House Calls With Her Physician Father Sparked an Interest in Palliative Care for Janet L. Abrahm, MD

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Nationally regarded palliative care expert Janet L. Abrahm, MD, was born and reared in San Francisco. Her father was a solo practitioner who saw medicine as a great profession. “My father would come home from his office for dinner and when he finished, he’d do house calls, often bringing us with him. He focused on the individual relationship with his patients, which influenced my decision to become a doctor,” said Dr. Abrahm.

Janet L. Abrahm, MD

She continued: “I was always very interested in people’s lives. And for some reason, people trusted me from my teenage years on. I’d meet people on trains in Europe who opened up to me, a stranger. They saw I was interested in them and would keep their secrets.”

A Diverse School Environment

DR. ABRAHM recalled her high school as a lively melting pot. “My high school was multiracial, which was unusual at that time. I had Asian, Hispanic, and African American classmates. Everyone was together during homeroom. Studying and socializing with people who were so different than me began building the foundation of who I am as a physician.”

Tumultuous Times

IN 1966, Dr. Abrahm entered the University of California, Berkeley. It was the height of the Vietnam War, and Berkeley was the epicenter of antiwar marches and student strikes. “I remember tear gas and helicopters flying over. It was a pretty scary time. However, the University of California, San Francisco (UCSF) Medical School accepted high-performing junior undergrads. So, I went to UCSF without graduating from college, which worked out for me, as Berkeley was closed because of war protests for what would have been my senior year. The school didn’t hold a graduation ceremony for my class of 1970 until 1990, 20 years later.”

Dr. Abrahm enrolled in the UCSF Medical School in 1969, graduating with her MD in 1973. “The education at UCSF formed my philosophy of what it was to be a doctor. We worked with a variety of clinicians, so I saw medicine as a team effort for the sake of the patient. I had an amazing education at the San Francisco County Hospital, the VA, and the UCSF’s Moffitt hospital,” said Dr. Abrahm.

A Role Model

DR. ABRAHM’S first medical role model as an academic physician was Faith Fitzgerald, MD. “Dr. Fitzgerald was an internist who later was named an MACP [Master of the American College of Physicians] for her clinical expertise. She was the first woman I could emulate as a career model. After her residency, she became Associate Chief of Medicine at the county hospital.”

“The education at UCSF formed my philosophy of what it was to be a doctor.”
— Janet L. Abrahm, MD

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It was the early 1970s, and although the Women’s Liberation Movement was in full swing, the medical establishment was still largely a male domain. “At medical school, I was 1 of about 15 women in a class of 150. Back then, women filled fewer than 10% of the seats in medical school. It was a tough time for women and we weren’t always welcome.”

Pioneering Women

DURING MEDICAL school, Dr. Abrahm was selected for the national Alpha Omega Alpha (AOA) Honor Society. “The year I was inducted into the AOA, the reception was held at the Playboy Club. The men running the event didn’t expect a woman to get into the Society, so they weren’t quite prepared for me. I felt bad for the bunnies, but it was an interesting experience, to say the least.”

In 1973, Dr. Abrahm was chosen for an intern position at Massachusetts General Hospital (Mass General). “It was the first year in Mass General’s history to have more than one female intern. I was the West Coast selection; there were three others from around the country. They didn’t have uniforms for us in my intern year, so we had to buy our own. We had to wear skirts, which was ridiculous. There was a certain amount of sexist hostility, but I knew what I wanted to do, and if that was the price, so be it,” said Dr. Abrahm.

Dr. Abrahm finished her hematology/oncology fellowship at the University of Pennsylvania just at the point in which researchers were growing colonies of immature white blood cells. “I wanted to be part of that research. I was fascinated by the science and loved clinical work. It gave me a chance to have a career in academic medicine, which is where I wanted to be,” she shared.

Following her fellowship, Dr. Abrahm stayed on to do hematopoiesis research. “The University staffed the local VA hospital, and I went there with the purpose of recreating the interdisciplinary team I’d learned about in medical school. I had, in effect, a blank canvas to develop the best management strategies for the veterans. It was an exciting time in oncology; we were making true progress, and I wanted to be part of it.”

Palliative Care: Beginning of a New Discipline

AT THE TIME, palliative care was not a well-defined discipline. Dr. Abrahm noted that her early entry into the field was treating patients from the VA who had Hodgkin lymphoma and were suffering from severe nausea and vomiting. “When I started in oncology in the 1980s, we didn’t have effective antiemetics. We used prochlorperazine and lorazepam. We also didn’t have long-acting morphine. All we used for pain was oxycodone and acetaminophen, meperidine, and methadone. I would lose my young patients with testicular cancer because they couldn’t stand the nausea from the platinum. They’d go to the Caribbean and get coffee enemas and die.”

