Doctors to the dying: Helping patients at the end becomes a growing specialty

Palliative care attracts many physicians who see it as a noble calling.

By Larry Beresford, amednews correspondent — Posted Jan. 26, 2004

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When David Weissman, MD, entered the field of palliative care in 1991, there were few training programs. Dr. Weissman had a background in oncology and pain advocacy work with the Wisconsin Cancer Pain Initiative, so he just jumped right in. Now, less than 15 years later, he is a national leader in an emerging specialty.

Dr. Weissman coordinates the Palliative Care Center at the Medical College of Wisconsin, Milwaukee. He is responsible for a consultation service, an outpatient clinic, a dedicated inpatient unit and an educational and research program. He advises medical fellows and directs the online End of Life/Palliative Education Resource Center and the National Residency End-of-Life Education Project, which has introduced end-of-life curriculum into 320 primary care residency programs nationwide since 1999. He even edits a professional journal, The Journal of Palliative Medicine.

He is now routinely contacted by students and residents interested in exploring palliative care as a career.

"A senior medical student recently called me to set up a one-on-one meeting. He's interested in finding out where the field is going: Will he find jobs? How much will he get paid?" Dr. Weissman says. "I'll tell him that there are way more jobs in palliative care right now than people trained to fill them." Such positions typically pay somewhat below the midpoint of physician salaries, "but I also tell students it's a noble calling."

Medical pioneers in end-of-life care, which includes hospice and hospital-based palliative care, often were driven by personal experiences and extolled for their compassion to dying patients. Today, growing awareness of the field, expanded fellowship opportunities and full-time positions are mainstreaming the specialty as a more viable career choice for young doctors.

One of Dr. Weissman's current fellows, Chad Farmer, MD, is now job hunting while completing a degree in bioethics and wrapping up a two-year palliative care fellowship. "I have found that the market is wide open for anyone with fellowship training. Right now, demand is out ahead of supply," Dr. Farmer says.

There are 45 palliative care fellowship programs nationwide, according to a list posted on the Web site of the field's professional association, the Glenview, Ill.-based American Academy of Hospice and Palliative Medicine. Dr. Farmer organized a special interest section within the association for the palliative care fellows, a group that grew from 21 members last year to 36 this year. On the section's list-serve, "we talk a lot about jobs -- what's out there and the jobs people end up getting. It's surprising to me the huge variety of those positions," Dr. Farmer says.

"I looked at academic centers with established palliative care programs and lots of teaching. I'm also looking at large regional hospice organizations with full-time positions for physicians," he says. "One place asked if I would be willing to do internal medicine clinic work part time while its palliative care position grows. I told them that at my level of training, I don't want anything less than a full-time position in my field."

Marching to a different drummer

Dr. Farmer's interest in end-of-life care began with his experience as a hospice volunteer at the University of Oklahoma College of Medicine in Oklahoma City. "I wanted to see if I could handle death and dying, and I fell in love with it. In medical school, during your rotations, everything seems very businesslike. In hospice, you're talking with patients about their lives and really seeing their satisfaction."

When he was doing an internal medicine residency in Arizona four years ago, his attendings and teachers found his interest in end-of-life care a bit hard to fathom. They have since become more supportive of his career path and recently asked if he would be willing to come back to start a palliative care program.

Gary Graham, MD, also sees robust employment opportunities in the field, which he credits in part to the aging population. On the other hand, he says, "I'm not sure that many doctors look at this field as totally legitimate yet. I think people who choose to go into end-of-life care still have a strong sense of mission and are marching to a different drummer."

Dr. Graham is one of six medical fellows at San Diego Hospice, in San Diego, which employs 10 full-time physicians for its research, education and clinical services. The independent hospice collaborates with local professional schools and has a steady stream of doctors and others passing through on rotations.

Dr. Graham, 52, is looking for full-time hospice or palliative care work, although he enjoys teaching residents. After practicing obstetrics and family medicine for 20 years in his hometown of Great Falls, Mont., he was looking for a way to get out of "medicine as usual." He even helped set up a holistic care clinic in Great Falls, but that closed after a year. Then he took a break from medicine.

"I needed to get out of there and figure out what I wanted to do with my life. I just knew that there was something better," he says. While pursuing a theology degree in pastoral ministry at St. John's University in Collegeville, Minn., Dr. Graham learned about hospice care. He volunteered once a week with Allina Hospice in St. Paul for a school practicum, then did a one-month observership at the Palliative Care Service of the Royal Victoria Hospital in Montreal, Canada.

"It seemed like a way to put my medical background together with my interest in spiritual issues and in healing as something more than just physical. I thought I might be too old, but I started making fellowship applications, and San Diego Hospice was interested in having me," he says.

"Now I'm really on track. I'm enjoying myself so much here, I spend a lot of extra time trying to get as much out of this one-year experience as I possibly can." Dr. Graham's fellowship includes a stint on a freestanding inpatient hospice unit, teamwork with the home hospice team, home visits to patients and staffing a hospital consultation service.

