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Young Doctors Flock Toward New Specialty in End-of-Life Care
by
April Dembosky, San Jose Mercury News
February 6, 2012
Picture Credit: Gary Reyes
As Daniel Shaine approaches the end of his battle with terminal cancer,
he is no longer surprised to find a troop of young doctors, some with
pregnant bellies or sparkling engagement rings, at his side at the Palo
Alto VA hospital.
"Sometimes I muse to myself, I'm old enough to be this person's
father," said Shaine, 67. "I try to push that away."
Increasingly, patients at the end of their lives are talking about
end-of-life decisions and do-not-resuscitate orders with doctors on the
brink of giving birth. These freshly minted physicians are among a new
wave of specialists in the growing field of palliative medicine.
Since medical boards only started recognizing the treatment of pain and
end-of-life care as an official subspecialty four years ago and new
rules effectively bar older physicians from getting certified, the
cohort of doctors spearheading palliative-care departments across the
country are increasingly in their early- to mid-30s.
The stark generational differences are showing up at hospitals across
the country.
"We acknowledge that we are young, and we only have the wisdom that
comes with our 30-something years," said Kavitha Ramchandran, 34, an
attending physician in the Hospice and Palliative Medicine unit at
Stanford Hospital. "I think there's a steep learning curve in this."
Palliative care doctors manage pain, gauging symptoms and prescribing
pain medicines that don't conflict with the patient's other
medications. But even more so, they spend a lot of time talking with
patients and their families about the dying process, discussing
end-of-life decisions and coordinating care with other doctors.
Early research shows the generation gap can interfere with delivering
the best care, according to Joanne Lynn, principal investigator of the
largest study on end-of-life care, the SUPPORT study. Her research
showed that elderly patients were unlikely to disclose important
medical information to young doctors, especially sensitive conditions
like incontinence or depression.
"We found that patients did not tell interviewers about certain things
until the interviewers were older -- that is, past 60," she said. "So,
young doctors are going to have to make a special effort to get this
sort of information."
Overcoming barriers
Stanford University's fellowship program in hospice and palliative
medicine trains medical students and recent graduates how to overcome
generational barriers, but confusion among patients still pops up, said
V.J. Periyakoil, the program director. She recalls one young doctor, a
woman many months pregnant with her first child, who spent 45 minutes
talking with an older man at the veterans' hospital. Just a couple
hours later, the patient demanded to know when a doctor was going to
come check on him.
"He didn't realize that she was a doctor," Periyakoil said.
Doctors have been informally practicing palliative medicine for
decades, managing patients' pain and symptoms alongside curative
treatments for disease, and starting difficult conversations about
end-of-life when treatments no longer work. Internists and oncologists
learned these skills on the job or taught themselves.
Now there's a defined path for training the new -- and first official
-- generation of palliative care doctors.
About 12 percent of the doctors certified in hospice and palliative
care in 2010 are now 36 or younger, according to the latest data
available from the American Board of Medical Specialties. That
percentage doubled in two years and is expected to dramatically grow
under new rules that prevent older doctors from being grandfathered
into the specialty. Starting this year, doctors must complete a
one-year training fellowship in palliative medicine, a position that
offers a meager salary that few mid-career doctors will opt for.
Stanford's fellowship program is one of about 70 similar programs
formed in recent years, and among the first launched.
As much as they gain medical skills and knowledge, trainees say they
learn how to handle themselves with patients, either by assuming the
role of a grandchild or just being humble.
"Sometimes it is scary to know you are much younger than your patient,"
said Domingo Maynes, 30, a resident with the program. "But by putting
myself in their shoes and talking to the family, I can start to wrap my
hands around the intangibles."
A sympathetic ear
For some patients, a doctor's youth doesn't matter.
"I'm not interested in what their age is," said Warren Harding Atkins,
93, who gets treated for severe back pain at the Palo Alto VA. "I want
them to find solutions to my problems."
Atkins tells stories of working in the merchant marine during the
1940s, once delivering a baby on board his ship in the middle of the
sea with no medical help.
While he
bemoans his grandchildren's generation for not appreciating what they
have or learning from history, he is happy with the young doctors
looking after him.
"They listen to me, and that's all I need," he said.
If anything, the young doctors say their generation is particularly
well-suited to this kind of care, especially at these early stages of
the field when hospitals across the country are opening brand new
hospice and palliative care departments.
"This is a generation that grew up hearing about startups and
innovation," said Stephanie Harman, 35, who helped launch the Hospice
and Palliative Medicine fellowship at Stanford. "The idea of the
specialty of palliative care being a new field, with a lot of
opportunity to innovate, and work in a team structure, that's something
this generation is much more primed to do and excited about."
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