Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, March 18, 2010

Palliative Care: An Unnecessary Specialty

I love reading Dr. Bob Centor. He's sort of my inpatient counterpart, even though he's an internist and about ten years older than I. Still, what we have in common is a passion for patient care. That's why I was so tickled to read this recent post of his, where he says in so many words that the extensive sub-specialization that is the hallmark of American medicine is bad for patient care.

Dr. Bob also harps on the importance of making an accurate diagnosis before initiating treatment; the "evaluation" as opposed to the "management," immortalized in the expression "E/M". This seems so obvious as to be ridiculous, and yet failure to grasp it is the major confounder in the calculations of non-physician health care policy experts. Medical treatment isn't all that difficult. Really. I'm not going so far as to say that any trained monkey can perform surgery, or that driving this baby isn't tricky, but it's completely inappropriate to plug someone into, say, a congestive heart failure treatment algorithm unless and until you know that the patient actually has CHF. Much has been written about the complexities of the human body. and while some treatments certainly require a great deal of individualization, making an accurate diagnosis can be far more complex than any treatment regimen.

But there are two different kinds of treatment: curative, intended to eliminate the cause of the symptoms and restore patients to health (defined as not being under medical care), and palliative, intended to alleviate symptoms. These treatments often overlap; radiation that makes a tumor disappear relieves many of the symptoms directly caused by the tumor, such as pressure on surrounding structures. They also often overlap in time: salt water gargles and ibuprofen won't cure strep, but they will make the patient feel better while the amoxicillin is killing the germs.

So in a way, I was a little surprised when one of his posts as ward attending mentioned consulting with the "Palliative care team," a multi-disciplinary group of doctors, nurses, social workers et al whose sole purpose appears to be providing comfort care instead of curative care. As it happens, there was also a long article recently in my local newspaper about Palliative Care Teams, which emphasized their role in communicating with patients' families about difficult situations.

Excuse me: why do you need a brand-new "Team" to treat symptoms and talk to families?

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.

As for talking to patients and families about difficult decisions when curative treatment is no longer an option, that too is part and parcel of my job. I do it every day in my office, and the only reason I don't come to the hospital to do it is because I can't get paid for it, and I can't afford to work for free.

Maria, a psychiatrist and blogger (Intueri) who completed a fellowship in Liaison psychiatry, has opined that doctors appeared to consult Psychiatry rather than talk to their patients. The reasons are legion. Psychiatrists are perceived to have more expertise with difficult conversations, probably because they have more of them. They aren't as afraid of them (same reason), and they have more time available for them (because they take it). There is a role for the psychiatrist, but it is not to take over the job of talking to the patient.

Likewise, the role of the "Palliative Care Specialist" is redundant in the setting of an informed, caring, up-to-date primary physician. I can see their involvement in cases where primaries are uncomfortable dealing with hospice situations, but by and large, the "Palliative Care" movement represents yet another attempt to carve out a piece of my practice that is well within my scope of knowledge and ability to care for my patients.

Americans don't seem to realize that they don't really need a pediatrician for the first eighteen years of their life, an internist and/or gynecologist for the next forty, and a team comprised of a cardiologist, urologist, orthopedist, and geriatrician for the rest, with a Palliative Care specialist stuck in at the end. It's called Primary Care for a reason. It comes first. And it's what I do.



(Full disclosure: I actually enjoy hospice and palliative care so much that if things continue to deteriorate, one of my possible exit strategies is to shift gears and certify in Palliative care. Think about the demographics. What's the next thing the baby boomers are going to all start doing? That's right: dying. And they're going to need a lot of Hospice docs to care for them.)

21 Comments:

At Thu Mar 18, 04:35:00 PM, Blogger little d, S.N. said...

And THAT is why I want to do primary care things after I get my Nurse Practitioner degree (to start after I graduate my BSN degree in July)

 
At Fri Mar 19, 02:07:00 AM, Blogger shadowfax said...

