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

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.

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 older 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.”

Editor’s Note: The following was written under a MetLife Foundation Journalists on Aging Fellowship in partnership with New America Media and the Gerontological Society of America.