Thursday, May 7, 2009

Oncology Fellow on Palliative Care: "It's a Refuge (for me)"

HemOnc Today has a personal essay from Dr. William Wood, an oncology fellow at UNC, about why he likes palliative care. He is in a cohort of medical learners with an increasing exposure to palliative care from medical school to fellowship. The historical perspective on the slow culture change in medicine to accept palliative care demonstrates an increasing acceptance with earlier and consistent access to palliative care teams. Here he describes working with the pallaitive care team during his residency:

"I was lucky to be in a program where my senior residents and attendings were heroes. Their thoroughness, competence and compassion were widely emulated by interns, who tried hard to live up to their examples."
Later in the essay, he makes an impressive statement referenced in the title of this post:
"As an oncology fellow, palliative care is everything it was before, but it has taken on a new dimension for me now — it is a refuge.

Paradoxically, though the goal is no longer cure or prolongation of life, providing this kind of care can feel extremely satisfying."
It is these satisfying interactions between professional and patient which inspire so many clinicians to pursue a career in palliative medicine or at least embrace palliative care from within their specialty. I am glad to see so many medical learners with the opportunity to have these personally rewarding opportunities to 'comfort always.'

He ends with a few probing questions about health care policy and the structure of oncology as a business:
"Yet, I am still troubled. Why does providing good palliative care feel like a refuge to me now in ways that it didn’t before? And why are there so many palliative care physicians who no longer primarily treat cancer? Could the structural and institutional organization of our cancer care delivery system, and the incentives therein, present subtle barriers to the ability of good oncologists to deliver good palliative care throughout the disease continuum?"
These organizational challenges to ethics may start to emerge in many specialties as we have more doctors like William Wood who promote palliative care within their specialties. When a critical mass of gastroenterologists start challenging automatic PEG placement without a exploration of the appropriateness and efficacy they may change policy or even reimbursement mechanisms. Same issue for oncologists and chemo, radiation oncologists and prolonged fractions when a few may do, or nephrologists and offering dialysis to patients they feel will not survive regardless of dialysis. We may be on the cusp of small internal revolutions in other specialties as palliative care education becomes the norm. What do you see at your institutions?

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