The only quibble (and it's a little one) I have is the notion of a palliative care TEAM is a good idea. I agree that one internist (or FP or oncologist) should be able to serve this function as well as another, but a dedicated team approach is a great thing.

For example, a Hospice patient show up at my ER with acute decompensation from their underlying disease. The patient is clearly terminal, but the family is freaked. Instead of admitting him or her, I call the hospice doc, who approves the patient to go home. At home, they are met by the hospice nurse who has the supplies for a morphine drip, and in the morning the social worker/counselor stops by to see how the family is coping. Much better than admitting the patient to die in the hospital, which is probably what he or she wanted to avoid in the first place.

Full disclosure: my mother in law is a cancer counselor, so maybe she's infected my brain on this...

 
At Fri Mar 19, 11:47:00 AM, Blogger SHELLY said...

I'm one RN (BSN) standing firmly with you up on the Primary Care soapbox. Since I am both an RN and a mother of small children, I frequently get the "which pediatrician?" question from other moms. Imagine their surprise when I tell them they don't NEED a pediatrician...........that's why some physicians are called FAMILY doctors. Not always a popular view, but one that I keep preaching nonetheless. I'm still not sure when they think they're getting from a pediatrician that they won't get from a family doc. Any thoughts?

 
At Fri Mar 19, 11:57:00 AM, Anonymous kcpk said...

I am a solo Family Doctor on the other end of Pennsylvania. I agree with much of what you said: especially that communicating with patients and being able to offer palliative care is part of being a primary care physician. I also serve as an Associate Medical Director for a Hospice Organization. And while I'm not sure if the Palliative Care Team in the hospital does the same thing, I must say that the depth and breadth of knowledge and skills possessed by nurses who are immersed in the field of Hospice care day in and day out does exceed my mine. I am constantly learning from them, especially when it comes to things like pain management and end-of-life symptom management. Just as I don't even try to manage a patient's dialysis, I would hope that someone who is not well-versed in palliative care has someone to turn to for help. We unfortunately cannot be all things to all patients. And I fully realize that I know much more about this stuff because I happen to love it, but not everyone does. BTW, thanks for all you do. I think of you as a role model.

 
At Fri Mar 19, 03:52:00 PM, Blogger Christian Sinclair, MD said...

Dr. Dinosaur,

I found your post from a palliative care doc (@doclake) on Twitter. I am a board certified hospice and palliative medicine doctor just to be clear. I think your title is provocative (and potentially misleading), but actually serves to undercut some of your main points which are valid.

To a degree I would have to agree that as a specialty palliative medicine SHOULD NOT be necessary in an ideal world. But as you know our current medical system is far from ideal with very few doctors taking primary responsibility for a patient. Especially in the hospital where several different specialists come by and declare there 'organ' is 'looking good today', while the whole patient deteriorates. The hospitalist should fill the communication gap, but is often too overloaded with patients and administrative issues to be able to have a 60-90 minute family meeting to evaluate the goals of care. Thus to fill an (frequent and important) unmet need, the birth of a palliative care team and eventually a specialty as the body of knowledge has increased greatly in the past decade.

If you don't believe there is enough of a body of knowledge to warrant specialty status, check out the past 5 years of postings on my blog Pallimed. We cover the academic knowledge important to the specialists who practice everyday in the field. It is much more than morphine, ativan and holding hands.

I often use as a teaching point that all doctors practice palliative care since many diseases are not easily cured, but must be managed with palliation of symptoms. But I everyday I see an increased complexity of symptoms that are difficult to manage even with our specialty training. I often inherit these patients from primary doctors or cancer specialist who may not feel as comfortable with aggressive symptom management and multiple powerful medicines. But the bread and butter palliative care and hospice patient can often be cared for very well by family practice and internal medicine docs. I don't see every patient on my hospice service because the docs are doing great. The are good palliative care doctors (even if they are not board certified).