“At medical school, I was 1 of about 15 women in a class of 150. Back then, women filled fewer than 10% of the seats in medical school.”
— Janet L. Abrahm, MD

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Driven by a desire to reduce suffering, Dr. Abrahm poured through the existing literature. Then high-dose metoclopramide hit the market. “We were giving patients with testicular cancer 100 mg/m2 of metoclopramide every 2 hours with platinum along with a lot of lorazepam and diphenhydramine. I was using state-of-the-art antiemetics and will never forget when the mother of a patient with Hodgkin lymphoma called me in tears because for the first time, her son wasn’t vomiting. She thanked me profusely. It was truly a beautiful moment in my career.”

Sloan Kettering: A Who’s Who in Pain Management

IN 1992, Dr. Abrahm took a sabbatical and went to Memorial Sloan Kettering Cancer Center to fine-tune her knowledge of pain management. “It was an amazing experience. Everyone in pain management was there—Kathy Foley, MD; Russ Portenoy, MD; Jimmie Holland, MD; and great people from the anesthesiology pain team and ethics. I was immersed in an incredibly rich environment. By the time I returned to the University of Pennsylvania, I had fully embraced palliative care as my career, although at the time we called it a hospice consultation team,” she noted.

In 1995, Dr. Abrahm wrote a grant for the newly formed Project on Death in America, an end-of-life disease management program. It was a pivotal time in palliative care’s acceptance as a subspecialty separate from hospice, and confusion still exists. Dr. Abrahm said, “Eduardo Bruera did a study showing that using a term like ‘supportive care’ actually encouraged oncologists and patients with cancer to participate. It’s been a long road, but palliative care medicine is now considered an integral component of the oncology care continuum.”

Dana-Farber: Early Adopter of Palliative Care

DR. ABRAHM joined Dana-Farber Cancer Institute in 2001. “Dana-Farber was far-seeing to bring palliative care on board in 2001, when at the time it was pioneering. I was lucky to be there at the right time. They saw that I wasn’t just putting cool washcloths on patients’ foreheads; I was providing high-quality supportive care that relieved the distress from symptoms such as pain and nausea and starting conversations about patients’ goals and wishes regarding advance care planning.”

In 2013, Dr. Abrahm stepped down from her position as Division Chief to pursue other interests, mainly research and work with interpreters in palliative care. “About half of my time is spent on our consult service and in our intensive palliative care unit. I’m also working with a social worker who ran an interpreter service. At Brigham and Dana-Farber, we work with interpreters in palliative care dialogue conversations; in a diverse population, there is a lot of cultural brokering that goes on during end-of-life discussions. Our goal is to empower the interpreters, so they are confident when partnering with oncologists in these difficult clinical scenarios.” 

Physician Burnout

DR. ABRAHM noted that oncologists have among the highest rate of burnout across all medical disciplines. “There are a lot of factors for this. One is that we ride the emotional roller coaster with our patients. Our hopes go up and are often dashed. We don’t know if the plane is going to go up or down, and we’re pulling on the joystick as hard as we can. And, even with our palliative interventions, oncology is the discipline that ironically induces the most suffering among patients.”

“It’s been a long road, but palliative care medicine is now considered an integral component of the oncology care continuum.”
— Janet L. Abrahm, MD

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She continued: “Moreover, we’re on the cutting edge of science, so we are constantly studying to keep up with the latest advances. It adds one more layer to a very heavy workload. Electronic health record documentation has also stretched our day, which is why many of us work nights at home.”

One way to relieve burnout is to ensure palliative care is brought on early in the disease process. “Then it relieves the oncologist of that burden,” she noted. “We also need to help oncologists with their end-of-life patient conversations. Increasing their competence will decrease the stress that leads to burnout.”

What does a super-busy palliative care expert do to avoid burnout? “I exercise and read nonmedical stuff—any chance I get. I have to get away in my mind; it helps lessen the inherent stress of the job. And I love to work. Palliative care is incredibly rewarding. We develop deep, moving relationships with our patients and their families.”

DISCLOSURE: Dr. Abrahm was a consultant/advisor for Novartis and is currently one for Pfizer; has received royalties for editorial work in UptoDate as Section Editor for Pain in Palliative Care and as author for Johns Hopkins University Press; and has received travel/ accommodations/expenses from Novartis and fees from Pfizer.