A Geriatrician Has Devoted Her Life to Easing Pain and Suffering
In 1982, Dr. Robert Butler, a force on behalf of older adults within and beyond hospital walls, founded the Department of Geriatrics at the Mount Sinai School of Medicine—the first geriatrics department at a United States medical school. And in 1983, Dr. Diane Meier joined the new department. That was her first job after completing a residency in internal medicine, followed by a fellowship in geriatric medicine. But the new specialty faced skepticism and even outright hostility on the part of her colleagues.
We know how to treat old people, many specialists claimed. From cardiology to oncology, orthopedics, and endocrinology, the doctors across these and other areas of specialization were already caring for older adults. Why create a whole new specialty? What was the point?
Dr. Meier saw things differently. Instead of splitting medicine into ever narrower fragments, she favored a holistic approach to patient care. “I’m a lumper, not a splitter,” she said. “I wanted to treat the whole person, taking into account their socioeconomic status, family, race, neighborhood, upbringing, and personal circumstances, past and present.” In other words, the social determinants of health.
Dr. Meier and I are related by marriage. However, you’d have to be an anthropologist to untangle the kinship ties that define our relationship. We also live in the same New York City neighborhood—but we didn’t really know each other than by reputation: hers as a leader in geriatrics and palliative care, and mine as a former singer who happens to write about health and medicine for a living. How delightful, then, that she accepted my invitation to lunch, including an interview, last month.
Because we’re related, I’ll switch from calling her Dr. Meier to using her first name, Diane, in the rest of this post.
A national leader in palliative care
The late Dr. Butler, Diane’s most memorable and life-changing mentor, taught her how to be a “citizen physician,” one who is concerned with the health of the entire public. He also encouraged her to apply for the Project on Death in America (PDIA) Faculty Scholars Program award, which she received in 1995. That turned out to be the start of her mid-career education and the discovery of her true calling.
The relationships she forged with her fellow scholars were critical to the development of the then-new field of palliative care, “despite the barriers each of us encountered at our home institutions,” she said.
“I was never taught to manage pain in medical school. None of us were,” but managing symptoms and pain turned out to be the easy part. The hard part, she said, was caring for patients in a culture that didn’t admit to any goals other than “cure.” The biggest surprise was the explosion of demand for palliative care.
That rise in demand had a lot to do with several important cultural changes during the 1990s and early 2000s: Jack Kevorkian and the “right to die” movement, the rise in chronic illness, reports of high levels of pain and suffering in America’s best hospitals, the healthcare financing crisis, and the ageing of the population. Palliative care emerged as a logical response to several of these trends.
Getting a new specialty off the ground
The next leap forward came in 1999, when the Robert Wood Johnson Foundation approached Diane and Dr. Christine Cassel, then-chair of the Department of Geriatrics and Adult Development at Mount Sinai, to discuss the creation of a national organization aimed at providing technical assistance to hospitals across the country wishing to establish palliative care teams or even entire departments.
The new entity, the Center to Advance Palliative Care (CAPC), would be housed at the Mount Sinai School of Medicine, where it continues to live to this day.
En route to establishing the the CAPC, Diane received the education she needed beyond what she learned in medical school, as valuable as that was. “There were important non-medical dimensions to making the project happen,” she said—mainly, making the business case for it, along with the marketing case.
The business case centered on long-term cost savings. “Our patient population makes up the 10 percent of patients with the most complex illnesses but account for 70 percent of the country’s total healthcare costs. My patients may have some or all of the following: diabetes, kidney disease, dementia, cancer, and cardiovascular disease, all of which require treatment.”
The marketing case had to do with messaging. The central message to doctors: A palliative care consultation saves time and helps you provide optimal care. To patients and families: The benefits of palliative care are relief and help, without having to give up on life.
Diane proceeded to explain the palliative medicine paradox: Decoupling palliative care from death and dying increases the chances that a patient will—eventually—have a good death.
What, exactly, is palliative care?
The CAPC defines it as care focused on relief of suffering and support for the best possible quality of life, independent of prognosis.
Early on, opponents within and outside the medical community felt that the rush to support palliative care was tantamount to “turning our backs on the dying.” But that view wouldn’t be long for this world.
In 2008, the Centers for Medicare and Medicaid Services set forth new guidelines and an updated definition: “Palliative care means patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.” To me, that sounds like the foundation of ethics in every domain of life.
Back to the Future
Diane told me that close to 100 percent of medical school-affiliated teaching hospitals have palliative care teams today. However, much remains to be done.
Here’s a quick list of what needs to happen to fully integrate palliative care into medical and nursing school curricula and into patient care at every accredited hospital:
First, Diane said in a 2019 podcast, we need robust evidence that palliative care actually makes good on its promise to reduce costs, benefit patients and families, and help doctors deliver high-quality care.
Second, training. “We need to train future clinicians in the skills they’ll need to treat patients with serious illnesses and at the end of life. That includes communication around what matters most to patients and families; pain and symptom management; and coordinated care across the trajectory of an illness.
Third, public awareness. Take a look at getpalliativecare.org to get a sense of what she means by that.
Fourth, we need policies that make it possible for palliative care to survive financially.
And fifth, the field needs accountability: standards and oversight by the appropriate regulatory bodies and coalitions, many of which are already in place.
Diane didn’t expressly voice a preference for a universal healthcare system—Medicare for All, for instance, or socialized medicine (I’d settle for either of these)—but she finds the fee-for-service system in America inimical to the health and well-being of patients and families, especially those at or near the bottom of the income scale, who make up 80 percent of the patients she treats.
Diane’s Credo
In the Health Affairs article she authored in 2014, she said: “With the right training and skills, doctors can honor the relationship between doctor and patient throughout the patient’s experience of illness, even and especially when disease-focused treatment is no longer beneficial.”
Diane recently stepped down from her position as CAPC’s director, but she continues to be a national advocate for palliative care. And she continues to see patients at Mount Sinai. As a beloved geriatrician and palliative medicine physician, she helps patients and families navigate the complexities of illness and manages their symptoms, whether they’re in pain or suffer from anxiety, depression, sleeplessness, loss of appetite, or difficulty breathing.
During our lunch, her phone rang. She saw that her office was calling, so she answered right away. She was then connected to a patient. I could tell from the expression on her face that the news wasn’t good.
After the call ended, I asked her how she deals with the heart-breaking challenges of caring for patients whose levels of suffering are painful for most of us to imagine. She answered my question without missing a beat: “I know I can make a difference.”