To summarize:

*Ideally everyone would be great at palliative care (symptom management and communicating with families)
*But it isn't happening
*A wide body of knowledge in the field exists justifying specialty training
*All doctors practice palliative care (as they should)
*Complex symptoms can require a team approach from specialists who are very comfortable with powerful medications.

I know you were trying to lift up primary care which I fully support, but just make sure you don't tear down your potential future at the same time. ;-)

Thanks for bringing some attention to the field. I guess we really made it when someone says we shouldn't exist!

If you want any tips on studying for the HPM boards, let me know!

 
At Fri Mar 19, 04:48:00 PM, Anonymous R. Sean Morrison, MD said...

Thanks for opening up this discussion. I think we all agree that care for persons living with serious illness needs improvement. Studies consistently demonstrate that patients with serious and life-limiting illness are suffering unnecessary pain and other distressing symptoms, families are experiencing unnecessary emotional and financial burdens, and our health care system is ill-equipped to respond to the needs of these incredibly sick and complex patients.

The field of palliative medicine was created to address these concerns. Palliative care physicians (from 10 primary specialties) receive advanced training in pain and symptom management, communication, and transition planning. The goal of palliative medicine is to help all healthcare professionals improve the quality of life of their patients who are living with serious and life-limiting illness and to do so in concert with all other appropriate life-prolonging treatments.

Improving care for persons living with serious and life-limiting illness will require a multi-faceted approach. It will require that all physicians who care for patients with serious and life-limiting illness have core competencies in palliative medicine. It will require changes in how we educate future physicians (ensuring that they have the knowledge and skills to provide high quality palliative care). Finally, for complex cases, it will require specialists who have had advanced training in pain and symptom management, communication skills, and transition management. The specialty of palliative medicine addresses all three of these concerns by providing ongoing CME training, teachers and mentors in our nation's medical schools, and assistance to primary physicians with their most complex cases.

#1 Dinosaur is right. We all need to do a better job in caring for patients with serious illness. Studies clearly demonstrate that palliative medicine is a highly effective way to achieve this end.

I encourage you to get more information about palliative medicine by visiting www.aahpm.org, www.getpalliativecare.org, and www.palliativedoctors.org.

R. Sean Morrison, MD
President
American Academy of Hospice and Palliative Medicine

 
At Fri Mar 19, 05:33:00 PM, Blogger John A said...

As an occasional patient, I feel about this much as I do about "guidelines" in many other professions: Useful, but must not be mandatory!

Your main objection seems not to be so much with who knows more about what, in which dosage, best helps with pain, but rather who talks with the patient. And I largely agree - but there have been occasions when a doctor and I were trying to communicate and could have used an interpreter... Not often, only once or twice, with a doctor having a very high level of specialisation to the extent of near-literally being unable to understand the word "arm" nor realise I do not know (or all that much care, in general) the difference between "tibia" and "fibula." I am sure that he would find it difficult to comprehend my insistence, in my [former] field, on the necessity of distinguishing between "bps" and "Bps" rates.

 
At Fri Mar 19, 06:33:00 PM, Blogger Joe said...

If all primary care docs were well educated in palliative medicine, palliative specialists would be unnecessary! But they aren't.

After 28 years as a family physician, now that I am training in palliative medicine, I am learning lots that I wish I had known to have done a better job with my patients.

 
At Fri Mar 19, 06:50:00 PM, Blogger Brian McMichael, M.D. said...

Dear Dr. #1 Dinosaur,

I agree with your position in principle, however as has already been eloquently stated above, these ideals are not being met by a long shot, out there in the real-world, and it's patients and families who pay the price for this.

