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Growing specialty offers opportunity for hospitalists

Palliative care can be a good fit

From the February ACP Hospitalist, copyright © 2009 by the American College of Physicians

By Stacey Butterfield

When Philip H. Santa-Emma, MD, began specializing in palliative care back in 1995, it was barely a field at all. The American Board of Hospice and Palliative Medicine (ABHPM) didn’t even begin issuing subspecialty certificates until the next year, and at the time, almost no one knew what a “palliative care physician” would do.

That may be how Dr. Santa-Emma became so skilled at defending his specialty to those who doubted its significance. “It’s not just going in the room and holding their hand and saying everything’s going to be OK. It’s a lot of complicated medicine,” he said.

The results of palliative care physicians’ complicated work are better symptom management, fewer readmissions, shorter lengths of stay, lower costs and more satisfied patients, experts in the field say.

Today, Dr. Santa-Emma and his colleagues are finding fewer and fewer docs who don’t get palliative medicine, and more and more (including a fair number of hospitalists) who want to practice it. The American Board of Medical Specialties has gotten involved, approving hospice and palliative medicine as a subspecialty. And 1,500 physicians sat for the first certification exam in October 2008, more than half the number who earned the ABHPM certificate during its 10 years of existence.

Clearly, the benefits of palliative medicine are becoming apparent to patients, physicians and health care leaders and enabling this once-esoteric field to join the mainstream of inpatient care.

An expanding field

The number of U.S. hospitals with a palliative care program has increased from 632 in 2000 to 1,299 today. Even CMS announced last October that it would recognize the subspecialty, removing hurdles to reimbursement. The attention, along with other factors like the fulfillment of the work and a hot job market, is prompting more physicians to consider focusing on palliative medicine, whether they’re in the middle of their careers or at the outset.

“It’s now to the point where two to three [medical students] are approaching me from the beginning and saying I have an interest in this. They are almost tailoring their electives to increase their exposure to palliative medicine,” said Dr. Santa-Emma.

Those interested students will likely join one of the palliative medicine fellowships that are popping up around the country (159 slots in 67 programs at last count). After 12 months of training, they’ll be eligible to take the boards and be certified in the subspecialty.

The year-long fellowship is also an option for practicing hospitalists and other physicians who want to be recognized as palliative care specialists. It’s the course recommended by Susan D. Block, MD, co-director of the Harvard Medical School Center for Palliative Care. “I do feel in 2009, any young physician who wants to do palliative care needs to do a fellowship. We wouldn’t allow a cardiologist to say I really want to practice cardiology but I don’t want to do a fellowship,” she said.

Yet, for the next few years, prospective palliative care physicians can do just that. Through the 2012 board examinations, practicing physicians can be grandfathered in without fellowship training. If an internist has spent at least two years practicing palliative care, including at least 100 hours of participation with a hospice or palliative care team, and cared for at least 50 terminally ill patients, he or she is eligible to take the boards.

Some palliative care experts, like Dr. Block, have concerns about the loophole, but others see it as an opportunity to get more physicians into the growing field. “I think there should be a push for as many hospital medicine physicians as are interested to get board-certified before they have to do a fellowship,” said Diane E. Meier, FACP, director of the Center to Advance Palliative Care in New York City.

While they don’t offer the intensity of a fellowship, there are many shorter-term learning opportunities for physicians who want to specialize in, or just learn more about, palliative care, she said. Options include education online or in person, such as week-long site visit programs on established palliative care services. “It’s sort of like a Berlitz language course,” said Dr. Meier.

For those who aren’t ready for that kind of commitment, training opportunities also can be found closer to home. “I would encourage hospitalists who want to learn more about the field to think about spending a day or two with a local community hospice,” said Dr. Block.

The experience can be eye-opening, she said. “We in the hospital get very cavalier about sending very ill patients home to be cared for by their family who have no training in health care. It’s not until you see what it’s like that you really understand.” With a better understanding of what really happens after hospital discharge, inpatient physicians can take steps to reduce the likelihood of repeated readmissions as well as making other improvements in care, experts said.

Overlapping skill sets

Hospitalists may already have a firmer grasp of palliative care practice than many other physicians. “There’s so much overlap between the skill sets,” said Dr. Meier. She listed traits including sophisticated communication skills; an ability to work the broken health care system on behalf of patients and families; and the knowledge to identify and manage symptoms, especially in patients with complicated, chronic co-morbidities.

