Clinical

Palliative Care Can Be Incredibly Intense, Richly Rewarding for Hospitalists


 

 

Incredibly Intense, Richly Rewarding Dr. Bekanich

Incredibly Intense, Richly Rewarding Dr. Bekanich

After nine years in practice as a hospitalist in community and academic settings, Leonard Noronha, MD, applied for and in July 2012 became the inaugural, full-year, full-time fellow in hospice and palliative medicine (HPM) at the University of New Mexico in Albuquerque, one of approximately 200 such positions nationwide. The fellowship training qualifies him to sit for HPM subspecialty medical board certification.

Dr. Noronha says he was casually acquainted with the concept of palliative care from residency but didn’t know “when to ask for a palliative care consultation or what they offered.”

“I also had a sense that discussions about feeding tubes, for example, could happen better and easier than they typically did,” he says.

His interest piqued as he learned more about palliative care at hospitalist meetings.

“I grew more excited about it and came to realize that it is something I’d find rewarding and enjoyable, if I could get good at it,” Dr. Noronha says. “Over time, I found more satisfaction in palliative care encounters with patients—and became less comfortable with what I perceived as occasionally inappropriate and excessive testing and treatment [for some hospitalized patients who weren’t offered palliative care].”

Palliative care is a medical specialty that focuses on comfort, relief of symptoms, and clarifying patients’ treatment goals. It is commonly provided as an interdisciplinary consultation service in hospitals. Advocates say it can be offered concurrently with other medical therapies for any seriously ill patient, particularly when there are physical, psychosocial, or spiritual complications, and it is not limited to patients approaching death.

Experienced clinicians say palliative care maximizes quality of life and empowers patients and their families to make treatment decisions more in line with their hopes and values. They also say palliative care gives an emotional lift to providers, while reducing hospital expenditures. Some also suggest that palliative care is an additional tool for enhancing care transitions, potentially affecting readmission rates.

For Dr. Noronha, the one-year fellowship required a significant cut in pay, but he was prepared for the financial hardship.

“It was a great decision for me,” he says. “Some of my colleagues had encouraged me to think about using the experiential pathway to HPM board certification, but I knew I’d do better in the structured environment of a fellowship.

“There have been times when I’ve been outside of my comfort zone, sometimes feeling like the least experienced person in the room. But I knew the fellowship would help—and it did.”

He says the training gives him a better appreciation for things like illness trajectories, the nuances of goal clarification, and the benefit of an extra set of eyes and ears to assess the patient.

After completing his fellowship, Dr. Noronha became UNM’s second full-time palliative medicine faculty. He encourages hospitalists to talk to the palliative care service at their institutions and request consultations for complex, seriously ill patients who might benefit.

As for his new career path, he says that often he is asked if palliative care is depressing. “Some of these situations can be tragic, but I find the work very rewarding,” he says.

Service Models

In some settings, palliative care is incorporated into the hospitalist service. Hospitalists are scheduled for palliative care shifts or have palliative care visits incorporated into daily rounds. Such blended positions could be a recruiting incentive for some physicians who want to do both.

In other settings, palliative care is a separate service. Consultations are ordered as needed by hospitalists and other physicians.

Advocates like Marianne Novelli, MD, FHM, FACP, say hospitalists play a pivotal role in providing the basics of palliative care for seriously ill, hospitalized patients.

“Palliative care is part and parcel of what we do as hospitalists with the people we serve—who by definition are very sick, even to get into the hospital,” says Dr. Novelli, formerly the chief of the division of hospital medicine at Kaiser Permanente in Denver, Colo. She rotated off that leadership position in 2011 and has since divided her time between hospital medicine and palliative care shifts in the hospital, although she now does palliative care exclusively.

Initially, she watched palliative care consults and asked for mentorship from the palliative care team. Although it took time to get used to the advisory role of the consultant, and to working with a team, she eventually became board certified in HPM.

“Palliative care is incredibly intense but richly rewarding work,” she says. “The patients you see are never simple. It allows us to practice the type of medicine we originally set out to do, with people at the most vulnerable times in their lives.”

Research Highlights Palliative Care Contributions

Palliative care increasingly is the subject of clinical and administrative research in medical literature, with investigators examining its impact on costs and utilization of hospital care and other health services, as well as on such outcomes as pain and symptom management and patient and family satisfaction with health services.

