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Dedicated physicians, patient advocacy groups, and economic considerations have been the recent driving forces to improve the care of patients at the end of life. Palliative medicine has emerged as a medical specialty offering an array of pain management and medical interventions that shifts the focus of care from cure to comfort in dying patients. Career options are plentiful and include hospice and consultative hospital-based opportunities. For physicians who wish to fulfill their calling to the medical profession with a unique blend of medicine, psychosocial, and spiritual dimensions, palliative medicine is the perfect choice.
— John A. Fromson, MD*
The fast-growing specialty offers a variety of career paths, and no small measure of personal and professional gratification.
By Bonnie Darves, a Seattle-based freelance health care writer
Jane deLima Thomas, MD, an attending physician in the pain and palliative care program at Dana-Farber Cancer Institute in Boston, admits that she “certainly didn’t go to medical school intending to focus on end-of-life issues.” Neither did Lisa Marr, MD, who recently left the University of Wisconsin to help develop a new palliative care program at the University of New Mexico in Albuquerque. For both physicians, their career choices emerged as a calling, in part because of their personal experiences during training.
“You develop a passion for something if you see things done less than perfectly or in a way that patients were suffering,” Dr. Marr observes. “You feel there has to be a better option.”
For palliative-care researcher and educator Erik Fromme, MD, assistant director of Oregon Health & Science University’s Center for Ethics in Health Care, the calling came in the context of his early teaching experiences at the Portland VA hospital.
“I realized that the things I liked to teach about the most — sort of in the psychosocial domains – were most easily taught in the context of palliative or end-of-life care,” says Dr. Fromme, who completed a medical-education focused fellowship at Johns Hopkins University in 2001 and his palliative medicine fellowship in 2002.
“You don’t have to work very hard to convince people that quality of life and treating patients decently is important when they’re at the end of their lives – they get it.”
Despite having been in the field less than a decade, Dr. Fromme is actually a long-timer, because the field itself is so young. Certification has been available through the American Academy of Hospice and Palliative Medicine (AAHPM) for nearly eight years. In October 2008, the first American Board of Medical Specialties-certified examination was administered by the 10 specialty boards that co-sponsored the initiative. In addition, from only a handful of programs a decade ago, today 46 institutions offer fellowships, and several organizations offer less formal focused training in palliative care, for physicians who wish to improve their skills. (See sidebar.)
Practice Options Exist in a Growing Number of Areas
Similarly, career options in palliative medicine are expanding dramatically, according to one of the specialty’s founders, Porter Storey, MD, who is executive vice president of the AAHPM and a palliative care physician with Kaiser Permanente in Boulder, Colorado. “Prior to about five years ago, the only way to really practice palliative care was to work for a hospice, and that’s still a good way to make a living,” says Dr. Storey, noting that there are now 4,500 U.S. hospices, all of which need physicians – especially as more medical treatments are being provided to dying patients. “Then a second way of working with patients at the end of life opened up – in the form of hospital-based palliative care consultations.”
The latter option, as well as teaching in the growing number of training programs, is seeing rapid growth, as hospitals scramble to launch services in the face of growing demand and as more treatments are being included in end-of-life (EOL) care.
Today, 75 percent of hospitals with more than 100 beds either have or plan to start palliative care services, according to American Hospital Association survey data. That will translate into a growing need for palliative care specialists, in practice and administrative positions, field leaders predict.
“There is huge demand for fellowship-trained physicians, in a variety of positions,” reports Vicki Jackson, MD, MPH, director of the combined Massachusetts General/Harvard Hospital, Harvard Medical School palliative care fellowship program, which trains nine physicians annually. “Fellows are fortunate to have opportunities now to go to community and academic hospitals to start a program of their own because the demand has increased so much.” Newly trained fellows also find ample options to serve as junior faculty members in established academic programs, she adds.
Opportunities are also on the rise in outpatient-centered palliative medicine, as hospitals, cancer centers, and community physicians try to better serve patients with life-limiting illness who are receiving active treatment and are not enrolled in hospice but may soon be. The palliative care needs of such patients have sometimes been under-addressed, experts contend, and a movement is afoot to provide a more coordinated approach among palliative medicine and other specialists who may be caring for the individual.
