made rounds and gave medical grand rounds. Your activities at BUMC now are huge. The first thing you really got into was ethics. How did that come about?

RLF: Like most other things in my life, it happened through making a mistake and wanting to figure out what went wrong. In the first or second year of my practice, I had been called to the emergency room to admit a man who I was told had a stroke. (This was before computed tomographic scanners were available in the emergency room.) I took the man's history. He was a bus driver, and the history was considerably more interesting than a simple stroke. I said to him, “I fear something else is going on. I need to be honest with you. I fear you may have a tumor or something like that and we need to get a CT scan.” We got that scan, and sure enough he had what looked like a glioblastoma, and he had bled into it. I called neurosurgery, and while they operated I met with the family. I shared my concern with the family and told them I couldn't be certain from his history alone but I was afraid he had a malignant brain tumor, which would likely be something we could not cure. They said something along the lines of, “Whatever it is, don't tell him.” I said, “No. We have to tell him. If he's dying he's got to know and he's got to be able to say goodbye and make plans.” They still said, “Don't tell him,” and I made the mistake of arguing with them, thinking everything was okay and I was right because I was the doctor.

I had already been reading ethics for some time. It was another of my interests, and at the time I was really big into what we would call autonomy and believed that autonomy was an absolute value that should never be violated. The next morning, Dr. Tompsett called me and said the family had dismissed me and they were insistent that I not tell the patient of this dreaded diagnosis. Sure enough, he had a glioblastoma. I was very troubled and shaken by this event. I confided to a young oncologist on our staff at that time, Leon Dragon, saying, “I goofed up. I don't know what to do. I feel like this is wrong not to tell this man what's happening.” Leon agreed and noted it was a shame we didn't have a forum where we could discuss ethical issues in medicine.

Leon had actually known one of the pioneering medical ethics consultants, Dr. Mark Siegler, at the University of Chicago and suggested we needed a similar program at Baylor. Roughly the same year, 1983, a very important reference in medical ethics came out called the “President's Commission for the Study of Ethical Problems in Medicine.” This commission of experts suggested that hospitals establish ethics committees, as had the New Jersey Supreme Court in the Quinlan case in 1976. Although at that time we had an ethics committee at Baylor, all it did was put on an educational seminar once or twice a year, and it was not a forum for clinical consultation or reflection. So, when I got fired by a patient's family because of an ethical dispute, I asked to be put on the ethics committee at Baylor. Don Hunt, a vascular surgeon, was the chair of the committee, which included Lloyd Kitchens (an oncologist and one of my other mentors and teachers), 7 or 8 other physicians, the hospital's lawyer, and Chaplain Joe Gross, head of pastoral care. There were no nurses or social workers.

I proposed that the ethics committee could be something more, something different. I suggested a reformation of the committee with representatives from all branches of the healing environment. I proposed we have a nurse's view and a chaplain's view that would carry as much weight as a physician's view and that instead of being a closed-door organization of members who sat around and talked among themselves, we should become more open and develop clinical ethics guidelines and policies. I proposed that we provide more robust ethics education, not just for doctors but also for the whole medical center. Finally, and most importantly, I proposed that we have open-access medical ethics consultation. I basically said to the medical staff leadership, “Listen, this is an ethics committee. We don't make decisions or practice medicine. We render advice, and it should be open access. Any member of the treatment team should be able to pick up the phone and ask for an ethics consult.”

It took about 2 years to get these ideas through. John Fordtran, Marvin Stone, Perry Gross, and Ellwood Jones were all supporters of the concept. (Marvin had been involved early in the clinical ethics movement and had been responsible for the ethics course at the medical school, such as it was.) Marvin thought it was a good idea but wasn't sure about the real need. Ellwood Jones pressed for it but warned me, “Be careful what you ask for on this consultation business; you may get it and find yourself overwhelmed.” With the help of those kinds of individuals, we got the medical board to approve it, a real testament to Baylor's medical staff leadership.

