Why aren’t all primary care doctors palliative care practitioners?

I wouldn’t call myself a palliative care expert.  I kind of happened into the job.  The nursing home had a need, and the local hospice/palliative care program didn’t have the available staff.  I had always been good at handling end of life and pain issues, so I stepped up.  Of course, there are finer points that I could have learned in a fellowship program.  I don’t want to pretend that my qualifications are anything other than what they are.

But one must beg the question.  Why aren’t all internists and family physicians palliative care practitioners?  Don’t we strive each day to alleviate the pain and suffering that walks into our exam rooms?  Does it matter whether the cause is a broken arm or a metastatic cancer?  And since when do we farm out end of life discussions to someone else?  Someone who likely doesn’t have a longstanding preexisting relationship the way we do.

Primary care has become a conveyor belt.  We are no longer the chief operating officers.  We have become chief test orderers, chief prescription writers, and chief specialist consulters.

I don’t think this is the way we planned it.  We never wanted to hand over our autonomy.  But difficult things take time.  Overrun by an ever decreasing portion of the financial pot, and consumed with the moment to moment needs of documentation, most PCPs learn to survive by increasing throughput.  Skimp.  Delegate.  Move’em in and move’em out.

We let someone else handle the time consuming difficult conversations because we couldn’t afford to do it ourselves anymore.

So what is the most important job of a palliative care specialist?  In my opinion, it’s spending time with patients and families.  Real time, where long drawn out conversations take place on ethereal topics such as quality of life, individual choices, and plans for the future.

And of course we also talk about management of pain.

I tell my patients that they have other doctors to worry about their heart failure, cancer, and COPD.  I come to discuss their hopes and fears.

I have no other interest than their well being, regardless of our health care system’s current state of disease.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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  • http://twitter.com/shihjay2 Michael Chen

    Thank you, Jordan, for your thoughts. I think your words speak to the true value of primary care physicians, many of whom are silenced, minimized, delegated away, or thrown out because the current (or mainstream) system has apparently found no use for us. And when patients have nowhere else to go, but to go back to their primary care physician for their healing because no level of specialty care has met their satisfaction, our work and our knowledge as healers continues to be undervalued. We, as a group, must speak out or take action about the atrocities happening to our profession.

  • buzzkillersmith

    If you pay them, they will come.

  • http://www.facebook.com/claudia.herbei Claudia Herbei

    As a specialist (nephrologist) I see things in a different light. The PCP is never around when the patients are in the hospital. Hospitals are run by hospitalists these days, who have no relationship with the patients, nor do they desire one. They are under tremendous pressure to discharge the patients, home, to a SNF, to hospice, wherever, but just not have them in the hospital any more. They see the patients at their worst, after they just had a heart attack, a TIA, a bad infection, etc; the easiest and most logical thing for them is to call a palliative care consult. I find myself frequently the only one with a real relationship with the patient and their families, the only one with a bit of insight into their lives outside of the acute illness. It is a sad state of affairs.

    • ninguem

      Claudia, you know full well there’s a reason why the FP’s are no longer there.

      They were pushed out.

      It
      was the specialists who did it. You know that. FP’s are the lowest paid
      of the medical specialties. Every single thing they try to do in the
      hospital…….EVERYTHING…….got
      taken away from them. They’re not competent to do any ICU work, not
      competent to read EKG’s, work in the nursery, work in the OR, deliver
      babies, on and on and on…….

      So they left. They rearranged their lives to make up for what they got TAKEN AWAY FROM THEM.

      AND THEN THEY’RE BLAMED FOR THE CURRENT STATE OF AFFAIRS.

      “It’s not about money, it’s about patient care.” ……yeah right……..

      Having
      been pushed out of the hospital……meaning with nothing meaningful do
      do except do H+P’s on street people for free, can’t do anything unless
      you’re an “-ologist” in that field, I rearranged my life.

      Now I
      take call by cell phone, whether in Boston or LA or Seattle. My office
      hours increased, I break even economically, and have decided I like it
      this way.

      But remember, I did not go looking for this, I was pushed.

      Multiply my story by ten, twenty thousand or more.

      Oh,
      and the hospitalist group at my hospital, called me last week, they
      want me to pick up shifts, lacking people to cover the hospital
      adequately. They want me to do more hospital work.

      Not just no…..hell no.

      • http://www.facebook.com/claudia.herbei Claudia Herbei

        I am not blaming the FPs, I don’t think that is what transpires through my comment; I know you were pushed out, but not by specialists, by hospital administrators. If you were to take shifts in the hospital, you’d see that the hospitalists are not acting like the doctors of 10-15 years ago; they have different priorities and they answer to different people. I have seen quite a few of them ‘fired’ for not following the hospital guidelines on discharge and for speaking their mind when they were supposed to shut up. Pretty soon all the hospitals will hire PCPs and specialists to have even more control. It is part of what corporate medicine is becoming. I think the train left the station and it’s not coming back. Just try to stay healthy!

        • ninguem

          I know it’s not you personally. Many FP’s have learned to LIKE not being hospital-bound, and I’m one of them.

          I’ll disagree only on the specialist thing. They had plenty to do with the removal of FP’s from hospital work. Many a time the specialists initiated the action…….agreed the administration was more than happy to help. I mean, I was at the meetings. I have a “show the experience and the interest, accept the scut with the gravy, then join the fun” mentality, but was outvoted by those with the “ologist” mentality.

          If the stethoscope were invented today, with a code for using it, there would be “stethoscopologists” you’d have to consult to listen to the heart.

          And when the hospital hires the PCP, by the way………the fees go UP. The hospitals have ways to tack on fees that private physicians cannot do.

          See the Wall Street Journal article last August.

          http://online.wsj.com/article/SB10000872396390443713704577601113671007448.html

          By ANNA WILDE MATHEWS August 27, 2012

          “Same Doctor Visit, Double the Cost”

          Insurers Say Rates Can Surge After Hospitals Buy Private Physician Practices; Medicare Spending Rises, Too

          Contrary to the vocalizations of some pseudo-experts on this site, when hospitals take over physician practices, they are neither more efficient, nor better managers, they just charge more. They can get away with it.

          I could have told anyone that years ago, but the insurance companies are starting to recognize it as well.

  • http://www.facebook.com/Jodimelbinknapp Jodi Knapp

    Here are some views from hospitalists who struggle with the palliative care certification issue as well. http://bit.ly/palliativecertification. “On-the-job training and experience may have to be enough in some cases.”

  • http://www.facebook.com/people/Susan-Mazer-Smith/1616100041 Susan Mazer Smith

    Jordan, your thoughts and descriptions are lived out daily…not only with physicians, but with their patients and families. We would all rather discuss these issues with someone who really knows us, who we trust, and with whom we can share our deepest concerns. Yes, we have “out-sourced” our relationships in the name of efficiency. I encourage you to actively join in with Palliative Care and Hospice nurses to change the discussion. Be the activist you already are…with those who are most often talking to each other….

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