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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