This was 1984, 21 years ago. In 1985, John Fordtran gave us our first consult. The patient had had some type of open heart surgery and things weren't going well. His internist/cardiologist and his wife wanted to withdraw life-sustaining treatment, but the thoracic surgeon did not. Each physician was literally writing counter orders to each other. One would write “do not resuscitate; morphine 10 mg intravenously” and the other would write “cancel above order.” It was behavior unbecoming of physicians and left the nurses in a bind. They went to Dr. Fordtran, and John asked the ethics committee to help resolve the case. In the beginning, consults came just from nurses. Now, 95% are from physicians. A nurse would call and tell us the problem, and I would call the physician and say, “A nurse just called for an ethics consult.” And the physician would say, “Well, I'm not being unethical!” I would say, “I didn't say that. That's not what this is about. This is for advice to help everybody on the team think through and make the right decisions.” I think that first year we did five consults; three of them were retrospective. That is, nurses called and said, “If we had called you while the case was still going on, what would you have advised us?” We'd get the entire committee together, review all the literature, talk about the ideas, and render advice, sometimes weeks later. The next year we had 10 to 12 consults, and this model of full committee deliberation started to become impractical.

In year 3 or 4, Dr. Charles Shuey, who later became a very important member of the committee, called me and said, “I want an ethics consult. The nurses are going to call and ask for one anyway, so I thought I would call you first.” I don't remember now what the case was about, but I've often thought of it as a turning point for the committee. Today, the majority of our consults come from physicians and nurses in collaboration with each other. A number of years later I asked Charlie to be on the committee, and he proved to be a wonderful, wise, and helpful committee member.

WCR: Today, how many consultations do you get annually?

RLF: We get about 130 formal ones, where we write in the patient's chart. That's not the same as an informal consultation. People pick up the phone all the time and say, “I just want to run something by you.”

WCR: You see all of those patients?

RLF: I now see about 70% of them. Dr. Casanova sees a big chunk of them now. Dr. Millard also sees some of them. We have gradually spread out the work. We have also trained a couple of nurses who can handle some of the less formal consults. The 130 are those done by physicians. Often it takes a doctor to talk to a family. Even though the nurse knows everything I know and can say all the same words, the family needs to hear it from a doctor. A not-uncommon consult would be a critically ill patient in the intensive care unit, with six different specialists on the case. Five of the six say, “It's time to stop treatment,” but the sixth physician happens to be the attending physician who called all the other consultants in, and he or she disagrees. In a case like that it usually takes a doctor to talk to that doctor.

WCR: At the same time that you were building your private practice, clinical ethics consultations and committee meetings were growing each year and obviously taking more and more of your time. In addition you started palliative care consultations. Was that an offshoot of the clinical ethics consultations? How did that come about?

RLF: The whole concept of hospital-based palliative care consultations is between 5 and 10 years old. It was first suggested to me probably 5 years ago by Carl Noe, MD, the head of pain management, who was seeing a few palliative care consults. Carl called me one day and said, “Bob, I think Baylor needs a palliative care service.” I said, “Carl, I don't know why we need this. This deals with patients at the end of life. We've got the ethics committee, which helps doctors, nurses, and families resolve their disagreements and make decisions about when it's time to switch from care to comfort. We've got your service which manages pain, and we've got wonderful hospices here. What do we need palliative care services for?” So, I said no—a mistake, I think, in retrospect. But over time, as I watched this movement evolve, I began to see that palliative care was another way of serving patients who were being missed by clinical ethics, by pain management, and by hospice services.

About 4 years ago, Remy Tolentino, Baylor's chief nursing officer, and I started seriously studying the notion of bringing palliative care to BUMC. After getting administrative and medical staff leadership approval, we opened our doors for business on April Fool's Day of 2004. We currently see about 20 to 25 patients a month, and there's not been a drop at all in our ethics consults.

WCR: How do ethics consultation, palliative care, pain management, and hospice services differ?

RLF: Hospice serves patients at the end of life. The moral disagreements that we get involved with on ethics consults are usually near the end of life, and obviously pain management may serve patients with serious physical pain at the end of life. So clearly, there is some overlap.

To get on hospice the patient has to be willing to say, “No more curative therapy.” Well, if you're in the hospital, you are usually there because you want curative therapy, and every good oncologist or cardiologist will tell you, “My patient didn't come to the hospital to die.” You and I may know as doctors that they are dying, but that's not what they came here for. You automatically can't use hospice to serve patients with advanced life-threatening illnesses in the hospital until the patients have worked through their denial and the doctor has worked through his or her denial about what's going on. Palliative care can see those patients.

