Friday, March 19, 2010
Palliative Care: (Un?)-Necessary Specialty
For long-time readers of Pallimed, it would be obvious to most of you that palliative care is important enough to require dedicated specialized instruction to ensure the highest quality symptom management, skilled patient and family communication and balanced discussions of transitions in goals of medical care.
One of the web's more popular doctor bloggers, the anonymous* Dr. Lucy Hornstein (aka #1 Dinosaur - her blogging pseudonym), recently posted an entry titled: Palliative Care: An Unnecessary Specialty.
Now before you get too mad or defensive (like I first did), go read the post and the comments. She is a family medicine doctor and the main thrust of the article (despite the provocative title) is that all doctors and especially primary care doctors should be skilled in palliative care. A lot of the arguments come down to the frustration over too much specialization. An excerpt:
Excuse me: why do you need a brand-new "Team" to treat symptoms and talk to families?
I would agree that palliative care is practiced by many good clinicians (primary and specialist) every day whether they call it 'palliative care' or not. In fact this is one of my main teaching points to students and colleagues about the ubiquitous (and not foreign) nature of palliative care. I applaud the many health care professionals who focus on alleviating symptoms, talk with patients and families in a way that is open and clear, and effectively understand the patient's values to help in transitioning goals from curative to palliative at the right time for the patient.True palliative care -- the management of symptoms -- is part and parcel of everyday medicine. Itching; nausea; constipation; pain. Work them up to make sure there is no serious underlying problem, of course, but for crying out loud, don't tell me you now need another specialist to actually come TREAT them! This is fragmentation of care taken to outrageous extremes.
But there are a lot of patients and families who are not getting these services whether the case is simple or complex. Thus the field of palliative care was born.
And the funny thing about this post is...#1 Dinosaur likes palliative care so much, she is thinking of becoming a hospice and palliative care doctor.
(And a quick side social media side story.
- I saw a Tweet from Dr. Scott Lake (@doclake): This blog will make u mad "Palliative Care: An Unnecessary Specialty" http://bit.ly/cCH48U hoping someone more eloquent than I will respond
- I replied on Twitter: RT @doclake This blog will make u mad "Palliative Care: An Unnecessary Specialty" http://bit.ly/cCH48U "I haven't read it yet & already mad"
- I read the blog post and using 'Share This' connected to my Gmail account was quickly able to email it to Drew Rosielle, Steve Smith (AAHPM CEO) and Eric Widera (GeriPal) (all on Twitter, but I knew they might see it faster this way)
- Total time to now: 50 seconds
- I commented on the blog post (5 minutes)
- Meanwhile...Steve Smith had contacted Laura Davis (at AAHPM) who got in touch with Sean Morrison (President of the AAHPM) who wrote a great comment less than an hour after I first read about it.
Hopefully this illustration of how the networks connected to pass this information is helpful to see why we need our networks to be full, diverse, integrated and intact before we actually need them. See you on Twitter.)
*Late edit 3/19/2010 Apparently she was once anonymous and now revealed since she wrote a book.
10 Responses to “Palliative Care: (Un?)-Necessary Specialty”
March 19, 2010
Well done, Christian ~ and leave it to you to turn this into a teachable moment about the power of Twitter!
March 19, 2010
Thanks for the comment Marty. I try when I can to demonstrate how I use social media so that other people may learn from those examples. Otherwise people just think it is for tweeting about the last sandwich I ate. Which was a PB&J if you were interested!
;-)
March 20, 2010
Christian:
Great job with explaining the information dissemination...
Also, with regards to subspecialties, their strengths and weaknesses and the place for palliative care - a couple thoughts (which I will also share on Dinosaur's site):
One role for subspecialists is to raise the quality of care and body of knowledge for all clinicians. All family docs and internists should know about treating infections, but ID specialists help keep us all abreast of developments in the field, and elevate standards of practice. I actually had a similar discussion with some of the oncology fellows and attendings at my work: Shouldn't all oncologists know this stuff - a couple asked? Well yes and no. But my role, in this academic center, is to provide them with knowledge that all oncologists should have, and then to support care that is outside their expected range of practice (lidocaine or methadone infusions for severe pain, for example.)
Especially given the reality that there will never be enough palliative care docs to see every patient with serious life-limiting illness, especially as we expand our practice to help address symptoms and other burdens earlier in the disease trajectory, as a field we expect and hope and will endorse all physicians to expand their knowledge in symptom management, communication skills, and coordination of care.
Lastly - I ditto Marty's statement - this was a great example of how to use Twitter effectively - in a way that matters!
