Young doctors flock to new specialty – End-of-life care

April Dembosky | 2/14/2012, 5:40 p.m.

PALO ALTO, Calif. — 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 Veterans Administration (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.

Specialty Created in 2008

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 SUPPORT study, the largest study on end-of-life care. 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.