Our pain management colleagues are happiest if they can implant a pump, do an epidural block, and so forth. These are wonderful doctors, but they are not necessarily interested in treating spiritual pain. They learn all of these fine, manipulative techniques, and they need to primarily be utilizing those technical skills as far as I'm concerned.

Finally, ethics consults are often requested when there are disagreements or uncertainty, but ethics consultants don't write orders or treat patients; the service is strictly advisory in nature.

Palliative care has been able to come in and see a whole new group of patients. We see many patients with advanced life-threatening illnesses and provide what I call a “transition to hospice” type of service. We have seen a number of patients for the oncology service and for the heart failure service where the doctors will call and say they know the patient is dying but the patient or family is not ready to accept this sad fact. The physicians need help managing the symptoms; they need help convincing the patient or family to make that transition from aggressive life-sustaining treatment to better end-of-life treatment. That is what has been particularly gratifying about the palliative care service. We can do a wonderful job of pain management for a lot of patients with intractable pain, whether the pain is physical or spiritual.

WCR: When did the interfaith task force come about? How did you get involved?

RLF: About 5 years before the garden was built I was skipping down the stairway in Roberts Hospital and just about stumbled upon a Muslim man praying in the stairwell. He had his coat spread out on one of the flat landings and was praying. I was embarrassed that I had disturbed his prayers, and he appeared a little embarrassed. I thought to myself, “This is not right that a Muslim should have to go hide himself in the stairwell to pray.” I promptly went to the pastoral care office, explained my concerns, and asked for support in creating an interfaith task force to examine issues of religion, faith, and spirituality on our increasingly diverse campus. That same day I went to Boone Powell, Jr.'s office and asked for his support in this arena, explaining that we needed to figure out a way to make this wonderful institution more welcoming to people who are not of the Christian faith. Boone, without hesitation, told me to go for it.

I put together our task force with the help of Lloyd Kitchens and Jann Aldredge-Clanton, both of whom were key members. I very much wanted to build an interfaith chapel but I was shown the error of my ways. After lots of debate, studying, and reflection, the committee concluded that we needed a garden instead, and the garden would have a labyrinth for walking meditation. We had checked with all the major religious traditions and determined that the labyrinth as a symbol would not offend any religious sensibility. We then chose a site in the center of the campus and sought permission of a senior administrator to put the garden in the very heart of the campus, making a clear statement that Baylor welcomed people of all faiths. This first administrator was not exactly supportive, preferring that the garden be way off on the edge of our campus. He said to me, “Bob, what am I going to do if there are a bunch of Muslims praying in the garden and some Baptist ministers from East Texas walk through and see them?” I replied, “You just tell them that they are God's children too.”

I was not able to persuade this administrator of the importance of a central location and so I went back to Boone. I had a hard time getting time with him, but during his last official week at Baylor he invited me to his office to discuss our ideas about the interfaith prayer garden. Needless to say, I was pretty anxious about this meeting, fearing that the ideas would be rejected. At the meeting with Boone Powell and Joel Allison, I showed them a recent Baptist Standard article about a little church in Richmond, Virginia, that used a canvas labyrinth in the sanctuary for meditation and prayer after Sunday services. When Joel saw this article, he exclaimed, “My gosh—that's my youth minister from Abilene,” and if it was acceptable for his church to have a labyrinth, it would be acceptable for Baylor to have one. I thought to myself, “Thank you, God.” Boone and Joel gave me their blessing to move ahead with the garden if I could get the approval of the board of trustees and could raise the money.

We got the trustees' approval and then it took about 2 years to raise the money to build the garden. Ernie and Sue Wayne and their family came forward with half of the funding. Our medical and nursing staff came forward with at least a quarter of a million dollars for it. This project touched a chord in people's hearts. It's wonderful to see. I think it touched a chord with Christians and non-Christians alike.

WCR: How much did the garden cost?

RLF: About $1,500,000. I never had any idea that it would be that expensive. One person who really wanted that garden was Lloyd Kitchens. Lloyd had always been a supporter of mine and had lent his gray hair and wise counsel to me when I was a young activist but not always as politic or wise as I could have been. Lloyd was very helpful when we wanted to build this interfaith garden. Lloyd lent us some additional credibility. I had argued in our interfaith task force against the garden, but Lloyd had wisely seen its advantages. When Lloyd was dying, my last conversation with him was about the garden. We probably would not have the garden had it not been for Lloyd Kitchens.

