Palliative Care Fellow Alicia Susan Hilburn on the importance of training in palliative care to ensure excellent care
“When we talk about medical aid in dying, one of the concerns I have is, do we really understand how to manage pain? Do we really understand how to manage delirium? My McGill Fellowship has given me those clinical skills.”
By Devon Phillips. Alicia claims that coming to Montreal to do her Fellowship in palliative care was destiny. Although she is from the Southern United States, she had early exposure to both the cold (having lived in Alaska as a child), the French language (having studied French instead of Spanish in high school), and last but not least, she found love in Quebec! In short, it all came together and she spent a productive year receiving training in palliative care in four different Palliative Care McGill hospitals. She will be taking her expertise with her to her new position in a North Carolina hospice.
Q: I understand that you are from the Southern United States and you came to Montreal to do a Fellowship in Palliative Care. How did you manage the Montreal winter?
A: I grew up in Bainbridge, Georgia, an hour from Tallahassee, Florida, but I was actually born in Fairbanks, Alaska because my father was sent to Alaska when he was drafted for Vietnam. I was prepared for winter in Montreal because apart from Alaska, I moved to New Hampshire in 2005 to practise internal medicine in a hospital. My mother always said that I was destined to go to cold climate!
Q: So there you were treating inpatients in New Hampshire for ten years before you came to Montreal to do a palliative care fellowship. What brought you here?
A: That`s where e-Harmony online came into play! Long story short, a met this wonderful Quebecois guy who lives in Quebec City and so when I had decided to do palliative care, I thought of coming here. I read up on McGill’s palliative care program and the birth of palliative care and Dr. Balfour Mount and I was impressed. I submitted my application, got the interview, and then came here!
Q: Tell me about your Fellowship program.
A: Throughout the year, we did ward rotations, clinic, and consult services. I started at the Jewish General Hospital and then I went to Mt. Sinai and from there, I went to the MUHC. I also spent one month at St. Mary’s Hospital. It’s been very neat to go to four different hospitals because although the principles of palliative care are the same, there are very different approaches, not only depending on the hospital but also the attending physician or the staff person. It has been a pleasure to work with so many different people and learn from the different approaches. It’s helping me construct my approach, my style. We also do electives which are three rotations where we can choose what we would like to do and I really enjoyed working in the day hospital and the cancer pain clinic. I did inpatient and outpatient care. I also did a research project in which I reviewed the literature on supportive interventions for caregivers of patients with terminal illness. So in this Fellowship, I finally got that mix of things that I did not have the chance to experience before.
Q: You mentioned a research project on support for caregivers. Can you comment on the role of the caregiver?
A: Part of our mandate in palliative care is to think of the whole family, both the patients and the caregivers, because when a loved one is going to die, the caregiver will be grieving and needs caring too. A life-changing diagnosis for the person with the terminal illness is also life changing for all members of the family, not just the patient. The caregivers are often forgotten in the course of a person’s illness. One thing I have seen done particularly well on the wards here is the support with the family, that’s the piece that sustains patients at home to allow them the kind of death that they envision. The person supporting the patient must also be supported or they will burn out; they will have complicated grief and bereavement if we don’t provide that to them.
Q: Anything particular that you enjoyed in your Fellowship program?
A: I really enjoyed the home visits at Mt. Sinai. I value seeing a person in their own environment, where they live, how they live, their animals and plants. When you see people at home, you can get a good sense of what is important to them, and also what their needs are. It might be easy for a healthcare professional to say, “When you get home, this is what should happen”, but sometimes people don’t have the support or the resources to follow those instructions.
Q: Now that you have completed your Fellowship, where will you be working next?
A: My mom wanted me to come back closer to home and a job in Charlotte, North Carolina was open and it’s a good group, a large group of palliative doctors in a hospice. They have a foothold in places where you don’t often see palliative care ̶ cardiology, orthopedics, neurosurgery. I felt like this would be a place where I could continue to grow and learn. In this group, there is enough demand that individual providers can offer different services. Some physicians do nothing but clinic, some do only the hospital. I’ll be doing half inpatient and half outpatient.