An influential study of cost savings associated with hospital palliative care consultation services, conducted by R. Sean Morrison, MD, and colleagues at the National Palliative Care Research Center at Mount Sinai School of Medicine in New York City, matched 2,630 palliative care patients to 18,472 “usual care patients” and concluded that the cost savings averaged $4,988 per patient in direct costs per day for those dying in the hospital.3 A follow-up study in 2010 confirmed these results, and Dr. Morrison and colleagues have documented improved quality from palliative care based on a survey of bereaved family members of patients who received palliative care.4,5

A 2010 study by a group at Massachusetts General Hospital, led by Jennifer Temel, MD, reached the surprising conclusion that early palliative care for patients with metastatic non-small-cell lung cancer led not only to significant improvements in quality of life and mood and less provision of aggressive care at the end of life—but also to longer survival.6 The researchers have studied possible mechanisms for this result, as well as the integration of palliative care with oncology and the importance of palliative care support provided outside of the hospital, in community-based and outpatient settings. 7,8,9

Community-based palliative care is a significant new direction for palliative care in America, and the availability of palliative care outside of the hospital’s four walls is viewed as important to improving care transitions and preventing readmissions in the seriously ill patients typically targeted for palliative care. The effects of palliative care on 30-day readmissions rates was studied by Susan Enguidanos, PhD, MPH, and colleagues at the University of Southern California School of Gerontology; they found that receipt of palliative care following hospital discharge were a significant factor in reducing 30-day rehospitalizations.10

A study from Albert Einstein College of Medicine in New York explored outcomes from a dedicated acute palliative care unit in an academic medical center, while others have looked at the diverse landscape of palliative care in outpatient clinics and its potential for rapid growth.11,12

—Larry Beresford

Workforce, Fellowship, Board Certification

In October 2012, 3,356 physicians passed the hospice and palliative medicine subspecialty board exams offered by the American Board of Medical Specialties and 10 of its constituent specialty boards, with the lion’s share of them certified by the American Board of Internal Medicine. That more than doubled the number of physicians earning the HPM credential since its inception in 2008.

Even with the surge in palliative care training, workforce studies suggest the U.S. is woefully short of credentialed palliative care physicians. And many think hospitalists can help fill that void.

The Center to Advance Palliative Care (CAPC, www.capc.org) counts 1,400 hospital-based palliative care programs in the U.S., while the Centers for Medicare & Medicaid Services (CMS) recognizes about 3,500 Medicare-certified hospice programs. A 2010 estimate by Dale Lupu and the American Academy of Hospice and Palliative Medicine (AAHPM), however, suggested a need for between 4,487 and 10,810 palliative care physician FTEs just to staff existing programs at appropriate levels—without considering growth for the field or its spread into outpatient settings.1

In the past, mid-career physicians had an experiential pathway to the HPM board exam, based on hours worked with a hospice or palliative care team, but physicians now must complete an HPM fellowship of at least one year in order to sit for the boards. And, according to AAHPM, only 234 HPM fellowship positions are offered nationwide by 85 approved fellowship programs.

Dr. Bekanich

A one-year fellowship is a big commitment for an established hospitalist, according to Stephen Bekanich, MD, co-director of Seton Palliative Care at Seton Healthcare, an 11-hospital system in Austin, Texas. A former hospitalist, Dr. Bekanich says that in his region a fellow stipend is about $70,000, whereas typical hospitalist compensation is in the mid- to upper-$200,000s.

AAHPM is exploring other approaches to expanding the workforce with mid-career physicians. One approach, authored by Timothy Quill, MD, and Amy Abernethy, MD, the past and current AAHPM board presidents, is to develop a two-tiered system in which palliative medicine specialists teach basic palliative care techniques and approaches to primary care physicians, hospitalists, and such specialists as oncologists.2 The article also suggested equipping clinicians with the tools to recognize when more specialized help is needed.

“As in any medical discipline, some core elements of palliative care, such as aligning treatment with a patient’s goals and basic symptom management, should be routine aspects of care delivered by any practitioner,” Drs. Quill and Abernethy wrote. “Other skills are more complex and take years of training to learn and apply, such as negotiating a difficult family meeting, addressing veiled existential distress, and managing refractory symptoms.”

Dr. Bekanich is trying the two-tiered approach at Seton Healthcare. At facilities with no palliative care service, he is transplanting palliative-trained nurse practitioners in hospital medicine groups.

“This model is locked into our budget for fiscal year 2014,” Dr. Bekanich says. “We’ll train folks, starting with hospitalists and primary care physicians.”

The training will start with a pair of three-hour sessions on palliative care techniques for hospitalists and PCPs, followed by homework assignments. “Then we’ll meet again in three months to do some role plays,” he says.

Two final rounds of training will focus on skills, philosophy, values, and practice.

Palliative care is incredibly intense but richly rewarding work. The patients you see are never simple. It allows us to practice the type of medicine we originally set out to do, with people at the most vulnerable times in their lives.

—Marianne Novelli, MD, FHM, FACP, former chief of the division of hospital medicine, Kaiser Permanente, Denver, Colo.

On-the-Job Training

David Weissman, MD, FACP, a palliative care specialist in Milwaukee, Wis., and consultant to the CAPC, recommends hospitalists do what they can to improve their knowledge and skills. “There are a lot of opportunities for palliative care training out there,” he says.

HM conferences often include palliative care content. AAHPM and CAPC offer annual conferences that immerse participants in content, with opportunities to mingle with palliative care colleagues. AAHPM also offers specific content through its “Unipac” series of nine self-study training modules (www.aahpm.org/resources/default/unipac-4th-edition.html.)