WCR: You also played a major role in the skilled nursing facility. How did that come about?

RLF: During my residency, I developed tremendous respect for David Bornstein, Sue Bornstein's dad. David was a wise, compassionate, and well-informed internist who more or less limited his practice to geriatrics and also became a role model for me. Dave had a heart attack around June or July of 1981, just as I finished my residency. Twice a week Dave went to Golden Acres, where he was medical director, and he asked if I would be willing to go to Golden Acres and make rounds out there for him while he recovered. Also at that time a number of Russian-Jewish families had immigrated to the USA, and the elderly Russian-Jewish families who came to Dallas were housed at a special complex at Golden Acres. These patients faced language and transportation barriers, so I volunteered to open a clinic out there for them. The net result is that I went to Golden Acres 2 to 3 days a week to run the outreach clinic for this elderly immigrant population and to make rounds for Dr. Bornstein until he recovered from his heart disease.

I began to find geriatrics more and more interesting, and so I started reading the Journal of the American Geriatrics Society. Then, when Baylor decided to study ways to better serve elderly patients, I was asked to serve with John Gunn, the orthopaedic surgeon, on a task force on the care of senior citizens at BUMC. John McWhorter, a young administrative fellow at the time, was assigned to work on this project. We ultimately made a presentation to Mr. Hille and Mr. Powell on ways to deal with the care needs of senior patients at BUMC and the financial needs of the institution. We thought a good way to do this was to set up a hospital-based skilled nursing facility on campus, and we were one of the first hospitals in the country to do it. Having been one of the leaders of the task force that proposed this concept, I was then asked to become the medical director of the facility. That role then led me to take my geriatric boards. Ron Anderson and I took the boards together. He, like many internists, has a great interest in taking care of the elderly. We were some of the first board-certified geriatric physicians in Dallas at that time. Finally, as an outgrowth of this activity, I started the geriatrics committee, which eventually Wilson Weatherford took over because I couldn't do ethics and geriatrics at the same time.

WCR: What about the Caduceus Society? It is my understanding that you started that.

RLF: I don't know if I started it, but I was instrumental in its founding. The Foundation wanted to start an outreach group for young leaders in Dallas—the kind of people who may be future movers and shakers in the community. They wanted to target an age range of 25 to 40 and get these people involved with BUMC. We thought a good way to do that would be to have luncheons that were both social and educational, the idea being to show them what a wonderful jewel BUMC is in the middle of Dallas. One young committee member suggested that the group be called the “Poseidon Society.” I said, “I don't think we need such a militaristic name. How about a medical name? How about Caduceus Society?” The name stuck and the society is still going strong, but I'm now too old to be in it! They do invite me back to speak every now and then.

WCR: How often do they meet?

RLF: I think 4 or 5 times a year.

WCR: What time do you wake up in the morning?

RLF: 5:30 am.

WCR: What time do you leave home to get to the hospital?

RLF: It depends. If I have a 7:00 am meeting, I'm out of

the house by 6:40 am. If I don't have to see patients until 9:30 am in the office, I might stay at home until the last kid is out of the house. I drive carpool several days a week. Our youngest child attends the Hockaday School, so we leave home at 7:20, drop her off at 7:55, and I arrive at the office at about 8:15 am. That schedule is typical during the school year. I see patients in the office about 20 hours a week, whereas the typical internist schedules 36 or 40 hours a week.

WCR: But you used to see patients a lot more?

RLF: Yes. I gradually pared down my practice. For the first 10 years of the ethics committee, my efforts were a labor of love. Fortunately, I could afford to pare down my practice since my wife was and is a partner at a successful law firm. I was not the primary breadwinner in my family, so it allowed me to see fewer patients. Nevertheless, the financial toll began to mount and with the assistance of Glenn Clark, some partial financial compensation was arranged for the time I spent on clinical ethics. Now my challenge is to cap the time I spend on institutional ethics and to train Dr. Casanova, who I hope will be the future leader of these programs at BUMC. Now four other doctors provide palliative care consultations. I'm very proud of these younger physicians, all of whom are wonderful and every bit as effective as I am. I feel like I have two masters: my primary care practice and my ethics/palliative care work, and I love both. I'm desperately trying not to have to give up one or the other but to keep some balance between the two. They are both important to me and I think to my soul.

