Tuesday, March 15, 2011

"Hi, I'm Here to Place a Pleurx and Provide Palliative Care Consultation": The Interventional Radiologist as HPM Physician

I'll admit I was skeptical of this idea when I first read the abstract, but it's growing on me already.

The American Journal of Roentgenology published a retrospective review of all referrals to an academic interventional radiology service to determine how many of the referrals would be appropriate for a hospice and palliative medicine subspecialist.  In brief, 81% of referrals were deemed appropriate for either hospice or palliative care with about half of patients having a malignancy, 20% having end stage renal disease, and a smaller percentage having end stage liver disease or heart disease and other diagnoses.

It's important to note that they didn't characterize why the patients were deemed appropriate for palliative care consultation beyond the patient's diagnosis.  They also didn't describe how many of these patients received official palliative care consultation.  But perhaps that's irrelevant.  Every patient with a chronic/potentially terminal diagnosis can benefit from expert attention to palliative care needs, regardless of the patient's place in their illness trajectory.  When an interventional procedure is considered, it is often considered for the relief of symptoms and this provides an important opportunity to review the patient's understanding of their condition, prognosis, and goals of care. All of these could potentially be discussed as part of the informed consent conversation surrounding the procedure.

As of 2008, their were nine physicians from the American Board of Radiology who successfully achieved board certification in hospice and palliative medicine. (Edit: I'm told that all nine are radiation oncologists.)  We need a broad range of perspectives in this field and perhaps more importantly, we need to grow the workforce.  (All hands on deck.)  If you are an interventional radiologist who is interested in hospice and palliative medicine, the article describes the process for obtaining certification in HPM.  Unless you want to complete an ACGME accredited fellowship, you'll need to complete the grandfathering process and take boards in 2012 which will be the last opportunity to grandfather into the specialty.  The rate limiting step for any interventional radiologist will most likely be obtaining the interdisciplinary team experience that is required.  Physicians seeking HPM certification must provide documentation of at least 100 hours of participation in a hospice or palliative care interdisciplinary team.  I'd also encourage professional development in communication and non-interventional symptom management.

Of course, not many interventional radiologists will actually seek HPM certification.  However, those who do not seek certification can still count themselves amongst the primary palliative care providers on the front line.  Maybe all IR departments should have a palliative care champion that helps with education of the interdisciplinary team in the IR suite in matters related to palliative care?  (EPEC-IR anyone?)

Thanks to @PalliPsych (aka San Diego Hospice's Scott Irwin, MD) on Twitter for helping me warm up to this idea. 

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