Pain & Palliative Care
Palliative care fellows: Learning to provide 'whole-person care at its best'
Winnie Suen, MD, is still troubled by a patient she met while training at an urban medical center a few years ago. The woman, in her 70s, was in declining health after refusing treatment for a swallowing condition, and she was confused and screaming out for her dead relatives when her family called Suen from home near the end. "What else can we do?" Suen recalls the relatives pleading. The attending physician said the team was doing the best it could, and the woman died a few days later.
"Although I didn't know all the right medications, the family was grateful they could talk with me," Suen says, "but I felt helpless and thought, 'There must be something else that could be done.'"
She's doing something now. The 31-year-old enrolled in a palliative care course for practitioners, and is currently halfway through a one-year palliative care fellowship run by Dana-Farber, Brigham and Women's Hospital, and Harvard Medical School, in collaboration with Massachusetts General Hospital.
The fellowship program gives a handful of doctors each year the opportunity to gain skills necessary to help patients with chronic or life-threatening illnesses cope with their symptoms and improve their quality of life. From some of the field's leading experts, these fellows learn about the physical, social, psychological, and spiritual aspects of palliative medicine and end-of-life care, as well as ethical, legal, and cultural issues that arise. They explore the dimensions of grief and the importance of taking care of themselves in an often-intense line of work.
Palliative Care Fellowship Director Janet Abrahm (right) confers with one of this year's fellows, Bruce "B.J." Miller.
"Our goal is to help our fellows become role models, clinicians, educators, researchers, and administrators in this relatively new field," says Fellowship Director Janet Abrahm, MD, also director of the Pain and Palliative Care Program within Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC). Launched at Dana-Farber in 2001, the fellowship was one of the first of what currently number roughly 60 such programs in the country.
This year's eight fellows attend classes and rounds (see related story), see patients under the supervision of attending physicians, and work with a multidisciplinary team of mentors who represent medicine, psychiatry, nursing, social work, pastoral care, and pharmacy services. Each trainee spends time at Dana-Farber, Brigham and Women's Hospital, and Massachusetts General Hospital, as well as several weeks at local hospices with dying patients and their families. Additionally, they have the option of seeing pediatric patients at the Jimmy Fund Clinic and Children's Hospital Boston.
"I feel very lucky to be here, and at this time," says fellow Bruce "B.J." Miller, MD. Not only is he learning from such "palliative medicine heroes" as Abrahm and Dana-Farber's Susan Block, MD, this is a watershed moment as BWH opens a 12-bed unit for patients with acute pain-relief needs this winter.
Close encounters
Like many of his colleagues, Miller is drawn to the holistic nature of palliative care, which involves tending to the whole patient, as well as his/her family. The fellows work on their communication skills, explore how to navigate prickly family dynamics, and consider ways to set personal boundaries so they don't become overly attached to their patients.
"I've been surprised by how much there is to learn," says Miller, 35. "So far, it has honed my ear. I listen better to other people and, therefore, to myself."
Miller, who lost part of three limbs during an electrical accident in college, is not the only fellow whose personal experience heightened his interest in the field. Says Cindy Lien, MD, whose brother was diagnosed with nasopharyngeal carcinoma while she was in her medical residency: "I realized how much psychological and emotional angst there can be around cancer, and how inadequate we as a family felt to address that."
Although such work can be difficult and sad, Lien appreciates the chance to relieve patients' symptoms "so that their time — if they're still conscious — can be spent focusing on the things that matter," such as saying goodbye to loved ones. "It's one of the most profoundly touching, most important moments you're witnessing."
Reflecting Dana-Farber's mission to train future researchers and caregivers, the palliative care fellowship is one of several fellowships offered at the hospital (see Medical Education & Training). It provides a salary — thanks to funding from the National Institutes of Health, Dana-Farber, and the Friends of Dana-Farber Cancer Institute and many opportunities.
'The right field'
After their year here, fellows often start or join existing palliative care programs around the country. Glen Komatsu, MD, and Kathy Selvaggi, MD, for example, are now leading palliative care teams in California and Pennsylvania, respectively. And Dana-Farber's Alexander Smith, MD, is currently conducting research to help enhance advance care planning (expressing wishes for medical care at life's end).
"This fellowship," says Smith, "affirmed that palliative care was the right field for me, and I think that's true for many of the fellows. We went into medicine to take care of the entire patient, from issues of pain control and medical management, to psychological distress and existential suffering, to working in teams. This is whole-person care at its best."
With the knowledge she has gained so far, Suen believes she would have handled the woman screaming in pain differently. She would have learned more about the family's goals for care, offered different symptom-relief drugs, and referred the patient to hospice after she had opted out of treatment.
"With each person I see," Suen says, "I learn more about how different patients and families react, and how we can help guide them."