I plan on taking a fellowship in Hospice & Palliative Medicine because I have treated too many patients forcibly shoved into categories that they do not fit. That is, patients being evaluated and managed improperly ( and to my sensibilities, unethically and inhumanely subjected to long series of painful and futile treatments). These scenarios often are set into motion because for one reason or another the patient showed up in an emergency department, too sick to fight anyone off. And in two shakes of a lamb's tail they were intubated, mechanically ventilated, with central venous access obtained, and then bundled off to the ICU ASAP. These patients wind up restrained to a procrustean ICU bed committed to an algorithmic course of treatment that leads through nosocomial and iatrogenic mishaps, e.g., CTs for PTX, CHF, HAP/VAP, line sepsis, hematoma evacuation, C. diff colitis toward traching and PEGing, all when there was never any reasonable hope to extubate, step-down or discharge the patient to rehab or to a SNF, much less cure the patient and discharge home (I think, "flogging the patient" is the parlance). And I have witnessed the awareness emerge that we were in too deep for what was actually going on with a patient, but no one, attendings included, knew how to bring the situation to any sort of reasonable, dignified, humane and appropriate resolution, or a soft(er) landing.

Like prognosis, palliation is simply not adequately, if at all, taught or modeled in training, nor is it widely practiced routinely or well in the health care system at-large.

I find awaiting me an interesting and satisfying career's-worth of medicine, working in interdisciplinary teams to take care of patients with life-threatening and life-limiting illnesses, and in working with their families. I like the problems that these cases present, the goals of this kind of care are utterly compelling to me, and I'm good at this sort of thing. The same things are not true for many physicians, even if they ought to be. And so a subspecialty is born, and so enter the subspecialist.

 
At Sat Mar 20, 12:03:00 AM, Anonymous Eric Widera said...

Far too much of this conversation is focused on what the physician can or should do for patients. I mainly work with elderly patients with advanced illnesses. If there is one key principle that I have working with this population it is that it takes a team to provide high quality care. Physicians may have excellent competency in dealing with the biomedical issue facing patients with advanced illnesses. However, patients often have other social, psychological, and spiritual needs. And yes, these needs may influence how patients do with our medical plans.


Patients with chronic or advanced illnesses deserve teams who can take care of their total needs, or at least have physicians who can facilitate means to get their total needs addressed (like consulting a hospice or Palliative Care team). There is also some pretty good evidence that this team approach for patients with advanced illnesses improves outcomes and satisfaction scores. Sadly though, our current healthcare system does not value the importance of teams, or even non-physician disciplines like social workers and chaplains.

 
At Sat Mar 20, 01:53:00 AM, Anonymous Anonymous said...

To get down to brass tacks - in CA, you cannot call in a CII unless you are a hospice/palliative physician and the pt is a registered hospice pt.

Otherwise, the MS, oxycodone, whatever has to be handwritten. So - they've got to wait until you can/want to get to the office to get the rx, get it to me & I fill it. With a hospice team, its all done over the phone.

I cannot begin to tell you the numbers of patients who I've helped in relieving suffering when the hospice nurse calls in oral MS concentrate, atropine drops, stool softeners & whatever else will provide relief at all times of the day & night.

State law prevents anyone other than a hospice associated physician to authorize these....so you're climbing an uphill battle.

It doesn't matter how much you want to talk to your patient. when push comes to shove. How fast can the family start morphine & lorazpam?

 
At Sat Mar 20, 03:26:00 AM, Anonymous mv said...

Great idea. As a patient I would love to find an informed, up-to-date primary physician that didn't think they needed a team comprised of specialists to treat me. The turf is being invaded because most of the existing inhabitants have become extinct.

 
At Sat Mar 20, 01:14:00 PM, Anonymous MP said...

Fragmentation of "Care" has been a downfall in our system for too many years to recall. It is time that we as "Licensed Health CARE Providers," take ownership of our professions and put Care back with Health. Palliative Care is an integral part of Health Care and those who espouse Primary Care are pivotal in providing what is Primary inclusive of Palliative Care. As a Licensed Advanced Practice Registered Nurse that works in multiple settings including but not limited to specializing in Hospice and Palliative Care I see serving Humanity through the Art and Science of Nursing and Medicine inclusive with our Allied Professionals ie Pharmacists,Social Workers and Chaplains as an integral approach to Patient Centered Primary Care. Fragmentation of Care has destroyed our Health Care System. Let us find ways to work together to improve our patient's outcomes, and allow individuals to live and die with dignity and respect.

