The ABMS, the ABHPM, and the future of a specialty

Abstract

hospice and palliative care learned their craft on the job; opportunities for full-time employment were rare, and formal postgraduate education was nonexistent. Common wisdom held that the average medical student received approximately six hours of education in end-of-life issues (implying that half the students received even less). Hospice nurses are, in some areas, the most independent practitioners in the whole field of nursing; they are often faced with a “do whatever and I’ll sign it” attitude by doctors whose fund of knowledge in basic symptom control is sorely lacking. Nurses have learned to practice without the input of knowledgeable physicians for the most part, but this freedom tends to be as frightening as it is liberating. Endof-life care, as all care, should be practiced within a team model. When one member of the team is missing, the game will often be lost (to stretch the metaphor). Primary care physicians are not really to blame for this situation, any more than high school students who graduate without learning to read should be blamed if no one notices or remedies the problem. Of course, the world is no longer quite so bleak. Medical schools, for the most part, are adding mandatory contact hours in end-of-life care, and elective rotations in hospice or palliative care are increasing. The number of full-time jobs for hospice medical directors is also increasing as hospice finally reaches the far corners of our country, and hospitals and cancer centers are sprouting palliative care services like spring flowers. This begs the question, however: who will fill these new positions? In my talks across the country, I have always asserted that symptom control and end-of-life care should be an integral part of every primary-care practice. I often half-heartedly joke that our goal should be to make physicians such as myself obsolete—as long as we wait until I retire to do it. As our specialty progresses and becomes more evidence-based, and as it becomes more technically advanced, with tricky opioid rotation schedules and highly evolved procedures, I realize that my dream of a specialty-free world of primary care physicians practicing state-of-the art palliative care is untenable. However, the current milieu is unacceptable as well, and so a compromise must be found. Consider cardiology; this is an essential subspecialty of internal medicine that practices a remarkably advanced form of medicine, with rapidly advancing research and technology. Most primary care physicians refer to cardiologists readily, but they don’t do so in a vacuum. Before graduation, internists and family practitioners have had intensive training in the diagnosis and treatment of circulatory disorders and are quite comfortable treating congestive heart failure, hypertension, and other common maladies. If the relationship between primary care and cardiology was analogous to that of primary care and