That movement is spawning a type of “hybrid” position, in which the palliative care physician may work in various settings and capacities, and represents yet another career option. For example, Gobi Paramanandam, MD, MHM (master’s in health sector management), started in a newly created position with the Center for Pain and Supportive Care in Scottsdale just weeks out of his fellowship at Mayo Clinic Hospital in Phoenix, Arizona, in summer 2008. He works with an oncologist who is also board certified in anesthesiology, in the outpatient and inpatient setting. The team’s hope, Dr. Paramanandam explains, is to broaden their service to work with not only oncology patients but those with other life-limiting illnesses, such as congestive heart failure or end-stage renal disease.
“It doesn’t matter what state of disease patients are in, or whether they are pursuing chemotherapy or dialysis. While they’re continuing with those treatments,” Dr. Paramanandam explains, “many patients have poor quality of life or are suffering. We’re trying to help them and the physicians who are managing them.” He also sees a growing need for educating caregivers and the community about the timing for initiating hospice services and ways that palliative medicine specialists can serve as a bridge for patients and families, by working with other specialists.
“Palliative medicine actually has a tremendous range within it. It can be strictly outpatient, or it can be strictly consultative inpatient management, and there are several different models for that,” says Dan Handel, MD, director of the palliative medicine fellowship at the National Institutes of Health Pain and Palliative Care Service in Bethesda, Maryland. “There are a lot of interesting and somewhat unusual ways to do this, and I think the future will be even different than it is now.”
Dr. Handel adds that as physicians, hospitals, and health care providers “learn more about who is best served by this type of intermediate care, where you don’t have all the aspects of hospice but you’re bringing a more personalized approach based on all the symptoms and quality of life,” even more palliative medicine practice options will emerge.
“The field is truly opening up; there are a lot more opportunities available than there were 10 years ago,” Dr. Handel explains. “Before, you had to forge your way. Now palliative medicine is becoming much more formalized, both in terms of training [and] career opportunities.” Most sources interviewed for this article, including Dr. Handel, agreed that fellowship is the ideal route for obtaining the requisite skills to competently practice palliative medicine.
Several of the specialists acknowledged, however, that such a path might not be feasible for some physicians, especially those in mid-career or whose professional or family demands preclude taking time for a fellowship. In such cases, where the added expertise would be an addition to an established internal medicine practice, for example, targeted courses or preceptorships (see sidebar) might suffice.
Public Pressures, Cost Considerations Spur Field’s Growth
Physicians who have chosen palliative medicine as their specialty surely wish to believe that all of the factors underlying the field’s substantial growth are altruistic in nature. Most are, but some arise out of economic considerations. In particular, there is growing recognition that many patients nearing the end of life remain in the hospital longer than warranted and undergo unhelpful treatments, when they can be perhaps better cared for (and more comfortable) at home or in another setting. In short, specialist-directed palliative care can save money. Hospitals and health systems are establishing or expanding services accordingly, Dr. Porter notes, and health plans and payors are following suit in modifying or increasing reimbursement structures.
Generally speaking, under Medicare the patient’s status and the physician’s role in the overall care — as either an employee or non-employee, or as consultant or attending — determine which services can be billed, who does the billing, and the rate of reimbursement.
From the patient care standpoint, several developments have put palliative care and palliative medicine in a more visible spot in recent years. For one, there has been a substantial push from advocacy organizations and the public to improve the care of patients with life-limiting illness. The Robert Wood Johnson Foundation’s funding of several initiatives focused on improving EOL care, and the Open Society Institute’s now widely known Project on Death in America, have emerged as a call to action for the medical profession and for hospitals. Care providers are being prodded to more openly address the problem of poorly managed inpatient deaths and assist in ameliorating cultural, family, and caregiver conflicts that result in unhelpful, sometimes painful, and often invasive treatments. The American Medical Association’s Education on Palliative and End-of-life Care and the Stanford Faculty Development’s End-of-Life Care Curriculum for Medical Teachers are examples of recent initiatives directed toward physicians.
“There is a tremendous need being met by palliative care programs,” maintains another of the field’s founders, J. Andrew Billings, MD, chief of palliative care at Massachusetts General Hospital. Besides assisting with pain and symptom management, physician specialists help with difficult decision making and coordination of care across settings, Dr. Billings notes. There is a growing recognition, he adds, among physicians and hospital administrators, “of the unmet needs of these patients and of the value of specialized services.” On the science front, significant advances in pain management and emerging knowledge on how to best address other severe EOL symptoms such as shortness of breath, nausea and opioid-associated constipation, have positioned palliative care as a key component of “whole-patient” focused care. Palliative medicine physicians are specially trained in the psychosocial and spiritual issues that patients and families struggle with at the end of life. The physicians work hand in hand with the nurses, social workers, and pastoral-care providers who may comprise the palliative-care team, and together the health professionals play an important role in alleviating some of the distress that often arises.
