In Comfort, with Dignity
Fellowship trains physicians in palliative medicine and hospice care
Despite medicine’s absolute mission to better human health, there comes a time for many patients with serious illness when a cure is no longer the primary goal. “Palliative medicine is both a way of care, and a philosophy,” says Raymond Yung, M.D., chief of the Division of Geriatric and Palliative Medicine in the Department of Internal Medicine. “The main goals become comfort, and relief of pain and suffering. No matter what we as physicians might hope to do, we have limitations.”
Physicians have always worked to ease the pain and suffering of the seriously ill and dying as part of the spectrum of patient care, but that care has traditionally focused on physical symptoms and discomfort. The growing field of palliative medicine and hospice care recognizes that patient needs — and those of family and friends — go far beyond the physical to encompass emotional issues, legal issues, issues of faith and relationships, grieving and mourning.
The Medical School established a fellowship in palliative medicine and hospice care in 2008, which now claims four cohorts of graduates skilled in end-of-life care, including communicating effectively with patients and family. Adam Marks, M.D. (Residency 2012), who completes his fellowship this year, recalls a story that took place during the first month of his internship. An ICU patient with terminal lung cancer was put on a ventilator because of respiratory failure. The family’s strong religious beliefs put them at odds with the medical team. “I was totally out of my element,” Marks recalls. With the help of the palliative care team, delicate, respectful conversations led to removal of life support, “and what could have been a very difficult family interaction became a positive experience because of the nature of faith involved.” The complexities of palliative medicine led Marks to pursue training, and he chose the U-M because of its strong pediatrics component. This summer Marks will join the Medical School faculty, devoting one-third of his time to pediatrics and two-thirds to palliative medicine. “There are some great clinical mentors here,” Marks says, “and an increasing awareness of palliative care. Patients even ask for it using that term now.”
The fellowship combines clinical and research experiences, as well as rotations at the VA Ann Arbor Healthcare System, University Hospital, C.S. Mott Children’s Hospital and Arbor Hospice. Two of the program’s three slots are funded by the VA, where fellows consult and round and are part of a five-bed inpatient palliative medicine unit. Didactic training — lectures, grand rounds, case discussions — contributes to the fellows’ experience. Fellowship Director Marcos Montagnini, M.D., an associate professor of internal medicine, says graduates learn to provide care to a “wide range of pediatric and adult patients with life threatening illness. They also complete a scholarly project, such as writing a paper or developing educational materials, relevant to their career path and guided by a mentor.”
Yung cites Health System support as critical to establishing “a continuum of care in palliative medicine. A fuller academic structure, which includes research, education and patient care, will help the program grow. I see a gap that needs to be filled.” —RICK KRUPINSKI