Palliative specialists and hospitalists also tend to see the same patients. “When you talk about hospital medicine and palliative medicine, it’s a natural partnership. We’re seeing more patients with advanced and terminal illnesses being cared for in the hospital,” said Sarah E. Harrington, ACP Member, a hospital-based palliative care physician in Little Rock, Ark.

Teamwork—both among physicians and with other medical professionals—is another commonality between the fields. “Palliative care is really about co-management. It’s not about a line in the sand, where we’ve done everything we can and now we’re going to do palliative care. It’s really about co-managing patients from day one,” said Dr. Santa-Emma.

But practicing palliative medicine requires a real shift in mindset from hospitalist work, according to Eva H. Chittenden, ACP Member, who previously split her time between the two specialties at University of California, San Francisco, and now practices and teaches palliative care at Massachusetts General Hospital in Boston.

“When you’re a hospitalist, you have to see a lot of patients quickly and need to balance the management of their complex medical issues with attention to palliative issues. You don’t always have the time that symptom and communication issues deserve,” she said.

The priorities of a hospitalist, by necessity, are acute medical management and efficiencies of care. Palliative care physicians, on the other hand, focus more specifically on symptom management and, with the help of the interdisciplinary team, the psychosocial issues that patients inevitably face with advanced illness. Palliative care providers typically have more time to sit with the patient and family at the bedside and explore the meaning, implications, and logistics of facing an ultimately terminal illness, Dr. Chittenden noted.

“When I’m a busy hospitalist on my service, I don’t always have time to really do justice to some of the communication needs of the patient and family. I will sometimes call the palliative care team even though I’m a palliative care doctor. This also allows me to get the help of the palliative care social worker and chaplain.”

The back-and-forth may sound confusing, but Dr. Chittenden readily recommends this split career track. “Changing hats adds variety to the work. Palliative medicine also informs my hospitalist work in a very positive way. It’s nice to have a slightly different niche clinically,” she said.

Dr. Harrington agreed. “The great thing about palliative care is it can be really integrated in whatever specialty you already have—for example, if an internist wanted to do halftime as a palliative care specialist and the other half as a hospitalist,” she said.

Help wanted

In addition to being fulfilling (“You will have to look hard to find a more satisfied group of doctors,” Dr. Meier said), palliative care jobs are also easy to find, the experts agreed. Openings in the field are extensive right now and only likely to grow as the population ages.

“The needs far outstrip the ability of us to respond,” said B.J. Miller, MD, a palliative care physician at the University of California, San Francisco. “Clearly, there’s a huge inpatient need for palliative care and that’s where a lot of the explosive growth is happening.”

The increases span all kinds and sizes of hospitals, noted Dr. Block. “There’s been dramatic growth in the number and size of palliative care programs across the country, in academic hospitals and community hospitals.” According to a 2008 survey by the American Hospital Association, 77% of hospitals with more than 250 beds have a palliative care program and 47% of those with at least 50 beds do.

Hospitals’ interest in palliative care is likely driven by research finding that the programs save money. A study published in the Sept. 8, 2008, Archives of Internal Medicine compared costs for admitted palliative care patients with a control group who received usual care. Among the patients who were discharged alive, palliative care reduced cost, on average, $1,696 per admission. The savings among patients who died were even greater— $4,908 per admission. Much of the cost savings came from pharmacy, laboratory and intensive care unit expenses, the study found.

The numbers look good right now, but Dr. Miller worries that they are not sufficient support for the permanent existence and expansion of the specialty. “We have gotten this far by making the argument to hospitals that we save them money. But if that’s the imperative, that’s going to be problematic and come up short,” he said.

The other benefits of palliative care—improved quality of care, patient satisfaction and pain and symptom management—are gaining more exposure and acceptance among hospital administrators and physicians in general, said Dr. Santa-Emma. “The integration into the culture is becoming more and more complete. It’s moving more and more upstream.”

That’s good news, but it raises more worries for Dr. Miller, who wonders what palliative medicine will look like when it gets to the head of the stream. “One of the questions on the table for the field is: Now that we’re becoming part of the mainstream, what happens to the field? We could find ourselves again becoming part of the system that we were bucking in the first place.”

Many of the palliative medicine experts expressed concern that their specialty not be downsized to focus exclusively on pain management. As palliative specialists are included in the care of more chronic and terminally ill hospitalized patients, the doctors hope to still have time to deal with less obvious needs, such as spiritual and family issues.

One thing is sure about the growth of palliative medicine, Dr. Block said: “It’s a tremendously good thing for our patients and their families, because more people will have access to our services.”

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