I make my way down the aisle of the plane, squeezing past my fellow passengers and plop down in my assigned seat. Sitting next to me is a middle-aged woman with a kind smile. As the plane takes off, she begins making small talk. "What do you do?" I silently debate: do I adopt my travel persona or answer truthfully? Answering honestly will result in one of two things: either we will continue our trip in an awkward silence or my fellow passenger will begin sharing her very personal stories. "I’m a physician," I respond and hope the conversation will turn to the weather. "Oh! What area do you work in?" A deep breath, "I work in hospice and palliative medicine." Crickets………"Oh wow, isn’t that sad? How do you do it? You must be an angel." I smile.
Yes, we are faced with suffering, illness, and death; however, we are also faced with light, with healing, and with the chance to make an actual difference in the lives of our patients and their families every single day. It is rare to find a field in medicine that incorporates the physical, the pathophysiological, the spiritual, and the social in the everyday care of our community. Modern medicine has become a bastion of technology, of life-saving innovation, of efficient care but unfortunately, as I peruse social media I often see blogs and articles, Facebook posts and comments from practicing physicians lamenting the increasing restrictions on their ability to provide the appropriate care for their patients. In a recent Medicare survey, only 50% of physicians were satisfied with their chosen profession and, strikingly, the majority of internists and family medicine physicians would now choose a different specialty. Primary care physicians are expected to coordinate the care of an increasingly fractionated health care system while being accountable for innumerous quality measures (from insurance payers) which may or may not be applicable to their practice, and simultaneously cater to a consumer-driven model of patient satisfaction where patient surveys and comments are posted online. It is easy to see why many primary care physicians are seeking nonclinical jobs or leaving medicine altogether.
Many of us who went into medicine, especially those who chose primary care in the form of internal medicine, family medicine, pediatrics, or geriatric medicine, did so because we believe in the importance of a longitudinal relationship with our patients. We value the story that accompanies each person walking into our office. The advancements in our health care allow us to fix heart valves without even cutting the chest. We can provide chemotherapy which targets gene mutations to allow for decreased toxicities and improved responses. But along with these gains, we have lost something. Now, as physicians, we have to fight to maintain those therapeutic relationships with our patients. Shifting insurances: "your doctor is no longer in network, sorry," pressures for efficiency: "you only have 10 minutes to review these 25 problems, sorry," a waiting room full of patients to maintain quotas: "I don’t have time to hear your story, sorry," and payment incentives that historically favored "doing" rather than "thinking" have all contributed to the fracturing of primary care.
Hospice and palliative care bring back into focus the importance of relationships, the dialogue and understanding among our patients, their families, and the physician. As a hospice physician, I can bear witness to the messy, beautiful, ugly, painful, healing truth of human nature. It is rare we are allowed to see beneath all the layers of shrouds we protect ourselves under. It is hard to witness grief and loss but we are grateful to be there when those we care for are scared and in need. This is the foundation on which medicine was built. We are not going backward but, rather, reclaiming what has been lost. Humans are unique and complex medically, socially, and emotionally and often cannot be cared for by one physician alone, and certainly not in a 15-minute visit. This is why hospice work is so fulfilling. A team comprised of nurses, social workers, chaplains, aides, therapists, nurse practitioners, physicians, and the patient and family lean on each other’s strengths to provide support and care. So much of what is needed is not strictly medical, and I would argue that this is often true in nonhospice patients as well. There is so much more that goes into achieving well-being, which should be the ultimate goal of medicine, though this often gets overlooked. We in the hospice world understand that people can be healed even when there is no cure available.
--Dr. Laura P., chief medical officer