March 20, 2010
christian-
your comments are on target and thoughtful and kind. dinosaur #1's commentary is partly about what palliative care and palliative medicine is, vis a vis the debate about language moved along by meier's and morrison's comments at AAHPM which i have reflected on at the AAHPM blog and gerimed, and also about wishful thinking. about language: in reality, however we in PC want to define or redefine or move upstream our field, mainly what we do and what we will do is take care of dying people, and that is what we love to do. yes we are good with symptom management and goals of care discussions but how we GOT good at that and stay good at that is taking care of dying people. as we move upstream, which we should, we can modify our practices and our language, but our defining core should not change. most primary care docs and specialty care docs don't do much of this and don't like it that much either. that is the wishful thinking part. lots of data show that, whether a FP or a med onc like me, most may say the know PC, can do PC, can do PC well, and do PC now....... but they don't do it!!!! that is why we are and will be needed. they don't do it and aren't planning on doing it any time soon, and patients and citizens and hospitals are demanding it, so here we are, in our nascent "specialty" (calling?), doing it, because it is what we want and need and love to do. so go for it, dinosaur #1, but show us how much of it you do and how soon in your practice, and don't expect many your colleagues to follow your example any time soon.
March 24, 2010
And thanks for all the traffic!
Seriously, I appreciate all the commentary. I hope it's obvious that there was no offense intended. My meaning was primarily decrying the mis-use of palliative care consults to further fragment patient care.
I, too, love taking care of dying patients. But I also love taking care of well children; and men with pneumonia; and women with arthritis; and so forth. That's what drew me to Family Medicine. What keeps me there is my unwillingness to give up taking care of everyone else to focus on just one group (those at the end of life).
As the private practice environment continues to deteriorate, though, I'm having to re-think my career. When I get to the point where something's gotta give, you may very well be getting a new colleague.
March 25, 2010
Suzana,
Excellent point about the role of the specialist in disseminating knowledge. I have already used that line with two people this week.
Clay,
Great to see you commenting on blogs. I saw you commenting over at Geripal and was wondering when you were going to leave those left coasters and hang out with the Midwest Palliative care blog! ;-)
I think your points are important and I would nominate you to be in a debate about the language and focus of HPM. I am hoping they finally do a debate format for one of the plenary's next year. you would be great up there.
#1 Dino,
I am so glad you came around here for comments. I was afraid we scared you off since you had not commented on your own blog or here. I am glad your traffic spiked. Probably a good example of how a palliative care community has formed in social media that can be mobilized quite rapidly. If you care to share some stats with me privately (ctsinclair@gmail.com) I would be interested to make a little case study about this to demonstrate the flow of conversation.
I think many got your focus and no meaning of ill-will. i think it just got some people a little riled with the title, but if they bothered to read past it, I think most understood your points. I was a little afraid that someone was going to go off on you in the name of palliative medicine but seeing as how most of us are pretty savvy about communication it appears that was less risky than I imagined!
We would welcome more palliative medicine colleagues, but you better hurry because the experiential track is closing!!
March 25, 2010
Oh and #1 Dinosaur if we could get on your blogroll that would be great. Didn't see any palliative medicine blogs there.
March 27, 2011
Oh and #1 Dinosaur if we could get on your blogroll that would be great. Didn't see any palliative medicine blogs there.
March 27, 2011
Christian:
Great job with explaining the information dissemination...
Also, with regards to subspecialties, their strengths and weaknesses and the place for palliative care - a couple thoughts (which I will also share on Dinosaur's site):
One role for subspecialists is to raise the quality of care and body of knowledge for all clinicians. All family docs and internists should know about treating infections, but ID specialists help keep us all abreast of developments in the field, and elevate standards of practice. I actually had a similar discussion with some of the oncology fellows and attendings at my work: Shouldn't all oncologists know this stuff - a couple asked? Well yes and no. But my role, in this academic center, is to provide them with knowledge that all oncologists should have, and then to support care that is outside their expected range of practice (lidocaine or methadone infusions for severe pain, for example.)
Especially given the reality that there will never be enough palliative care docs to see every patient with serious life-limiting illness, especially as we expand our practice to help address symptoms and other burdens earlier in the disease trajectory, as a field we expect and hope and will endorse all physicians to expand their knowledge in symptom management, communication skills, and coordination of care.
Lastly - I ditto Marty's statement - this was a great example of how to use Twitter effectively - in a way that matters!
March 27, 2011
Well done, Christian ~ and leave it to you to turn this into a teachable moment about the power of Twitter!
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