Dr. Weissman

On the job, Dr. Weissman says hospitalists should ask for consults for patients with complex needs. Also pay attention to how the service works and what it recommends. Taking a couple of days to round with the palliative care service could be very educational. It may be possible to take a part-time position with the team, providing weekend or vacation coverage. Hospitalists can participate on planning or advisory committees for palliative care in their hospitals or on quality improvement projects.

“If there isn’t a palliative care service, advocate for developing one,” he says.

Local hospice programs, especially those with inpatient hospice facilities that need daily physician coverage, might have part-time staff positions, which could be a great moonlighting opportunity for hospitalists and a way to learn a lot very quickly.

“I can tell the difference between physicians who have spent time working in a hospice, where you can learn about caring for people at the end of life because most of the patients are so sick, and those who have not,” says Porter Storey, MD, FACP, AAHPM’s executive vice president and a practicing palliative care physician in Colorado. “You can learn how to use the medications to get someone comfortable quickly and how to talk to families in crisis. It can be some of the most rewarding work you can possibly do—especially when you have the time and training to do it well for some of the most challenging of patients and families.”

Dr. Storey recommends that hospitalists join AAHPM, use its professional materials, attend its annual meetings, and, if they feel a calling, consider fellowship training as the next big step.

“Palliative care programs are growing in number and size but are chronically understaffed,” says Steven Pantilat, MD, SFHM, hospitalist and director of the Palliative Care Program at the University of California at San Francisco. “This creates a great opportunity for hospitalists. I have heard of places that were having trouble recruiting palliative care physicians but were willing to sponsor a hospitalist to go and do a fellowship, supplementing their salary as an incentive—and a reasonable one—for a hospitalist interested in making a career move.”

He says that palliative care, like hospital medicine, has been a significant value-add in many hospitals and health systems. More importantly, it correlates to positive patient outcomes (see “Research Highlights Palliative Care Contributions,”).

Dr. Pantilat

“What’s new is how it connects to current issues like improved care transitions and readmissions reduction,” Dr. Pantilat says.

Advocates say palliative care helps to match medical services to patient preferences, thereby improving patient satisfaction scores, especially for those who aren’t likely to achieve good outcomes. Dr. Pantilat says it puts plans in place for patients to get the right services for the post-discharge period and for responding to anticipated problems like chest pain.

“It’s not just how to get patients out of the hospital as quickly as possible,” he says, “but to do that with a plan that sets them up to succeed at home.”


Larry Beresford is a freelance writer in San Francisco.

The Difference Palliative Care Can Make

Valerie Phillips was diagnosed with stage IV breast cancer in 2010 and is a shining example of the difference a palliative care consultation can make. After she was diagnosed, the Austin, Texas, native continued to work and enjoy a relatively normal life. But when the disease metastasized to her hip, she began to take opioid analgesics for the pain.

Phillips says she felt foolish when she ended up in the ED, profoundly uncomfortable from a four-day impaction due to the analgesic and oral cancer drugs. “But nobody told me about all that,” she says.

She thinks her oncologist was giving good care, “but her area was treating the disease.”

Upon admission, a hospitalist referred Phillips for an inpatient palliative care consultation with Stephen Bekanich, MD, a former hospitalist who now co-directs Seton Palliative Care for the Seton Health System in Austin.

“I learned there’s a big difference between fighting the disease and treating the needs of the patient as a person,” Phillips explains. “A palliative care doctor like Stephen changes everything. He found a way for me to better navigate the healthcare system, carrying all of that information in his head. He said to me, ‘OK, we’re going to make sure this doesn’t happen again.’

I trusted him—and it worked.” Phillips says she understands that her long-term prospects aren’t great, and she expects to enroll in hospice soon. She hasn’t been back to the hospital, but has continued to see Dr. Bekanich as an outpatient.

“For me, there was an informational and educational gap, and I have a master’s degree and a career in management,” she says. “Stephen was able to tie everything together for me.”

Phillips says hospitalists should focus on the connection between disease treatment and the quality of life palliative care affords. “They should go hand in hand. Patients should be able to count on somebody who can take us by the hand and make the whole process as painless—and worry-free—as possible.”

—Larry Beresford

References

  1. Lupu D. American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
  2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.
  3. Morrison RS, Penrod JD, Cassel JB, et al. Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
  4. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
  5. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.
  6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
  7. Irwin KE, Greer JA, Khatib J, Temel JS, Pirl WF. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10(1):35-47.
  8. Von Roenn JN, Temel J. The integration of palliative care and oncology: the evidence. Oncology. 2011;25(13):1258-1260,1262,1264-1265.
  9. Yoong J, Park ER, Greer JA, etc. Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med. 2013;173(4):283-290.
  10. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
  11. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center [published online ahead of print May 10, 2013]. Am J Hosp Palliat Care. PMID: 23666616.
  12. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661-668.

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