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Robert Friedlander, local oncologist, makes mid-career switch to palliative care

  • Robert Friedlander, a long-time oncologist at New Hampshire Oncology and Hematology who's returned to Memorial-Sloane Kettering in New York City for a fellowship in palliative care, poses for a portrait at his home in Concord on October 15, 2013. <br/><br/>(ANDREA MORALES / Monitor staff)

    Robert Friedlander, a long-time oncologist at New Hampshire Oncology and Hematology who's returned to Memorial-Sloane Kettering in New York City for a fellowship in palliative care, poses for a portrait at his home in Concord on October 15, 2013.

    (ANDREA MORALES / Monitor staff)

  • Robert Friedlander at the bus stop the day he moved down to New York City to start his fellowship in palliative care at Memorial-Sloane Kettering.<br/><br/>Courtesy photo

    Robert Friedlander at the bus stop the day he moved down to New York City to start his fellowship in palliative care at Memorial-Sloane Kettering.

    Courtesy photo

  • Robert Friedlander, second from right in the top row, with some of the group he's working with at Memorial-Sloane Kettering in New York City. Friedlander was a long-time oncologist at New Hampshire Oncology and Hematology and recently left that to begin a fellowship in palliative care. <br/><br/>Courtesy

    Robert Friedlander, second from right in the top row, with some of the group he's working with at Memorial-Sloane Kettering in New York City. Friedlander was a long-time oncologist at New Hampshire Oncology and Hematology and recently left that to begin a fellowship in palliative care.

    Courtesy

  • Robert Friedlander, a long-time oncologist at New Hampshire Oncology and Hematology who's returned to Memorial-Sloane Kettering in New York City for a fellowship in palliative care, poses for a portrait at his home in Concord on October 15, 2013. <br/><br/>(ANDREA MORALES / Monitor staff)
  • Robert Friedlander at the bus stop the day he moved down to New York City to start his fellowship in palliative care at Memorial-Sloane Kettering.<br/><br/>Courtesy photo
  • Robert Friedlander, second from right in the top row, with some of the group he's working with at Memorial-Sloane Kettering in New York City. Friedlander was a long-time oncologist at New Hampshire Oncology and Hematology and recently left that to begin a fellowship in palliative care. <br/><br/>Courtesy

How do you want to die?

Where?

If medicine can prolong your life by a few months, would you want to try?

What if doctors could promise only a few weeks? What if they were likely to be filled with pain and discomfort?

These are some of the toughest questions many people will ever face. They are the questions Dr. Bob Friedlander wants to help more people answer.

Friedlander, who is 57 and lives in Concord, ended his 30-year career as an oncologist with New Hampshire Oncology and Hematology this summer to retrain in a new medical specialty, palliative care.

He will spend a year at Memorial Sloan-Kettering Cancer Center in New York City in a fellowship, learning his new specialty and joining a group of fellows half his age.

In many ways, though, his career switch isn’t a change at all, he said.

“I feel like I’ve always been a palliative care doctor. What was always important to me was what I called the human side of medicine,” he said.

Palliative care is a phrase that’s not only new to Friedlander; it’s new to medicine.

The American Board of Medical Specialties approved Hospice and Palliative Medicine as a subspecialty in 2006. The first board-recognized examination was administered in 2008.

Hospice and palliative care are often mistakenly believed to be care for the dying.

Palliative care can be particularly helpful for people near the end of their lives, but is more accurately defined as care for people with life-threatening illnesses.

Often, patients recover from those illnesses, but they can still benefit from palliative care while they go through treatment.

“All physicians provide palliative care to some degree, and many of them do a great job,” Friedlander said.

But what led him to uproot his career was a growing dissatisfaction with his own ability, within the confines of oncology, to do that work as well as he thought it needed to be done.

In a typical follow-up visit, for instance, he would have 15 minutes with a patient he had known for years.

He’d spend most of the time checking on their physical well-being, answering questions about their treatment and symptoms.

“Then,” he said, “you’d have two or three minutes left to ask them, are they sad? Are they anxious? Are they feeling overwhelmed? What kind of thoughts are they having about the future?

“I would have to shortchange those discussions and I would feel, after I left one of those interactions, disappointed, demoralized, not feeling like I had done a meaningful job at this part of care that was so close to my heart.”

Though they practice symptom management with patients, the main procedure a palliative care doctor will perform is a family meeting, Friedlander said.

