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POLICY & MANAGEMENT

ISSUE: 5/2008 | VOLUME: 34:05

Palliative Medicine New Career Path for Anesthesiologists

Larry Beresford

When the American Board of Anesthesiology joined with the American Board of Medical Specialties and nine other specialty boards in

2006 to recognize hospice and palliative medicine as a subspecialty, the move culminated a 10-year process of advocating for

mainstream recognition of this growing field as legitimate, evidence-based medicinenot just compassion and hand-holding.

Opportunities for anesthesiologists to participate in hospice and palliative care were highlighted at the 2008 annual congress of the

International Anesthesiology Research Society (IARS). Currently, demand for physicians certified in the subspecialty far outstrips

supply, giving those who possess this credential the pick of job opportunities in hospice and palliative medicine (HPM) settings. One

avenue into the field is a one-year fellowship in HPM. Currently, 62 such programs exist nationally with an estimated 145 slots, many of

them filled by mid-career physicians.

One of the presenters at IARS was Perry Fine, MD, professor of anesthesiology at the University of Utah School of Medicine in Salt

Lake City and a widely recognized expert in HPM. Early in his own training as a family practice resident, Dr. Fine discovered that manyof his patients experienced problems for which there were no answers, not in the medical library and not from the gray hairs who were

teaching us, he said.

After pursuing a fellowship in pain management in Toronto, Dr. Fine was approached in 1985 by a local nursing agency back at Utah

that was organizing a hospice program and needed a physician to participate on the team and make home visits to hospice patients.

I discovered that a lot of the skills I possessed as an anesthesiologist and pain doctor had prepared me well for this work, Dr. Fine

said. There are very powerful applications of the tools you all know how to use, and it can be extraordinarily gratifying to use them with

these patients.

New Process of Certification

The first certifying examination for HPM under the auspices of the American Board of Medical Specialties (ABMS) will be offered on

Oct. 29, 2008. Applications for the 2008 test have closed, but additional sittings will be held in 2010 and 2012. A clinical experience

pathway to HPM credentialing is available to physicians who have worked with an interdisciplinary HPM team and have actively caredfor patients with terminal illness. After 2012, certification will require completion of a one-year fellowship in an HPM program accredited

by the Accreditation Council for Graduate Medical Education.

Dale Lupu, vice president for professional development at the American Academy of Hospice and Palliative Medicine, said HPM is a

field with quite serious research about both symptom management and health services deliverynot just which medicine works, but

how to organize care so that the medicine gets to the patient. Ms. Lupu noted that eight peer-reviewed journals now cover HPM, along

with frequent articles published in the Journal of the American Medical Association and The New England Journal of Medicine.

When the federal Agency for Healthcare Research and Quality examined the state of the science in palliative medicine in 2004, it

reviewed 5,210 abstracts and 911 journal articles in detail.

Everyone recognizes that palliative medicine is weaker in bench research, Ms. Lupu said. We also face real challenges in designing

double-blinded clinical trials for this population [patients with life-threatening illnesses], although were not unique within medicine in that

regard.

An existing certification process for physicians specializing in HPM has been in place since 1995, although the independent American

Board of Hospice and Palliative Medicine created for this purpose was voluntarily phased out, after ABMS and the 10 specialty boards

agreed to take on HPM certification.

Of the approximately 3,000 physicians who currently possess board certification in HPM, 57 (2%) are anesthesiologists. Most of them

were led to HPM through their interest in pain management, said Paul Sloan, MD, an anesthesiologist at the University of Kentucky

Chandler Medical Center in Lexington. Dr. Sloans career path includes studying palliative medicine, anesthesiology and pain medicine.

Today he practices all three in clinic, hospital and academic settings; his analgesic research focuses on oral opioids, spinal analgesia

and adjuvant analgesics. Starting in July, Kentucky will offer its anesthesiology residents a one-week rotation in HPM at Hospice and

Palliative Care of the Bluegrass, also in Lexington.

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I sometimes hear other anesthesiologists say they are more interested in cancer pain treatment than, say, chronic back pain or

interventional treatments, Dr. Sloan said. Palliative medicine, he believes, could offer a natural career path for them.

However, although pain management is an essential component of the practice of palliative medicine, the latters focus is broader,

encompassing the management of other symptoms, quality of life and whole person carewhich includes attention to psychosocial

and spiritual as well as physical consequences of illness.

Dr. Sloan emphasized that palliative care also is appropriate for patients from the point of diagnosis of a serious illness, often

concurrent with treatments aimed at curing the underlying diseasenot just for the end of life. Palliative medicine addresses issues

like: How are the patient and family coping with the illness? Is this patient better off at home or in the hospital? How well is the patientsspouse prepared for a prognosis that may not be good? he said. Often managing the pain is the easy part, and youre left with

someone whose pain is betterbut whose life is not. The ultimate goal is to relieve pain and other symptoms so that patients are left

clear-thinking and able to live out the remainder of their lives as fully as possible.

Published data on average salaries for physicians working in HPM are scarce. The American Academy of Hospice and Palliative

Medicine (AAHPM) plans to do a large-scale survey later this year. A September 2005 electronic survey of its members conducted by

AAHPM found the median salary for full-time employment in the subspecialty was $168,000 (mean, $181,225). However, those

averages reflect only the 41 respondents who both supplied salary information and stated that at least 70% of their work time was spent

in palliative medicinebut not in hospice carein the United States. Of those 41 working palliative medicine physicians, five reported

earning more than $290,000 per year. All five were in private practice, three in pain management and two in anesthesiology.

Very Satisfying Work

Physicians who work in palliative medicine sometimes hear the reaction from colleagues: You must be a very special person to do this

kind of work. While acknowledging that they can form deep bonds with the patients they care for, HPM practitioners try to emphasizethe serious medicine behind palliative care, as well as the job satisfaction it can offer.

I compare it to the role of the fireman who, while everyone else is running out of the burning building, is running in, Dr. Sloan

explained. If you dont know what youre doing, it could be very intimidating. But if you are prepared to do the job, it can be very

satisfying. These are issues and problems that, for the most part, we can actually treat and resolve, often using the tools of the

anesthesiologist.

He cited one of his current patients, a teenage boy with leukemia. His disease, seemingly, is in remission, but he was experiencing

back pain from the treatments, and hes also dealing with the issue of having a potentially life-limiting illness at such a young age, Dr.

Sloan said. On the boys last visit, Dr. Sloan had changed his oral opioid and increased its dose.

Today hes doing better. Hes out of pain, with no side effects. Hes out of his wheelchair, and hes ecstatic that, after six months,

someone finally believed that his pain was real.

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