 
At Sat Mar 20, 04:28:00 PM, Anonymous Anonymous said...

It seems that with the evolution of evidence based medicine, so to came specialization. It is impossible for one doc to keep up with everything. There does need to be more focus on primary care(hence patient centered medical homes), with appropriate use of consultation-including palliative care.

 
At Sun Mar 21, 12:36:00 AM, Blogger Lynn said...

Agreed. Primary care docs should be doing this stuff. But... doing consults as a hospice and palliative medicine fellow, I constantly wondered, where were these patients pcps? Many patients with serious illnesses haven't seen their pcp in months since they've been in and out of the hospital, facilities, and specialists' offices so much.

I now work in a snf, doing short term rehab. I am the true "middle-man" (well, "middle-woman") between the hospitalists and the primary care physicians, but very frequently I am the one addressing goals of care. I'm glad I had my training because these discussions can be really, really tricky, and I sure didn't learn how to do them in residency.

 
At Wed Mar 24, 01:12:00 PM, Blogger Rogue Medic said...

I similarly find a lot of satisfaction in helping patients deal with palliative issues. I could add to all of what the palliative specialists wrote, but it would only be repetition.

When my father ended up in the ICU after his implanted defibrillator kept him from dying, we found out that he was aspirating some of his food. The food in the lungs was causing pneumonia. The pneumonia was causing arrhythmia.

He was told that he would need to eat and drink through a feeding tube for the rest of his life. This was a couple of decades ago, so I don't know if this would be handled much differently, now.

He was 82 and was adamant about not wanting to live that way. He wanted the defibrillator turned off (the pacer function remained on). I tried explaining this to everyone in my family, but like a Thanksgiving dinner argument, there is so much connotation that communication never happened.

There was no palliative care. There was only a chaplain. He was not of the same denomination as my family, so it was easy for them to discount what he said.

One part time nurse, took my family off to a family room, sat them down, and explained things until they understood. What she did more than anything else is listen.

Primary care doctors can be great at that. My father's was not.

Emergency physicians can be great at that. I have seen some. Some is not anywhere near enough.

IM/hospitalists can be great at that. My father's was not. Neither was anyone else on his team.


I would trust you to provide almost all of the palliative care for me or for my daughter, if it were needed.

I would also trust you to know when there is more that you do not know and to call a specialist.

Emergency medicine could be handled by primary care doctors. That does not mean that it should be handled by those who do not keep up with the research, by those who do not keep up their skills at the infrequent procedures that require skills maintenance.

I used to work in a trauma center. I still transport patients to trauma centers. If there is anything that requires special attention (family coming from out of town, translation, . . . ) I try to make contact with the social worker before I leave. They are easy to spot. They are standing in the background, staying out of everyone's way, and remaining attentive to the people, rather than the procedures.

Hospice, palliative care, and social workers contribute to patient care in much more than hand holding and turning up the opioid dosage.

Sometimes it the simple stuff, like knowing that a regular DNR is not valid for EMS in Pennsylvania. Only a Prehospital DNR may be honored without first contacting medical command for permission to stop CPR - not withhold CPR. While contacting medical command, EMS is supposed to initiate CPR on this patient with a valid DNR, unless that DNR is a Prehospital DNR.

I have seen very few Prehospital DNRs. I have seen many advance directives that EMS is not permitted to honor (without medical command permission to stop CPR), even though they are valid legal documents.

How many people in EMS will actually call medical command for permission to honor a non-prehospital DNR? Even if they do, will they be violating the DNR by performing CPR, so they do not violate state EMS rules?

Maybe you were aware of that, but it does not appear to be common knowledge among those writing DNRs.

That is just one example of specialized knowledge. This should not be seen as any kind of attack on primary care.

Palliative care deserves to be its own specialty because the patients deserve that level of specialization.