WCR: What time do you leave the hospital at night?

RLF: I do my best to be home by 6:00 pm.

WCR: What time do you go to bed at night?

RLF: Generally, I watch Jon Stewart until 10:30 pm and then read for about 30 minutes.

WCR: You used to have quite a few patients in the hospital. Has the hospitalist program been useful to you?

RLF: Yes. When I'm on call for my MedProvider group, I can have the hospitalists admit my partners' patients if needed. This has been a boon to every office-based, middle-aged physician on our staff because we don't have to come in at 2:00 am and admit somebody and then have a full day of practice in the office the next day. If the patient is one of my own, I will generally come in and admit that patient, or certainly if the hospitalist admits my patient, I always pick up my own patient the next day, unless, of course, I will be out of town. At this point in my career, I travel a good bit and do more teaching out of state. Fortunately, I'm blessed with a generally highly intelligent, highly motivated patient population that is very interested in prevention. A high percentage of my patients are on statins. Their blood pressure is generally well controlled. They are up to date on their preventative care. Thus, it is rare to see an acute myocardial infarction among my patients or have other types of acute medical problems that require emergent hospitalization.

WCR: How much time do you take off each year?

RLF: I take about 4 weeks of vacation. I take off other times for conferences or for civic activist work at the state level. I couldn't do that without my partners being reasonably tolerant and Dr. Casanova being particularly tolerant and helpful in picking up the slack when I am out of town.

WCR: Where do you like to go on vacation?

RLF: Cities—New York, London.

WCR: Do you get an ethics call or a palliative care call almost every day?

RLF: Pretty much. The palliative care work is a little different from ethics. We have divided up the palliative care work between five physicians who provide consultations. Two of us are now board certified, and eventually all five will be board certified. We divide those calls up 1 week at a time. I'm on palliative care call this week, and I will continue treating any patient whom I pick up until he or she leaves the hospital. Thus, I get palliative care calls 1 week out of every 5 weeks. But, because I'm the chief of this new program, it is my responsibility to pick up any cases that the other physicians can't get to in a timely fashion, and so I take on a few extra cases every once in a while. The ethics calls vary. There might be a week with none and then five calls in a day. I try to handle about 70% of those and ask either Dr. Casanova or Dr. Millard to handle the other 30%.

WCR: What do you do when you get home?

RLF: Cook dinner, usually. I'm the family cook. We now have just one child at home, our 16-year-old. She likes to talk politics and she has a wry sense of humor. Most teenagers don't want to talk about their day at school, but she often will with me. Sometimes I play my guitar. I almost always walk our dogs, and that is sometimes a family talk time. I sometimes work out. During basketball season I watch the Mavericks, and I read.

WCR: What else do you do for fun?

RLF: As a younger man, I loved woodworking. I built my kids' swing sets, and I built the first kitchen table and hutch that Nina and I had. I don't do woodworking anymore. I used to dabble in artistic stuff. As a young man I sailed a lot (Figure 7). We like to travel and see different places.

Figure 7.

Sailing with his family in the early 1980s.

WCR: What time does your wife get home?

RLF: It varies, but generally she gets home a little bit later than I do, and that's fine. She's the family salad chef but otherwise I'm the everything-else chef. It works well for us.

WCR: Do you like to cook? Is that a hobby?

RLF: Yes. My oldest daughter, the medical student, is also quite a cook and better than I am. We just prepared an Indian food feast for the palliative care team.

WCR: Religion must have been an item of discussion when you and Nina were dating. It's my understanding that almost half of Jewish people marry Protestants. It's also my understanding that those couples often become nonreligious or each continues his or her own faith; if they do switch religions, there is more switching by the Jewish partner to the non-Jewish partner's religion. You switched from the Protestant arena to the Jewish arena. How did that come about? What was your thinking process?

RLF: It was complicated. How many of us really know why we do what we do? My last name, Fine, is often thought of as Jewish. As a young boy growing up in Dallas, I had been subjected to anti-Semitic slurs without knowing what they were. People would say, “Fine, you gonna try to Jew me down on this?” As a young Methodist and then Presbyterian, I didn't know what they were talking about, so that kind of slid over me. Then in high school, when learning about World War II and the Holocaust, I started thinking, “Are people being anti-Semitic towards me?” I still didn't think too much about it, but I realized what was going on.

