Armed with the belief that as our population ages there will be a continued and growing need for palliative medicine physicians, there is concern that fellowship programs will not be able to keep up. An article in the Journal of Pain and Symptom Management (one of the main palliative medicine journals) tries to quantify the projected need to help guide discussions going forward.
statistics
Palliative care teams typically include physicians, nurses, social workers and chaplains. Only about 2/3 of palliative programs have physician members, and a large number of hospital based teams are nurse or social worker driven. While there are questions about the optimal provider mix, physician presence is critical (my bias).
Current studies show a large unmet need for palliative medicine services for the in-patient, hospitalized population. Approximately 3% of hospitalized patients meet with palliative care teams. But rough estimates show that 13% of patients admitted to the intensive care units, 33% of hospitalized oncology patients, and a vast number of hospitalized patients with kidney disease and other chronic conditions (heart failure, copd) would benefit from palliative care input. This demonstrates a large unmet need for palliative services.
The author’s calculate a conservative estimate of the need for HPM physicians as increasing from the current ~6400 physicians to 10,604 by 2040; a more ambitious modeling projects a need of 23,916 physicians. This is a large number of physicians especially given that current fellowship programs graduate ~325/year.
While I can’t intelligently comment on the author’s methods for coming up with these estimates, two concerns immediately come to mind, which compels me to add my two cents to the discussion.
Where are we going to get these physicians?
At what price are we training up more HPM docs?
One potential fix,
is for recent retirees to seek additional training and return to the medical workforce as palliative providers. I don’t know of specific statistics, but in my immediate world, I’m seeing a bunch of physicians in their late 50’s/early 60’s retiring early from practice. They are still quite vibrant, mentally intact, but psychologically tired. Tired of feeling like they are serving the EMR instead of their patients. Tired of feeling like a technician and not a physician. Basically they still enjoy patient care, but are worn down by the burdens of our current health care delivery system. And in fact, a number of palliative medicine fellows are mid-career physicians. So shifting to palliative medicine is a unique opportunity for keeping experienced physicians from a variety of specialties (not all are primary care providers) in clinical medicine.
This is a good thing.
But it’s not nearly enough to meet the purported need.
Good news (?)
I am meeting some amazing young people, who very early on (even when just considering medical school) are expressing interest in going into palliative medicine. And I had the privilege of working in a palliative medicine fellowship training program and worked with dedicated- fresh from residency- primary care physicians, planning to go into palliative medicine.
So while it’s terrific to see that people early in their careers are understanding the importance of this specialty …
I want to yell noooooooooooo!, because it breaks my heart to see these wonderful/enthusiastic physicians being siphoned away from primary care. These are the exact providers we (the US healthcare system as a whole) need to stay in general practice where they can bring their understanding of the importance of holistic patient care to a wider number of patients than an individual palliative physician will ever do.
The true fix
Buried in the discussion section of this article is a bland, easily overlooked sentence that led to no additional discussion:
“…the need for continued honing of generalist (palliative medicine) skills and knowledge should not be overlooked”.
My belief is that this is the true take-home message from this article.
And it goes back to my bias that improving communication skills of all providers- would go a long way to improving overall health care delivery and to improving the general outlook of US physicians (all medical providers really). While there is a definite need for specialist palliative medicine physicians, the most effective way to meet the expected need for more palliative providers is to train ALL providers in primary palliative care. These basics/constructs need to be integrated in the everyday practice of medicine no matter the specialty, period.
This requires that communication training and basic symptom management skills be prioritized in medical schools and residency programs. A couple of didactic lectures or an elective course offering is not sufficient; this training must be incorporated into all aspects of medical education.
This will allow all trainees to see how they can use these skills as part of their everyday practice- and this applies to all providers, both primary care physicians and specialists.
I am convinced that all patients and providers as well as our healthcare system as a whole will be the better for it.
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