St. Barnabas Hospital is located in the heart of Bronx, New York, and as such, it has a culturally diverse, largely poor, patient population. The backbone of successful palliative care services is the doctor-patient communication bonding process. However, many of the patients with late-stage cancer at St. Barnabas present cultural and language barrier challenges for oncologic and palliative care services. To shed light on these issues, The ASCO Post recently spoke with Steven Reichert, MD, Director of Palliative Care Services at St. Barnabas Hospital.
Early Years
Please tell the readers a bit about your background.
I was born and reared in Ohio and went to undergraduate school at the University of Michigan. I studied literature but always wanted to become a doctor. I received my MD degree from the University of Cincinnati College of Medicine and did my residency training in internal medicine and primary care at Baystate Medical Center in Springfield, Massachusetts. Then I worked for a year at a hospital emergency department and another year in private primary care practice.
After that, I ended up taking a faculty position at Mount Sinai Hospital in New York. I was in general medicine, and since there was no hospitalist profession then, I did both inpatient and outpatient care.
Growing Interest in Palliative Care
What circumstances led you from primary care into palliative care?
During my first year at Mount Sinai Hospital, I was an attending on a geriatric ward with Dr. Sean Morrison who, along with Dr. Diane Meier, was considered one of the early founders of palliative care. It was 1995, and at that time, most people did not understand the underlying principles behind palliative care. That experience began to pique my interest in the field.
During my time at Mount Sinai, I really enjoyed working with residents, so I decided to remain in academic medicine. Eventually, I became Associate Program Director at the Englewood Hospital and Medical Center in New Jersey, where I was involved in training and teaching medical students. Everything was primary care-based. While there, I took what was called EPEC training, which was an intense 3-day course in end-of-life care for physicians.
The person leading the course was a palliative care doctor named Cynthia Pan. I spent 6 years at the Englewood Hospital, and from there, I went on to be an internal medicine program director at New York Hospital Queens, running the program for about 9 years.
During my tenure at New York Hospital Queens, I was also appointed the head of the quality assurance program. So whenever there was a challenging patient, they called me. And it became readily apparent at our hospital, which was handling 300 to 400 internal medicine patients at a time along with 60 to 80 chronic bed patients and a lot of Medicare end-of-life care, that we needed palliative care services. So I began lobbying the administration for the go-ahead to create a palliative care program. Finally, the administration sent me and three other doctors to Minneapolis to take an intense course on how to begin such a program.
When we returned, we knew the basics of setting up a program but did not have the hands-on knowledge to run a palliative services department. So once again, we lobbied the administration, and they reached out and hired my previous EPEC instructor, Dr. Pan, as Director of Palliative Care Services. Meanwhile, I’d been working in palliative care by default because there was no one else to do it.
When Dr. Pan arrived, I became interested in making a career shift and asked her if I could work with her. She said yes, and since I was a program director, I thought I would just take an exam in palliative care, pass, and become a palliative care specialist. Wrong. I did not expect the avalanche of learning that followed, from communication skills to pain management.
I also quickly found out that up until then, I had been doing many things wrong. For one, I wasn’t patient-centered; I wasn’t assessing my patients’ emotional and spiritual needs. Taking full advantage of Dr. Pan’s teaching and feedback, I began to grow as a palliative care doctor. In 2012, I took and passed my boards. So, that’s the story of my journey to palliative care.
Fledgling Program
What led to your position at St. Barnabas Hospital?
My work situation at New York Hospital Queens changed, and I began to reach out for new opportunities in palliative care. Ironically, my best friend from high school was the Chief Medical Officer at St. Barnabas Hospital. He had inquired about my joining the St. Barnabas team in the past. So I called him, explained that I wanted to do palliative care, and asked what kind of program he had. Their program consisted of one nurse practitioner. With that, he asked if I would like to head a palliative care service at St. Barnabas, and I became director of the hospital’s palliative care services 2 years ago.
Please tell the readers about the experience of running a palliative care unit in the inner city.
Because of the information I’d received from the course I took in Minneapolis, I expected a slow start to a fledgling palliative care program, about 50 consults the first year and an incremental growth in volume. Well, in my first 6 months at St. Barnabas, I did about 200 consults. Last year, I saw more than 700 patients, and the volume and demands continue to grow. The program is receiving accolades from patients, their families, and the hospital administration, which is very gratifying, especially since this is still a young program.
A Population in Need
Please describe the patient population and the clinical challenges you and your staff face.
We are located in the heart of the Bronx, and our patient population is predominantly low-income Hispanics and African-Americans. About half of our services need to be conducted in Spanish, which I am fluent in. These are some of the poorest people in the country. Moreover, most of our patients are deeply religious, which presents challenges for me. Studies show that very poor and undereducated religious individuals tend to have extremely high expectations at the end of life.
Quite honestly, there’s also a lack of trust in the system that many of these patients have, especially when a white doctor is treating them. There is a cultural barrier that needs to be addressed, and I’ve found the best way to do that is to connect on a spiritual level.
I’ll never forget an experience during my second month running the program. I was at the bedside of a very sick African-American patient with cancer, and his daughter was across from me. I mentioned God, and his head perked up. His daughter asked me if I believed in God, and when I said, yes I do, she said, ‘You’re our man.’ I was able to work closely with her as her father made a peaceful transition to hospice care. I’ve learned that in my patient population, connecting on a spiritual level is tantamount to best practices.
Another challenge is to get the rest of my staff to fully understand the needs of our patients and their families. It’s easy to be impatient with people who do not understand why their loved one is unresponsive. Our job is to work through those barriers in a respectful and thoughtful manner.
Closing Thoughts
Do you have any last thoughts on the future of palliative care?
I think the next area of growth needs to be centered on the palliative care outpatient setting. This will be part of a newer movement toward thinking of the health-care system not in silo models, but in a shared responsibility between providers and patients. A central goal of palliative care is to work with oncologists to prevent emergency room visits. Also, it is important to get the primary care doctor involved early in the care of a patient with cancer. A well-coordinated system ultimately creates better outcomes. ■
Disclosure: Dr. Reichert reported no potential conflicts of interest.