Like a lot of young people in my high school years, I was questioning things theologically. My parents were Christian, but my father in particular was a highly rationalistic type of person. He had a set of books called The Interpreter's Bible, which was like an encyclopedia but covered the archeology and history of the stories in the Bible. I read parts of it and discussed it with my father. We were encouraged to debate religious ideas. My mother was the church organist, and sometimes I would bring her to tears with these discussions. Early on, I remember a debate with a Sunday school teacher who had said something like, “If you just believe in Jesus, all would be forgiven.” I said, “Does that mean Hitler would be forgiven?” So, I grew up with many conflicting thoughts and ideas and feelings. I went off to college, met Nina, had many Jewish friends, and took a fascinating course in Jewish-American literature. I became more and more interested in Judaism, initially through literary exposure to Jewish culture and then from Jewish culture to Jewish theology and, in particular, reformed Jewish theology.

I found a number of ideas in Judaism very attractive. One was the notion of tikkun olam, or mending the world. This is the idea that creation is not complete but is ongoing, and humans are to be God's partners in this ongoing creation and mending of an obviously broken world. Another notion that appealed to me was that true forgiveness had to come from the person you wronged. God would forgive all but, ultimately, that's not what was important. What was important was in essence seeking forgiveness from the person whom you had sinned against or harmed in some way. I found that very meaningful. I liked the Jewish notion that God is ultimately not knowable by us mortals. We can't really know God's name, and God is greater than we can grasp. Contrast that to Christianity, where you can know God through Jesus, God in the flesh. I had always struggled with that as a young Christian in Sunday school. So, when I came across this faith that says, “You can't quite know God but you can help God mend an imperfect world,” I found myself a spiritual home that made sense to my soul.

Another factor in my conversion was my mother-in-law, who said to me one day, “Bob, do you know the meaning of not granting Hitler a posthumous victory?” I said, “Yes, I think I know the meaning of that.” I realized at that point that it was very important to Nina's mother that there be Jewish grandchildren. Nina's mother had escaped from Germany as a young woman, only to get to England and be put in a camp for Germans. She got out of that camp, went to London, and survived the London bombings but lost her parents at Auschwitz. It was very important to her, and I was very happy to accommodate that wish because I had found a spiritual sense of peace and less questioning. I do question chosenness. If a group of us converts to Judaism get together and let our hair down, the discussion often includes, “What is this chosenness business all about?” I have a hard time with that, as do many born Jews. I also have a fair amount of trouble with the notion of the land of Israel. I struggle with the Jewish concept that says God gave this land to the Jewish people. I daresay that I have many Christian friends who put more weight on that part of Jewish (and Christian) theology than I do.

WCR: Did your parents have a problem when you converted to the Jewish faith?

RLF: My dad had no problem at all. My mother momentarily was afraid I would go to hell but quickly caught herself and dropped those sentiments. Before I converted I had already left the organized Christian faith, and after I converted I became very active in synagogue life, serving on the board and various committees. This actually then made my mother say that she was very happy because I was active religiously, in contrast to the time when I had left organized Christianity but had not replaced it with any other religious activity. She very much believed in the power of religion and faith, and after a short while she got over my conversion. Now I would describe myself as a very spiritual person but not a particularly religious person in terms of ritual.

WCR: It sounds as though each of your three girls has done beautifully. When were they born?

RLF: Lauren was born on August 26, 1980; Rachel, on August 17, 1983; and Rebecca, on July 21, 1989.

WCR: What is each of them doing?

RLF: Lauren is now in medical school at the University of Pennsylvania, having just finished her first year (Figure 8). She is the real singer-songwriter in the family. She grew up playing piano and then taught herself guitar. She started writing music in about the fifth grade. I came home one day and she was playing a new song. I asked, “Did your music teacher give you a new piece of music?” She said, “No. I wrote it.” She also wrote an instrumental piece for her grandmother who was dying at BUMC. We realized that she was using her creative talents to express her emotions. We've tried to raise all three children to be creative in any pursuit they choose. As a firstborn, she is a pretty good example of the nut not falling far from the tree. When Lauren went to Brown University, she decided to major in bioethics and premed.

Figure 8.

With his oldest daughter, Lauren, on her entry into medical school.

