Palliative medicine fellowship: a study of resident choices.

CONTEXT: There are no data on the motives or characteristics of physicians choosing fellowship training in Hospice and Palliative Medicine (HPM). OBJECTIVES: To understand more about the residents who choose HPM and what leads them to this decision. METHODS: An electronic survey of HPM fellows initiating training in July 2009. RESULTS: Seventy-six physicians began the study, with 62 responders (82%) completing all questions. Fifty-five percent were aged 30-40 years, and 61% were female. Sixty-eight percent were non-Hispanic Caucasian, 24% were Asian, and none were African American. Fifty-five percent were trained in internal medicine. Most (86%) asserted that the care of a dying, critically ill, or symptomatic person impacted their decision to enter the field of HPM. Sixty-three percent did not feel prepared to manage dying patients, and 41% felt personal regret about the care they delivered. The major reasons for choosing the specialty were a desire to contribute to relief of suffering (79%), enhance end-of-life care (73%), and improve communication (78%). Ninety-five percent received negative comments about their career choice. Fifty-nine percent had no exposure to hospice or palliative medicine in medical school, whereas 61% had an exposure available during residency. Forty-seven percent decided to enter a fellowship in the third year of residency, and 33% applied after practicing in their primary specialty for a median of 10 years. Accreditation, strength of education, and a hospital palliative medicine service were required by the majority for selection of a fellowship program. CONCLUSION: Negative experiences with end-of-life care in residency, particularly in the intensive care unit, continue to be a factor in selection of HPM as a specialty. Many residents make their decision to enter the field and apply during Postgraduate Year 3. Most received negative comments about the choice. Fellows require a broad range of experience when selecting a fellowship program.

Integrating palliative care into the outpatient, private practice oncology setting.

CONTEXT: Quality care for patients with cancer is a national priority-for those with noncurable cancer, the stakes are even higher. Strategies to promote integration of palliative care into oncology practice may enhance quality. We have developed a model in which palliative care services are integrated into the private, office-based oncology practice setting. We have evaluated the feasibility and assessed outcomes for both the oncologists and the patients they serve. To our knowledge, an embedded clinic in an outpatient, private practice oncology clinic has not been described previously. OBJECTIVE: The primary outcomes assessed were 1) quality care outcomes through assessment of symptom burden and relief achieved through palliative care consultation, 2) provider satisfaction, 3) volume determined by number of palliative care consultations over time, and 4) time saved for the oncologist as a surrogate for the bottom line of the cancer practice. METHODS: Measurement of: symptom burden and relief with the Edmonton Symptom Assessment System (ESAS), physician acceptance of palliative care services through a provider satisfaction survey and volume of referrals, and billing data to determine potential oncologists' time saved. RESULTS: Palliative care consultation was associated with a reduction in symptom burden by 21%, evidenced by decrease in average total ESAS score from 49.3 to 39. Median provider satisfaction scores rating components of palliative care ranged from 8.5 to 9/10, with an overall provider satisfaction of 9/10. Over the study period, the "embedded" oncology group consultation requests increased 87% (67-120), with each individual oncology provider nearly doubled. The total time saved for the oncology practice in Year 2 was just over four weeks (9720 minutes; 162 hours). CONCLUSION: An embedded palliative care clinic integrated into an office-based oncology practice is feasible and may improve the quality of care. Formal study of this service delivery model is warranted.

A day in the life: a case series of acute care palliative medicine--the Cleveland model.

Palliative care in advanced disease is complex. Knowledge and experience of symptom control and management of multiple complications are essential. An interdisciplinary team is also required to meet the medical and psychosocial needs in life-limiting illness. Acute care palliative medicine is a new concept in the spectrum of palliative care services. Acute care palliative medicine, integrated into a tertiary academic medical center, provides expert medical management and specialized care as part of the spectrum of acute medical care services to this challenging patient population. The authors describe a case series to provide a snapshot of a typical day in an acute care inpatient palliative medicine unit. The cases illustrate the sophisticated medical care involved for each individual and the important skill sets of the palliative medicine specialist required to provide high-quality acute medical care for the very ill.

The business of palliative medicine - part 5: service utilization in a comprehensive integrated program.

The aim of palliative medicine is to provide multidisciplinary comprehensive care in advanced illness. Patient and family utilization of various product service lines offered by the Harry R Horvitz Center for Palliative Medicine at the Cleveland Clinic Foundation was studied. Newly referred patients were followed up prospectively until 85% had either died or been lost to follow-up. Demographic, clinical, and referral data were recorded; subsequent product service line utilization was updated daily. The total study period was 171 days, and 238 patients entered. Acute care inpatient unit, outpatient clinic visits, and 24-hour phone contacts were the most frequently used product service lines. Patients had a median of 3 contacts (range, 1 to 27) with individual service lines. Multiple palliative medicine product service lines were utilized often, with repeated use of the individual service lines. A comprehensive integrated palliative medicine program is necessary to fully meet the complex needs of those with advanced disease.