Hospice care is a whole different way to practice medicine, Dr. Graham says. "After the oncologist says there's nothing more to be done, my job is to say, oh yes there is, and to give hope back to the patient."

Once pain is managed, an essential role of the end-of-life physician is to create a sacred space for psychological and spiritual healing. "We have hard evidence that people's pain is often related to existential angst. Treating that pain takes time. Nothing will ever replace one human being sitting with and validating another human being."

Putting the pieces together

Alexie Cintron, MD, is on a palliative care fellowship at Dana Farber Cancer Institute, based at the Palliative Care Service at Brigham & Women's Hospital in Boston. He has already completed a research-oriented fellowship in general internal medicine. That research also examined end-of-life-related issues such as the use of advance directives and patients' decisions to enter hospice care.

"I actually didn't know there were palliative care fellowships until the second year of my first fellowship in medical research. But I really did want to learn about research methodology and get into the health policy arena," for which the internal medicine fellowship will be helpful.

"The palliative care field is still growing. We haven't put all the pieces together yet. That's what's so exciting -- we're making changes as we go along," Dr. Cintron says. He is looking for an academic position in palliative care. "If I wanted to be 100% clinical, I could find a position. But with my desire to also do research, I'll probably have to carve out my own position."

Dr. Cintron's interest in medicine dates back to the death of his sister Annette at age 16, when he was an undergraduate. Annette had cerebral palsy, among other medical conditions, and spent her final weeks in an ICU before the family decided to withdraw life support. "The medical team worked with my parents and gave them as much information and time as they needed," he said.

After Annette was placed on a ventilator, she entered a downward technological spiral, he says. "What would be added next, taking away what little quality of life was left to her? My parents felt that wasn't what they wanted for her. Still, it was a difficult decision."

Dr. Cintron's parents often ask him about his career interests. "The experience we went through together solidified the conviction we all hold that quality of life is what we would value over extending life for another week or month. We're very clear about our wishes. They are interested in hearing how I can help other people go through that experience."

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Palliative care, a growing specialty

Some 1,200 U.S. physicians have been certified as specialists in palliative care since 1996 by the American Board of Hospice and Palliative Medicine.

An estimated 3,200 hospice programs provided palliative care to 875,000 dying Americans in 2002, says the most current data from the National Hospice and Palliative Care Organization, Alexandria, Va.

Hospital-based palliative care services have emerged to offer a similar kind of interdisciplinary comfort care to patients earlier in the course of a serious illness. The Center to Advance Palliative Care at Mount Sinai School of Medicine, New York City, estimates that there are about 800 such programs in operation. The field is growing by 20% per year.

Although end-of-life care has sometimes been portrayed as a counter-cultural movement, Charles von Gunten, MD, medical director of the Center for Palliative Studies at San Diego Hospice, prefers to describe its practitioners as "pioneers who, like other pioneers, often face a reaction from the mainstream."

The field's growth has been driven by new knowledge and an increase in medicine's ability to relieve pain and suffering. "Now we're probably reaching the tipping point where significant numbers of doctors are deciding to enter the field."

Dr. von Gunten, ABHPM's vice chair, is one of the leaders of a national effort to get palliative medicine recognized as a legitimate medical subspecialty, equivalent to any other. This is an incremental, multiyear process, he says, but one making steady progress toward eventual recognition by the American Board of Medical Specialties, along with recognition for fellowship programs by the Accreditation Council for Graduate Medical Education.

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Resources available in end-of-life care

The path to a career in end-of-life care often starts with a mentor. Fortunately, such mentors are becoming easier to find, said Charles von Gunten, MD, medical director of the Center for Palliative Studies at San Diego Hospice. Today, most large hospitals have an acknowledged expert with an interest in end-of-life care.

An obvious next step, says Dr. von Gunten, is to attend a conference sponsored by the American Academy of Hospice and Palliative Medicine, Glenview, Ill. (link), which offers clinical practice standards and self-study modules.

Young physicians interested in a career in end-of-life care are encouraged to first seek residency training and board certification in a primary care field such as internal medicine or family medicine. Specialties such as psychiatry, neurology, surgery, anesthesiology or pediatrics are also avenues into the field. Other resources helpful to doctors exploring end-of-life care as a career option are:

  • The American Board of Hospice and Palliative Medicine, Silver Spring, Md. (link), which sets requirements for certifying doctors in the specialty of hospice and palliative medicine.
  • The End of Life/Palliative Education Resource Center (link) at the Medical College of Wisconsin, Milwaukee, which gives peer-reviewed, online educational resources.
  • The Center to Advance Palliative Care (link) at Mount Sinai School of Medicine, New York City, which promotes the development of hospital-based palliative care programs and recently launched six regional Palliative Care Leadership Centers for on-site training.
  • EPEC, Education on Palliative and End-of-Life Care (link), a train-the-trainer program designed to educate U.S. physicians on the essential competencies of quality end-of-life care, which was originally developed by the AMA and now is housed at Northwestern University Medical School in Chicago.

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