Housecall Providers’ new Medical Director, Dr. Pamela Miner credits her father for being one of her earliest palliative care mentors. A practicing general internist in Wisconsin, her father would come home and tell his family from time to time that he had visited one of his patients in the ICU because “he wanted the medical staff to know the patient as the person he knew before he or she had become so ill.” The type of attention he gave his patients would later be remembered and perhaps fueled her desire to focus her career in a relatively new medical specialty know as palliative care.
Dr. Miner’s medical career began at Northwestern University’s Medical School in Chicago, IL. After graduating, she completed one year of residency before transferring to Boston’s Beth Israel Deaconess, a Harvard institution, completing an internal medicine program.
“Through medical school and both residency programs, I worked with VA patients and found the mission to be one that resonated with me,” Dr. Miner stated. It made sense that her first job would be as a primary care provider for the Boston VA, in an outpatient clinic in Worcester about an hour outside the city. “It was a wonderful clinic because it had an interdisciplinary feel to it and being able to communicate with colleagues right around the corner was an enormous benefit. There were mental health supports, specialty services, occupational and physical therapy all available for the veterans to access,” she continued.
Dr. Miner found what she enjoyed most about her work were the conversations with her patients, mostly WWII veterans, asking them questions like “How was the hospital stay for you? Do you see yourself getting better?” This communication made it easy for her to introduce palliative care and hospice services, when appropriate. As the number of these interactions grew, so did her desire to delve deeper into palliative medicine.
She realized if she was going to be able to provide what her patients would eventually require, a palliative care fellowship would be the logical next step. So, she made the decision to return to Harvard and enter a one year fellowship in Hospice and Palliative Care. “It was the best decision I ever made. I appreciated the program because it had such a strong mental health component. The clinicians learned how to help patients understand that emotions, not only their bodies, but mind and spirit, played into what was happening with them,” she stated.
The World Health organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
Palliative Care and Consultations
“Palliative medicine really came out of a grassroots swell from our patients who said, ‘we are losing control over our medical care,’ she explained. The highly technical stuff is great, but when it can’t really cure you anymore, the burdens of it become very heavy. Patients want to be able to have conversations about all their options for care and make good choices for themselves.”
A palliative care consultation creates a space where the patient, family members, and caregivers come together to really understand what is going on medically, while discovering what is important and of value to the patient. Questions are asked to determine where the balance lies in terms of defining quality of life, what type of support systems are present, and also the patient’s goals, fears and hopes. Dr. Miner credits good symptom management as the fastest way to build trust with patients and families because it shows the team is sincere about the quality of life they want to bring to their patient.
“We are trying to help the patient have a conversation about the balance between the burdens and benefits of treatment and care. When it is unlikely the patient can be cured, we begin to look at helping them maintain a good quality of life that they will find acceptable,” she explained.
By the time her fellowship was complete, the new specialty had announced its first board examination, and health care systems were recognizing the benefits to patient care. The Pacific Northwest had always appealed to her, but it was Providence and the whole community of Portland that inspired the cross-county move. “There is a really strong palliative community here that is collaborative in terms of supporting one another across institutions,” she said. “Portland has been a leader in palliative medicine with Dr. Susan Tolle at OHSU credited for the creation of the POLST (Physician Order for Life Sustaining Treatment), Jocelyn White and her work at Hopewell House, and Dr. Woody English and his efforts at Providence St. Vincent, so that made it an easy choice.”
In 2008, Dr. Miner was hired as a hospice and palliative care physician for Portland Providence, which meant she was half-time in both hospice and Connections, their inpatient palliative care service. In 2011, she moved full-time to Connections.
An interdisciplinary team is the hallmark of a strong palliative care program.
Palliative care is the youngest medical specialty in terms of board certification. It emerged in the United States in the late 1980s, but today a program is present in 55% of hospitals with more than 100 beds and nearly one-fifth of all community hospitals. (Center to Advance Palliative Care, www.capc.org) This “newness” can make it difficult to define what a program looks like. “The hallmark of a solid program is one that addresses the physical, emotion, psychological and spiritual needs of the patient. Programs can look very different across communities and what is available to people in the hospital, might look a lot different than what is available when they get home,” Dr. Miner continued.
Dr. Woody English, president-elect of Housecall Providers Board of Directors and retired palliative care physician, helped to create the palliative care program at Providence St. Vincent Medical Center. Knowing the importance of addressing all the facets of a person’s entire being, his interdisciplinary team utilized the skills sets of a nurse, social worker and chaplain.
“Palliative care is probably the oldest discipline in medicine, a discipline that feels accountable for addressing the symptoms of the whole person, not just the physical, but the symptoms of relationship and spiritual (or existential) suffering as well. Due to the triumph of medical technology in curing and ameliorating physical disease over the past several decades, palliative care skills have fallen into disuse in many health care settings,” Dr. English stated.
Housecall Providers ahead of the curve
Since 1995, Housecall Providers has been delivering primary medical care in the home along with a few specific services that fall under a palliative care umbrella, namely social work support and the understanding that attention to people’s spirituality is also important. It has been within the last couple of months that the idea to create an interdisciplinary palliative care team has started gaining ground, spurred on of course by the addition of Dr. Miner to the organization.
“Because of the patient population we serve, our clinicians have been providing a level of palliative care since the beginning of our practice,” stated Primary Care Program Director Mary Sayre, RN. “What we are focusing on now is looking at the available resources to build an interdisciplinary team that will support all of our patients’ palliative care needs. Using this type of team approach, will help clinicians care for some of our most complex primary care patients,” she continued.
Housecall Providers has been ahead of the curve when it comes to delivering excellent patient-centered care. When the need was realized to play a more active role in our patients end-of-life care, we created a hospice program in 2009 to offer another layer of support. In response to concerns that our patients needed an advocate when entering or coming home from emergency services or the hospital, we established the transition team in 2012 to be that bridge.
Now, as 2015 approaches, palliative care will be added to Housecall Providers’ care model because it is yet another way to serve our patients well. Dr. Miner will lead our team into the creation of this program that has always been her passion in medicine. Dr. English explains, “Pam brings a deep experience in primary care and specialized training in palliative care to Housecall Providers. As a result, she has the perfect combination of skill and experience to lead this organization.”