Demand for palliative care has grown (.pdf) tremendously over the past decade. VJ Periyakoil, MD, director of Stanford’s hospice and palliative medicine fellowship program, has experienced firsthand how the burgeoning specialty has exploded, and how the nation’s physician workforce has struggled to keep pace.

“We are at a point in time where the demand for quality palliative care far exceeds the supply of clinicians with required expertise,” Periyakoil told me. “It takes a long time to train doctors and currently we are churning out about 300 fellows annually. Each year, the fellows who graduate from our palliative care fellowship get multiple job offers and most are often recruited to leadership positions.”

A recent American Medical News story offered a detailed look at the rapidly growing need for palliative care services, as well as physicians trained in hospice care:

From 8,000 to 10,000 physician specialists are needed to meet demands in hospice and palliative care programs nationwide, according to the [American Academy of Hospice and Palliative Medicine], a professional organization for hospice and palliative medicine physicians. But only 4,500 doctors specialize in the field, and training programs are expected to produce only an additional 4,600 specialists in the next 20 years, the academy said.

The demand for palliative medicine is driven in large part by advancements in biomedicine and the United States’ graying population. Additionally, a growing body of scientific evidence on the speciality is beginning to show it can improve quality of life for patients diagnosed with serious chronic illnesses and can reduce health costs. As a result, an increasing number of  hospitals are adding or expanding their palliative care programs and more patients seeking services.

In an effort to increase interdisciplinary training in hospice and palliative care, Congress is considering legislation that would allocate nearly $50 million for a range of programs, including training for doctors and fellowships to encourage mid-career physicians to transition to the specialty. The Palliative Care and Hospice Education and Training Act was introduced in July and would also provide awards to support educators in the field.

When I asked Periyakoil how the bill, in enacted into law, would help meet future hospice and palliative care demands, she responded:

If we look at the field of geriatrics, the federal Health Resources and Services Administration funds the Geriatric Academic Career Award (GACA) to increase the number of junior faculty at accredited schools of allopathic and osteopathic medicine. It also promotes the development of their careers as academic geriatricians who emphasize training in clinical geriatrics, including the training of interdisciplinary teams of health professionals. The proposed legislation is a similar effort to promote interdisciplinary palliative care.

The bill could also have important implications for Stanford’s fellowship program. Our fellowship is the oldest interprofessional palliative care fellowships in the country. Funded by the Office of Academic Affiliations, the program trains fellows from the field of medicine, psychology, social work and chaplaincy in palliative care. The fellows learn to train together and work together. Currently, this model is restricted to the fellows serving Veterans Affairs hospitals due to funding reasons. In the future, if the legislature passes, I hope that we will have funding to expand these interprofessional fellowships in academic medical centers.

Previously: Helping caregivers practice palliative care and Examining the generational gap between physicians and patients in hospice and palliative care
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Several years ago, I listened in a state of semi-shock as a doctor gave me a classic bad news-good news combination: The autoimmune system disorder I had was incurable and life-threatening, but researchers had recently discovered that a certain package of medications could put it into remission. I remember that conversation well, but I don’t recall the doctor mentioning much, if anything, about the side effects of those medications.

At age 12, Jena Graves of Napa, Calif. faced the same serious situation. She was diagnosed with the autoimmune system disease lupus, and among her essential medications was the same steroid I was given, prednisone. It’s a go-to medication for millions who suffer from conditions including asthma and diabetes; it’s also on a short list of commonly prescribed “obesogenic” drugs whose effect on the body includes rapid weight gain.

Graves, just 5 feet 2 inches tall, shot up from 120 pounds to 272 pounds and developed Type 2 diabetes and other obesity-related health problems.

A colleague recently shared Graves’ story, which was told again in today’s San Francisco Chronicle. In the piece, Stanford’s John Morton, MD, who performed gastric bypass surgery on Graves this summer, raises a flag on behalf of patients like her:

“All these medications are absolutely wonderful when they work in the right patients,” [said Morton]. “But we’ve got to figure out if it’s appropriate or not to blanket America with prednisone and other obesity-generating drugs that are creating problems.”

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Although smoking rates in the United States have been slowly declining, tobacco use is on the rise in several developing countries.

In a recent Atlantic post, Lindsay Abrams takes a closer look at the pervasive influence of cigarette manufacturers in the developing world and offers data from the latest Global Adult Tobacco Survey (subscription required).

Survey results show that nearly half of men in 14 developing countries are tobacco users and that women are starting to smoke at younger ages. Overall, researchers predict smoking will cause one billion deaths in the 21st century. Despite the grim outlook, Abrams says there’s reason to be optimistic:

Quit rates are noticeably higher in countries with programs in place for discouraging tobacco use and helping with quitting, such as the U.S., the U.K., Brazil, and Uruguay.

As the world looks to countries as models for tobacco use, Uruguay deserves note. It was included in GATS precisely because of its stringent anti-tobacco policies, including mandated graphic labels that take up 80 percent of cigarette packaging, sales tax increases, and bans on tobacco advertising and on indoor smoking in public places. Earlier this month, the International Tobacco Control Policy Evaluation Project (ITC) released a report indicating that the prevalence of tobacco use in Uruguay has decreased by 25 percent over three years.

Among other promising data, 70 percent of Uruguay’s smokers expressed regret for every having taken up smoking, and in the five-year period covered by the survey, over two-thirds of smokers at least attempted to quit. Positive health changes are already being seen, and may in part be attributed to these policies. The ITC found a 22 percent reduction in the rate of hospital admissions for heart attacks and a 90 percent decrease in air contamination in enclosed public spaces in the year after they were enacted.

Previously: A call to stop tobacco marketing, Study suggests genetics may predict success of smoking cessation methods and What’s being done about the way tobacco companies market and manufacture products
Photo by Alex Dram

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