“Palliative care is a blending of the spiritual and the scientific in the total care of the patient, and now that palliative care and hospice is considered a new specialty, people have an interest in standardizing things and making [that care] as scientific and research-based as possible,” says Eric Prommer, MD, a hematologist-oncologist who gradually moved into palliative care and directs the Mayo Clinic’s service in Phoenix. He suggests that focusing on “the academic portion” of the specialty is an important step in reordering the way that medicine in general perceives the service. “There is still the perception out there that you just sort of drop off the patient [when hospice is invoked], so a lot of effort now is being focused on palliative care as a legitimate scientific specialty.”
Dr. Handel concurs with Dr. Billings on both the expanded role specialized physicians are playing and the improved “standing” the field has attained. In other countries, palliative medicine has long been integral in the care continuum, but that’s just occurring in the United States, he observes. “Elsewhere, palliative care and hospice are built into the power structure of medicine, but they never had a place in that here. Now, as a formalized medical subspecialty, with a certificate program, it’s finding its way in,” Dr. Handel says.
Dr. Jackson says that palliative medicine’s expanding role can be seen in the way that forward-thinking and forward-moving institutions are engaging specialists earlier in the care of patients with life-limiting diseases, and providing more structured approaches to co-management of those patients, especially in oncology. “People are enjoying that collaboration because we’re understanding oncology better, and they’re understanding us better. It’s a two-way street,” she contends.
Ultimately, however, politics and power structures have little, if anything, to do with the reasons physicians are choosing the field. For his part, Dr. Fromme says he simply feels “blessed to be able to do this work.”
Dr. Thomas says she no longer has difficulty answering the question often posed by younger colleagues and age peers: How can she get up and go to work every day when all of her patients are dying, and why did she choose her field? “The reality for me is that doing this work comes as close as I can imagine to what I had hoped I would do as a physician when I first entered medical school,” she points out. “I come into situations where patients are suffering and families are distressed — and I try to make a bad situation more tolerable, more peaceful, more comfortable for patients and their families. That has a huge amount of meaning for me.”
This sentiment is one that many of his trainees articulate, Dr. Billings observes, and it’s at the root of their career choice. “[That is] the attraction of the field for many clinicians: Now I can practice the kind of medicine that attracted me to the profession.”
Physicians interested in exploring palliative medicine, as a career path or in the interest of better caring for patients with life-limiting illness, may find the following resources helpful:
American Association of Hospice and Palliative Medicine (AAHPM), in Glenview, IL; www.aahpm.org or (847) 375-4712. The AAHPM offers information on a wide range of education and training opportunities available through the academy or other organizations. Resources include up-to-date fellowship listings and shorter-duration training, such as the newly developed Clinical Scholars Program and the popular Current Concepts in Palliative Care update and review course.
American Board of Medical Specialties (ABMS), in Evanston, IL; www.abms.org or (847) 491-9091. The organization’s website provides details on the new Hospice and Palliative Medicine Certification Program and associated requirements. The ABMS-approved subspecialty certification program was jointly developed by the following boards for their respective diplomates:
The American Boards of:
Obstetrics and Gynecology
Physical Medicine and Rehabilitation
Psychiatry and Neurology
Center to Advance Palliative Care (CAPC), in New York, NY; www.capc.org; or (212) 201-2670. The CAPC is primarily geared toward assisting individuals and organizations seeking to start sustainable palliative care programs in hospitals and other health care settings. CAPC also hosts seminars and audio conferences, and operates the Palliative Care Leadership Centers, a mentoring initiative.
National Hospice & Palliative Care Organization (NHPCO), in Alexandria, VA; www.nhpco.org or (703) 837-1500. NHPCO provides up-to-date information on Medicare requirements and reimbursement issues, as well as data on hospice use and costs.
Observership opportunities. In addition to providing formal training or fellowships, many established palliative care programs, such as the NIH’s service, offer those who wish to start their own service an opportunity to observe and seek guidance from specialists.
*Dr. Fromson serves as the editor for Career Resources and is Vice Chair for Community Psychiatry, Brigham and Women’s Hospital; Chief of Psychiatry, Brigham and Women’s Faulkner Hospital; Associate Professor of Psychiatry, Harvard Medical School.