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.
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.