Tuesday, March 30, 2010

Origins: Physical Medicine and Rehabilitation to Palliative Medicine

In an effort to better understand what guides people to practice in hospice and palliative medicine, we are beginning a new series called 'Origins' featuring doctors from different primary specialties.  Obviously the majority of physicians in the field are from Internal Medicine and Family Medicine (as evidenced from the first year of board certification in 2008.)

The first edition of Origins is written by my colleague Pam Harris, MD who is an associate medical director with me at Kansas City Hospice and an ordained minister.  She recently passed her Physical Medicine and Rehabilitation boards and is board certified in HPM. 


To contribute to an upcoming Origins blog post please email me at christian@pallimed.org. We need representatives from any of the following specialties: psych, neuro, anesthesiology, radiology, EM, surgery, OB/GYN. 

Take it away Pam!

Thanks to my friends and colleagues at Pallimed for the opportunity to launch its “unconventional” guest blog event!

“Why would a Physical Medicine and Rehabilitation (PMR) physician specialize in hospice and palliative medicine (HPM)—isn’t that the exact opposite of what you were trained to do?”

I get that question a lot, especially from my PMR colleagues. My dearly beloved mentor looked at me with disappointment when I went to seminary [as those great theologians, the Grateful Dead, once said, “What a long strange trip it’s been”], but he looked at me with absolute unbelief when I told him that I was going to work for hospice. It was almost as if he believed that all my training to that point had been a waste of time.

On the contrary, PMR physicians are perfectly suited for HPM! Here are the top 5 reasons why:
  1. Physiatrists always bring friends. PMR was developed as an interdisciplinary field, complete with team meetings.
  2. We look comprehensively at the patient and family in the entire community and psychosocial context. We can’t treat patients in isolation from their support system/caregivers and we can’t treat the patient/family unit without considering their larger environment.
  3. Physiatrists are experts at musculoskeletal and neurologic physical diagnosis, pain management, bowel and bladder programs, skin care/wound management, and community resources to support our patients and families. Sound familiar?
  4. We’re all about improving quality of life and maximizing function. Even at the end of life, there is room for targeted therapies that help patients do the things that they want and need to do as long as possible and that teach caregivers how to care for patients in ways that protect both the patient and the caregiver.
  5. Physiatrists frequently provide care to patients with progressively degenerative and disabling conditions, adjusting treatment plans as diseases progress and patient abilities change. A Physiatrist can help provide valuable prognostic information to patients and families to help them make informed decisions about their therapy options.
I believe the biggest barrier to physiatrists considering practices in HPM is the false belief that rehabilitation and palliative care are opposites. (We rehabilitate until we can’t rehabilitate any longer and only then do we consider palliative care.)

Newer concepts of HPM look at palliation as an integral part of care, with the proportion of curative or restorative/rehabilitative interventions varying with the patient’s disease, goals, and preferences regarding care. There is an art as much as a science to navigating this spectrum of rehabilitation and palliation. It is OK to acknowledge that not everything is “fixable”, even with maximum therapies and treatment of mood disorders such as depression that might affect participation. If something is not working, it is OK to stop doing it and to re-evaluate goals/treatment plans. Not all patients, even those with excellent rehabilitation potential, want to spend their time and energy trying to achieve the goals we encourage them to adopt.

It’s important that we help patients balance their expenditure of time and energy against their likely payoff (e.g. likely function or choice of living arrangement), helping patients understand implications of their choices within their community and psychosocial support structure. Physiatrists are perfectly situated to help patients through this process.

I would encourage my PMR colleagues to consider HPM certification—tests this fall and in 2012 are available to candidates without fellowship training along an experiential pathway. You can find requirements on the official American Board of Physical Medicine and Rehabilitation webpage here. Contact your local hospices about opportunities for clinical practice experience—it could open new doors for your practice. After all, with all our experience, how can we help but grow up to be palliative care docs? ;)

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