Posted by: notdeaddinosaur | 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.)


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