Q: What has the response been to the fact you have completed a Fellowship at McGill?
A: I think one of the reasons I was hired by the group in North Carolina is because I did my fellowship at McGill. People in the States do recognize Canada’s, and particularly McGill’s strength in palliative care, and they were very interested in some of the things that we do here. They felt I was getting specific knowledge that I could bring back to the group. And that is true. Some of the things we are able to do in Canada we don’t yet have the buy-in from Medicare or private insurance in the US. One of things I want to explore is systems development and how to build new programs and in order to do that we have to be able to convince insurance companies, hospitals or health systems, that it is in their best interest to support palliative care services.
Q: Part of your training was clinical but part was psychosocial. Are those two parts necessary?
A: Absolutely. And to be honest, in my old job with hospital inpatients, I became frustrated with the approach to simply get people well enough to be discharged. We were not thinking about the future. So one of the things that has become important to me is advance care planning and getting people to talk about they want or don’t want.
In this Fellowship, I have found there were things that I was good at and things that I was not good at, and this training has helped me to get better at the things that I was not so good at. I always have had an interest in the psychosocial side of things. We talk about medicine being a union of art and science, and I have always been a little bit more on the art side. Science has always been more difficult and challenging for me, so I am learning how to meld those two things together. What I love about palliative care is that I get to do what I am good at and I get the time to it as well.
Q: It sounds like the year of learning in your Fellowship represents a positive shift in your own personal development.
A: In the last two to three years, if I wasn’t taking care of people in the intensive care unit, if I wasn’t putting in central lines, or working in the emergency room or if I wasn’t running codes, somehow in my mind, I wasn’t a doctor. The greatest thing for me is that I have gotten to a place in my own evolution where I can accept what I do well and what I do well is listening to people, hearing people and talking to people. Palliative care allows me to be me which is great.
Q: Do you feel you have come away with specific skills on the clinical side that will help you practice palliative care?
A: Yes absolutely. I think as physicians we convince ourselves that we know things we actually don’t know. The medicines we use every day in palliative care ̶ morphine, Dilaudid, Haldol ̶ I used those medicines too when I was a clinician in internal medicine. I thought I knew how to dose, titrate and manage these drugs, but what I found out when I got here was that I didn’t know a thing about doing that well and safely, or doing that in a way to really address someone’s pain and other symptoms. We have to educate providers over and over, especially in the US, because what we think we know is not what we actually know.
When we talk about medical aid in dying, one of the concerns I have is, do we really understand how to manage pain? Do we really understand how to manage delirium? McGill has given me those clinical skills. I am much better at managing those things than I ever was before. As a physician, I want to know what I know, and admit what I don’t know. One of the most valuable things in training is to ask when we don’t know. Training in palliative care is so necessary if we want people who really know what they are doing.
Q: Looking ahead, are you going to keep us informed as to how it’s going?
A: I will! I feel very close to all the people I have met here and the fact that there is the International Congress of Palliative Care in Montreal every two years is a reason to come back here. I recall being in the day hospital clinic where we were all standing together, people from anesthesia, interventional radiology, our Fellows from palliative care, and we started talking. One of the trainees was finishing her residency in oncology and going back to Iran and we were saying that McGill’s legacy is its international scope and how it would be neat draw lines on a map to show where residents and trainees go throughout the world! It’s amazing to think that in our Fellowship year, Mohammad will go back to Saudi, me to the US, Chris to British Columbia, and the philosophy of palliative care will keep branching out. I am really very proud of having come to McGill for my Fellowship and to have been part of this. Doing my Fellowship here has enriched my life and it’s going to take my career in a new direction.
The beauty of McGill is that it is so international, it just embraces the world and that’s what makes this place so special. I don’t think I have had a better experience in my lifetime and I just think the world of the people who make up Palliative Care McGill.