Rachel, our second child, was a gifted ballet dancer. Unfortunately, she wound up with bilateral spondylolysis during high school and had to quit dancing. It was painful for her not only physically but also emotionally. That for me has probably been one of the biggest challenges I've experienced as a parent, realizing that her condition would change who she had planned to be, and I needed to figure out how to support her as she reinvented her sense of self. I do believe that people have to periodically reinvent themselves. Certainly disease pushes people to do that.

We see that all the time. Just as Lauren always saw herself as doing both medicine and music, Rachel always saw herself as doing dance, and she was really good at it and that's gone. She is at the University of Colorado at Boulder (Figure 9), now halfway through, majoring in philosophy. I actually tried to discourage the philosophy degree, but she is absolutely set on the idea and really seems to like it. She has recently started talking about law school, but I think she will take some time off after college to work before doing that.

Figure 9.

Hiking in the mountains outside Boulder, Colorado, with Nina and their second child, Rachel.

Becca will start her sophomore year of high school this year (Figure 10). She also has spondylolysis, and I'm beginning to think it's a genetic thing in our family. She was a good athlete and has had to give that up. I think Becca's current passion is art. She is very creative in both form and color. She also writes unbelievably well for a person her age; in fact, she frequently writes better than I do.

Figure 10.

At a political march with his third daughter, Becca.

WCR: You have also been very active in certain endeavors here in the Dallas community, such as its AIDS program. Are those activities continuing?

RLF: AIDS, no. It's one of those things in my life like sailing. It came and it went. It was important when I was involved in treating a lot of AIDS patients and advocating on their behalf, and it is interesting how I came into that role. I had a patient ask me once if it bothered me that he was gay. I replied, “No.” He then asked me what I thought about gays. I said, “It's kind of a biological dead end but other than that, no problem.” We both laughed, and he said, “Well, I really want you to be my doctor.” That started up a doctor-patient relationship, and it turned out he was one of the young activist leaders in both the Dallas and national gay communities. He started referring his friends to me. This was just before the AIDS epidemic arrived. Thus, early on in my practice, I started treating a lot of young gay men.

Next, I'm pretty certain that I had one of the first cases, if not the first case, of AIDS at Baylor. Russell Martin, Ellwood Jones' former partner, called me one day and asked if I could see on short notice a patient who had been referred to him from out of town with a fever of unknown origin. I saw the patient that day. He was a middle-aged heterosexual who had had open-heart surgery in Lubbock, Texas, and later developed fever, chills, and weight loss that they could not explain in Lubbock or Houston, as I recall. He next came to Dallas, and I admitted him to the hospital and started doing a fever-of-unknown-origin workup. He developed pulmonary infiltrates and dyspnea, and I called David Luterman. David did a bronchoscopy and found pneumocystis. I called Bill Sutker and told him I thought we might have this new syndrome we had been reading about. It took a good while at that time to get a confirmatory HIV test, but this man's test came back positive. That was my first AIDS case and this was about a year before zidovudine became available.

That poor man died within about 6 months, and about that time some of the young gay men in my practice started getting sick. I wound up taking care of Bill Nelson, who was the first openly gay man to run for city council in Dallas, and Terry Tebedo, another gay civic leader. There is a clinic in town called the Nelson/Tebedo Clinic. They were both my patients. I took care of Mike Richards who founded the AIDS resource center, and his successor, John Thomas. With patients like that, it was only natural that I became involved in AIDS activist work as well.

There was a time early on when I and other doctors taking care of AIDS patients had a hard time finding enough consultants to see our patients. There was also a time when a member of our medical staff advocated that BUMC throw its weight behind an effort to quarantine all gays in this state. To the credit of BUMC and its leadership, all felt this was the craziest idea ever proposed to deal with the problem of HIV infection.

I ultimately had to close my practice to new patients between all of the things I was doing with ethics, geriatrics, community volunteer work, and suddenly having lots of very sick young men. This was before the combination and highly active antiretroviral therapies. AIDS meant eventual death for all of these men. Because my practice has been essentially closed for 14 years now, all of those early HIV-positive patients died. Since I rarely see a new patient, I just don't see the disease anymore; thus I no longer feel confident managing it.

WCR: Bob, I would like to thank you on behalf of BUMC Proceedings for pouring out your soul here. I'm sure your colleagues and readers will love the opportunity of getting to know you better.