“I do not hand over my patients when they are enrolled in a hospice. This is one of the most important times to reinforce the doctor/patient relationship.”

Since palliative care is considered a specialty with a fellowship/board certification I would not consider it “imagined”.

My experience as an oncologist:
Most primary care docs do not wish, or cannot afford to manage palliative/hospice care. Not a knock, just a fact. I or one of the palliative care docs end up managing end of life issues in this setting. I am sorry that is the reality of the situation.

If the AMA could add a code for “saying goodbye to a dying patient,” then patients can decide if they want doctors involved in their deaths. Perhaps the AMA could write a code for “being nice to patient during a crisis.” I know my insurance company doesn’t pay doctors enough to really care about the person that I am.

Ultimately, my relationship to my doctor is just a business relationship. I wouldn’t expect the guy that does my oil changes for my car to send my family a card.

I think context is important. Many of these primary care physicians are struggling just to keep their heads above water, from the business perspective. So what, to you, seems callous, is in fact a required consideration for anyone who is running a business.

I am often surprised at just how attached patients become to me – even inappropriately. I am a neurologist, but I had a patient wait 1 week to see me (not her primary care doc) in order that I could address her leg pain after a fall (she had a fractured hip!). I have sent patients to specialized epilepsy centers, because I needed help managing difficult to control seizures. They would not take the specialized center’s advice until they spoke with me first. I have fit patients into the clinic due to urgent situations, having them see my physician’s assistant, only to have them complain that they wanted to see only me.

The truth is, every patient wants their familiar physician to do things for them, in many, many contexts. In some cases, we don’t have the expertise. In other cases, we don’t have the time. Certainly there are concierge physicians, who charge a yearly fee to keep their business solvent, who CAN offer a lot more – but again, there is a bottom line to satisfy. If your small business closes, none of your patients will be getting any of your services.

How about doing something just for the simple reason that it is the right thing to do.

I reiterate for Kevin that we are not reimbursed for unanticipated phone calls and for signing reports. Yes, there is a billing code that can be submitted on a monthly basis for the DOCUMENTED interactions (how many of you document the 10-200 orders for prescriptions, equipment, tests signed in between office visits, in an average day); however, I have chosen not to compound my biller’s misery by forcing her to learn to do this the sporadic three times per year. As if Medicare doesn’t already provide enough monthly misery on her lap with arcane regulations. Additionally, which one of you is going aggressively bill from the get-go – the average hospice stay is 13 days (a topic of its own), far short of that first month of services needed to complete a billing cycle.

For my part, I would rather the spouse remember the care I gave his beloved by the personalized note and phone call I give after their spouse has gone to their final resting place, than by the bill/EOB they receive for my invisible services (albeit, that help to keep things running as they already should).

True, there are many physicians that are uncomfortable with this and may choose not to do it.

True, a palliative care specialist may be appropriate for a setting such as an inpatient hospice.

However, palliative care should be part of the basic training for all family physicians and internists.

We are always being told things we cannot, or should not do. First, obstetrics, then hospital medicine (let the specialized “hospitalists” do it) and now palliative care.

I do not hand over my patients when they are enrolled in a hospice. This is one of the most important times to reinforce the doctor/patient relationship.

The more we give up on this, the less we do, the less we are valued and the more easily we will be replaced by mid-levels.

I implore you, my fellow primary care physicinas, to stop cutting back on the scope of services you provide.

A family practitioner