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.

Tuesday, April 13, 2010

More on Palliative Care: Be Careful What You Wish For

My previous post has generated a gratifyingly large response that has been remarkably civil, for the blogosphere. I half-anticipated commentary along the lines of, "Dino, you ignorant slut," which is par for the course on the internet, and frankly, half the fun, given that none of it (for the most part) is intended or taken personally. In fact, it can be quite amusing to watch the fur fly publicly while exchanging warmly professional emails behind the scenes.

The major thrust of several comments was along the lines of, "Sure, it would be nice if all Primary Care docs could do palliative care, but with the current payment system, they just can't manage it." That's straight out of the 10th Law of the Dinosaur, "A bad idea held by many people for a long time is still a bad idea." The system is stacked against us, so we shouldn't even try? Sorry; I refuse to give up that easily.

Medicare and other payment systems have a provision for time-based billing. When more than half of the face-to-face time is spent counseling the patient, reviewing treatment options, etc. then the total time spent in the encounter can be used as the determining factor for payment. News flash: the topics discussed are NOT REGULATED. "Death panels" (ie, the proposed payment once every five years to discuss end of life issues) aside, I can and do (and always have) bill specifically for those visits.

The point was also made that although Family physicians could provide these services, too many of them don't. Point made; shame on them.

The whole "team" concept is also a red herring. I utilize all kinds of other professionals to care for my patients. I regularly call upon psychologists, visiting nurses, social workers, chaplains, and others for their help and expertise. Calling us a "team" is nothing but a semantic boost to the morale of professionals insecure in their role in patient care. Perhaps in the highly hierarchical hospital setting where contemptuous physician attitudes may be more on display, enforcement of the Team concept, complete with meetings and name tags, may seem useful. But out here in the real world, I able to communicate extensively with my non-physician colleagues -- including how much I value their expertise --without wasting their valuable time with "team meetings."

The real issue is the "Specialist" label. While not denying that the increasing body of knowledge about the relief of symptoms and management of patient care at the end of life may warrant specialty status, what are the actual advantages to patients of this further fragmentation of medical care? In fact, a recent article in the New York Times (discussed here and here) seems to point out the enormous disadvantage of palliative care physicians' proud assertion that they love to care for dying patients: if that's what they do, then a referral must mean the patient is dying!

Added to this is the American obsession with "the best;" the newest, the shiniest, the most expensive must be somehow "better." Better than what? Why is the concept of "good enough" so difficult to grasp? Although the fellow who places last in medical school is still called "Doctor," there are hundreds of fully qualified students for every spot. I firmly believe that grading medical students (and residents, for that matter) on any basis other than pass-fail is meaningless for that very reason.

Once you set Palliative Care up as a "Specialty," complete with board certification and all its administrative falderal, you are presenting to the public that you are the only ones qualified to provide this care. After all, if you're Board Certified in Palliative Care, the care you provide must by definition be "better" than that provided by someone not so accredited. It's similar to the unfortunate perception that only a cardiologist can manage high blood pressure, you need a pulmonologist to care for asthma, and you must be getting suboptimal care for diabetes if you don't see an endocrinologist.

How much more compassionate might care be at the end of life if, instead of being seen as yet another distinct specialty, palliative care were viewed as a vital, integral part of primary care. There would be no shifting of emphasis from "curative" to "just" comfort care, because symptom relief would be part and parcel of all phases of treatment. And who best to care for people at the end of their lives than those who have cared for them through the rest of it?

I do believe that self-designated Palliative Care Specialists should have important roles in academic and consultant capacities. Rather than a knee-jerk "referral to palliative care" when the going gets tough and the end may be approaching, I'd love to see primary care physicians in the forefront of caring for these patients, with consultant backup from our Palliative Care colleagues. Recently having dived into the archives at Pallimed, I've developed a new appreciation for the academic study of death and dying. But I still don't think Palliative Care needs to be an independent specialty.


At Tue Apr 13, 08:25:00 PM, Anonymous Anonymous said...

As an FP in the same town for a long time, when someone has a terminal condition, I have done one or more of the following: diagnosed their condition, seen them in the hospital during their surgeries, seen them during their chemo side effects (funny how the oncologist isn't ever around when they have a neutropenic fever on the weekend), and talked to them or family members about hospice. Why should I abandon them to a "specialist" just when they are needing me the most?

At Wed Apr 14, 07:57:00 AM, Anonymous Craig said...

Please get used to using the term "limited specialist" when you are referring to non-primary care doctors. You are a Board certified family physician which makes you a specialist, too.

At Sat Apr 17, 03:45:00 PM, Blogger Michael Kirsch, M.D. said...

I agree with you, even though I am one of those myopic GI specialists who view patients through 'tunnel vision'. Part of the problem you outline is fueled by primary care physicians who consult us and other specialists reflexively, rather than handle the clinical issue themselves. If I saw only the GI consults that required specialty training, then I would be out of work and would be standing on the corner holding up a sign stating, 'Will Do Colonoscopy for Food'. If FPs and other primary care physicians want to protect their turf, then they need to recapture it.

At Sun Apr 18, 01:53:00 PM, Anonymous Anonymous said...

You thread is all well and good on a theoretical basis, but the simple fact is you yourself break you own rule #10 and here's why. A large percentage of palliative care consults are initiated in the hospital after a dire presentation/diagnosis or an acute exacerbation/worsening picture of a chronic medical condition. For the PCP to be in charge of this situation from a palliative care standpont very simply, they have to see these patients in the hospital...period. IMO a large percentage of PCP's (yourself included) have abdicated their inpatient responsibilities for their patients. Don't get me wrong, I understand why, but you can't manage these patients from initiation of a palliative care standpoint from you weekly clinic. You have to go see these patients in the hospital. Until you actually decide to take this upon yourself, your argument is really rather meaningless. Additionally and sadly alot of PCP's (all doctors for that matter INCLUDING ONCOLOGISTS) are not that great at palliative care. Our training at the medical school level and residency level is still rather poor though much better than 10 years ago. Do you realize European countries require hundreds of hours of training in pallaitive care where we still have no real requirement? I still commonly see inappropriate narcotic conversion and underdosing of patients by docs who are afraid of the doses used without really looking at goals and hence leave their patients in pain.
Even as an oncologist I consult palliative care, especially when the patient may not clearly understand the implications of their diagnosis or our goals appear to be significantly different. I am sorry dino but you want to do palliative care, well then you need to be available to the patient in the hospital when they need you to do palliative care. This just is not just an outpatient clinic experience.
PS: To anon FP: I and my partners admit all of our own neutropenic fevers. For every anecdote about oncologists I can give you one about PCP's who have completely disappeared from the patient's care after the cancer diagnosis is made. What is you point?

At Mon Apr 14, 01:07:00 PM, Anonymous Kumail Arora said...

“Limited specialists” a good term suggestion….. Hey Craig; am agreeing with you…



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