 
At Thu Mar 25, 01:19:00 AM, Blogger Christian Sinclair, MD said...

A lot of great reading in these comments. i just want to thank all of the people who commented in support of hospice and palliative care.

I also want to thank #1 Dinosaur for even blogging on the subject since it drew out a lot of great commentary!

 
At Sun Mar 28, 04:59:00 AM, Anonymous Anonymous said...

My total experience with this was a last year medical school elective in Palliative. Not all of the physicians were boarded in it (internists and FPs).

To my eyes, the difference wasn't in the medicine or communication. It was in the details of practice - their day was scheduled differently and they were used to dealing with different agencies: Medicare's hospice stuff, religious agencies, hospices.

Once they were working exclusively as "palliative care" docs, their day consisted of home visits and hospice rounds. The difference was that they weren't working out of an office and that they had a lot of flexibility, and worked mostly out of their cars, did long visits, etc. It seems like once you're doing that, you can get away from office practice and work in a very different style. It's not necessarily the medicine that is so different.

 
At Wed Mar 31, 03:01:00 PM, Blogger Ab Brody, RN, PhD, GNP-BC said...

There are several strands of information flowing through the main blog article. I will try to bring them together using my experience as a geriatric nurse practitioner who provides home based geriatric primary care.

1. Primary Care Providers should be performing many of the services a palliative care provider does.

This is true, however, PCPs are no longer able to perform these conversations in advance of an illness event and hospitalization occurring. In order for a PCP to perform the intensive discussion of finding out a patient's wishes in various situations takes time. Medicare in particular, and private insurance as well, do not provide adequate reimbursement for these lengthy conversations and thus PCPs either have to eat into their own margins to have them or just don't do it at all. It is unfortunate and not the fault of the PCP but of the system they work in.

2. Palliative Care is work that can be performed by PCPs.

To some extent I agree. PCPs should be able to handle straight forward symptom and advanced illness management and goals of care discussions. However, to many PCPs do not do a good job of this (and I include my own prior bedside nursing experience, having seen how some family members and friends have received poor treatment, and discussions with many other professionals including PCPs). Some PCPs don't even have access to special prescription pads for schedule 2 narcotics!

Lack of competency where there should be aside, the most complex cases do require specialized care in order to alleviate symptoms and perform conflict resolution/goals of care discussions, and this is where palliative care should be focusing.

Additionally, many palliative care programs are interdisciplinary, and this allows for better care and patient satisfaction. PCPs just are not setup nor compensated to have IDTs.

3. Not a major point, but you do not need to be a hospice provider to call in a schedule II prescription in california. If a patient is terminal, then a terminal exception is applied. The California DPHS states:

"According to Health and Safety Code section 11159.2, physicians who write prescriptions for Schedule II drugs for terminally ill patients are not subject to Health and Safety Code section 11164, which pertains to the execution and contents of prescriptions for Schedule II-V drugs. These prescriptions must indicate that the prescribing physician has certified that the patient is terminally ill by using the words "11159.2 exemption," and can be written on an ordinary prescription form."

I have never had a problem calling in an RX under the terminal exception.

4. In conclusion, the system is not setup to allow PCPs to perform many of the functions that palliative care teams are now performing. While they CAN perform many of them, the reimbursement structure makes it very difficult to.

 
At Tue Apr 06, 10:26:00 PM, Anonymous Anonymous said...

Dino:
I do find it curious that you flame a field yet you don't even manage your own patients in the hospital. I find it rather appalling that you make a smarmy comment like "It's called Primary Care for a reason. It comes first. And it's what I do." Yet are absent when you own patients need you the most...in the hospital. Am I to conclude you get on your high-horse and pontificate when the time is convenient for you? Do you understand the word hypocrite? Care to elaborate?

 
At Thu Apr 15, 07:38:00 AM, Anonymous Hospice CA said...

It is a good summarize and point to point document for the viewers also give some other points related to the palliative care.Thanks

 

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