“What often happens with hospitalists is that they start out exploring palliative care, and it becomes very compelling,” Dr. Block adds. “The more competent you get at it, the more compelling it becomes. They find deeper meaning in their work. And then they’re hooked.”
A hospitalist can seek additional training and then incorporate palliative care tools, concepts, and perspectives into his or her daily work. An interest in palliative care may lead to involvement with the hospital ethics committee, a seat on a palliative care advisory committee, or a role in standards or protocol development, as well as pursuit of specialty certification in hospice and palliative medicine.
Although hospitalists may be obvious candidates to participate in more formal palliative care program development, “incorporating palliative care into a routine hospitalist practice is not a trivial thing,” Dr. Block adds. For starters, it requires additional training. “Most hospitalists don’t have the competencies to practice expert palliative care if they don’t seek them out,” she says. But the opportunities are increasing, with growing palliative care fellowship opportunities nationwide.
Two hospitalists at Chandler Regional Medical Center in Chandler, AZ, are among the 4 physicians who serve on that facility’s 12-member interdisciplinary palliative care team, attending weekly team meetings to review active cases and brainstorm program development. Both have attended national palliative care conferences, reports the palliative care service’s nurse practitioner, Donna Nolde. The service consulted on 89 patients in March, and about 70% of those referrals came from hospitalists.
“As hospitalists, we often deal with issues of death and dying,” especially when working in the ICU or with referring oncologists, notes Chandler’s Mahmood Shahlapour. “We can sometimes step back and see the big picture when other doctors have trouble letting go.” Dr. Shahlapour believes palliative care is a logical extension of good internal medicine and will eventually become a bigger part of the training of internists.
An atypical path to palliative care is that of Glenda Hickman, MD, who was a hospitalist for the Denver, CO–based HealthONE system until one of the system’s hospitals asked her to take on the role of freelance palliative care consultant. Hickman, who also works part-time for Hospice of Metro Denver as a team medical director and picks up lecturing and teaching assignments, accepts consultations from 3 HealthONE hospitals and bills third-party payers for her consultations. Her husband is office manager and biller for her home-based business, and she carries a cell phone and pager to promptly answer referrals.
“I had a reputation for the touchy-feely aspects of medicine at the hospitals where I worked,” Dr. Hickman relates. “Dying patients would often get referred to me.” Based on her interests, Dr. Hickman sought training in palliative care, but she found it difficult to juggle with her full-time job as a hospitalist. “The heart of palliative care in a hospital is talking with patients and families. These conversations take a long time,” she says. When the hospital asked for her help in meeting its JCAHO requirements in pain management and palliative care, Dr. Hickman was willing to explore a model for how she could hang out a shingle as a solo practitioner.
Business is growing, although the workload fluctuates widely. However, while Dr. Hickman works alongside social workers and chaplains at the hospitals, the biggest drawback has been the lack of a formal, interdisciplinary team. “This is high-maintenance, high-emotion work. It can be a big drain, and I don’t have a designated team with which to share the burden. My goal is to run a full palliative care team for the hospital,” she says, and there are signs that HealthONE eventually may move in that direction.