The patient, his family, primary physicians, a social worker and often a chaplain, will all gather to make decisions about care together.

They’ll discuss options and explore how the patient and his family feel about the choices. What would be the choice most consistent with their values and their lives?

“There have been cases where people have had days to live and I can’t think of a reason it will be helpful to continue treatment. But our goal is not to talk people out of things, but to help people come to a decision that they are comfortable with,” he said.

Often, that choice is stopping treatment or moving to a less intense setting, such as hospice. The cost savings that can come from that move are significant, and are part – but only part – of why palliative care is growing, Friedlander said.

The number of palliative care programs in U.S. hospitals with 50 or more beds increased from 658 (24.5 percent) to 1,486 (58.5 percent) from 2000 to 2008.

The real reason the field has grown significantly since becoming a recognized specialty is that it leads to better patient care, Friedlander said, pointing to a landmark study by researchers at Massachusetts General Hospital in 2010.

That study showed that when patients with terminal lung cancer received palliative care early after diagnosis, they had a better quality of life, were less likely to suffer from depression and lived a short time longer than patients receiving only traditional treatment.

“Unless there is a dramatic change in medicine, palliative care is here to stay, and it’s going to grow,” Friedlander said.

In New Hampshire, 18 of 26 hospitals had a palliative care program in 2011, according to a study by the Center to Advance Palliative Care.

One major hurdle for expanding or beginning programs, the study found, was a lack of certified palliative care physicians.

America has one cardiologist for every 71 people experiencing a heart attack and one oncologist for every 141 newly diagnosed cancer patients. But there is only one palliative medicine physician for every 1,200 people living with a serious or life-threatening illness, according to the study.

There will probably never be enough palliative care specialists to care for every dying person, Friedlander said.

If primary care doctors and oncologists and cardiologists and other specialists incorporated more of the patient-centered ideals of palliative care into their regular practice, that will leave Friedlander and his new peers to focus on the special cases.

In his four months in New York, he’s seen more patients in more intense pain and with more complicated symptoms than in his entire career previously, he said.

Memorial Sloan-Kettering attracts the most acute cancer cases in the world, often young people looking for experimental and innovative treatments.

He’s learned advanced treatments for pain, nausea, and emotional and existential distress, among other things.

It can be like looking directly at the sun, he said, this near-constant focus on death and mortality.

“But palliative care is as much about living as it is about dying,” he said.

He met one woman and her husband as they faced the end of her life. The last week of the wife’s life, family and friends from all over the world visited. All were focused on being present, being together.

“They were able to say that it was one of their best weeks together,” he said.

He’s also seen how his work supports the oncologists around him.

Some break down in tears during family meetings when a patient chooses to stop treatment.

Having been in their shoes, he understands.

“It’s very difficult for oncologists to say, after caring for someone for years, ‘there’s nothing left we can offer you,’ ” he said.

“There’s a tendency to say, let’s try one more thing, even though in ways they wish they wouldn’t, because they know more treatment will lead to side effects and toxicity. But they can’t help themselves. . . . They feel they are abandoning someone if they say there’s nothing that can be done.

“We sit with the family and we get to say, ‘There is no such thing as no more treatment. There may be no more chemotherapy we can do, but we will always be taking care of you.’ ”

He hasn’t had one moment of regret about his decision to change specialities, and as he has become more involved in the palliative care world, he’s met other physicians who left long careers in other specialties to practice palliative care.

“I think it appeals to people at an older age because it strips away the distractions of medicine and allows you to focus on what it really means to be a doctor,” he said.

“In just three short months, I really feel that I am a better doctor now, which is remarkable to me, and really exciting.”

(Sarah Palermo can be reached at 369-3322 or spalermo@cmonitor.com or on Twitter @SPalermoNews.)

I salute Dr. Friedlander for his career change choice, as we certainly need more doctors trained in palliative care, but what we really need is a medical system that is more attentive to the overall needs of its patients. Currently we have a system where each specialist weighs in on his or her section of your body, and the Personal Care Physician who should be coordinating it all feels inadequate to say anything that contradicts any of the specialists. So it is left to the patient and his/her caretakers to make sense of conflicting information. I am familiar with the 15-minute followups -- often not even with a doctor but with a nurse or physician's assistant -- that are often totally inadequate. Sometimes all a patient needs is simply more time with a trusted physician. And because they have inculcated us all to believe they are the true medical experts, we sometimes lack confidence in the nurses who in many cases may be able to provide the help and information we need.

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