TAFP PERSPECTIVE

No pain, no gain?

Family physicians practice palliative care day in and day out

By Ronald J. Crossno, M.D., C.M.D., F.A.A.F.P

I’ve been a family physician for 20 years. Never having heard of palliative care for the first eight of those years, I was surprised to learn I had routinely been incorporating it into my practice. I was enlightened by a hospice nurse, who had her administrator sign me up to become a hospice medical director. Since then, I have been formally and increasingly involved in palliative care, such that for the last two years, it has been my full-time practice.

The World Health Organization refined its definition of palliative care in 2002: “Palliative care is an approach which improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

This should ring familiar to family physicians. The unit of care is patient and family. A key component is prevention. The approach is holistic, not limited to just the physical. Perhaps the most defining characteristic is relief of suffering, something most of us have had to learn on the fly. Of note, palliative care now includes any life-threatening condition. Why limit relief of suffering to just those at the end of life? Palliative care includes the entire spectrum with hospice being that end-of-life subset for patients with terminal conditions.

The U.S. Congress has declared 2001 to 2010 the “Decade of Pain Management and Research.” Advances in the field have demonstrated the fallacy of “no pain, no gain.” Unrelieved suffering, of whatever type, has detrimental physiological effects that over time become difficult or impossible to reverse. Besides the inhumanity of failing to relieve discomfort when possible, the consequences of unrelieved suffering include an array of outcomes such as neurobiological remodeling (a cause of chronic pain), development of secondary conditions, and shortened life span.

Palliative medicine has undergone tremendous expansion over the last two decades. It is now a widely recognized specialty, soon to achieve formal recognition by the American Board of Medical Specialties. The majority of palliatists begin as family physicians or internists, though uniquely, any other specialty may lead into palliative medicine. As with other specialties, centers of excellence have come into being. Full-time practitioners are putting their knowledge in practice. But primary care physicians provide the bulk of the palliative care delivered in this country. As in the other specialties, this stratification can be classified as primary (part-time as part of their other normal practice), secondary (full-timers practicing only palliative medicine), and tertiary (researchers and specialized experts in various sub-fields of palliative medicine).

My point is not to recruit new full-time palliatists, but to ensure that each family physician realizes that he or she practices primary palliative care and should be competent in doing so. Family medicine has staked its claim on care of the patient and family from birth to death. Until recently, formal training about the end of that spectrum has received short shrift, especially in comparison to the time spent on the beginning. Family medicine residents spend months in obstetrical training, when only a minority continues obstetrics into private practice. Conversely, almost all family physicians will care for patients with life-threatening conditions, but virtually no training is dedicated to symptom management or end-of-life comfort care.

Half-jokingly, I recently asked my son, who just began his third year of residency, when he was going to take his palliative care rotation. His response was that he saw palliative care almost every day on the wards, so why take a separate course? Trying to answer that question was the initial impetus for writing this article.

Physicians-in-training rotate through, for example, pediatrics, obstetrics and cardiology, in order to optimize their understanding of those fields. So the answer to my son’s question is also a challenge to all primary care residencies: ensure competency in the provision of palliative care. Residents should spend dedicated time in palliative care rotations in order to become competent primary palliatists. For family physicians already in practice, there are resources to help attain such competency, such as the American Medical Association’s Education for Physicians on End-of-life Care (EPEC) curriculum.

The 16th century anonymous sage said of physicians, “To cure sometimes, to relieve often and to comfort always, this is our work.” There is another saying by those in the hospice field, “The mortality rate in the U.S. is still 100 percent.” The point is that everyone will eventually need comfort care. Competency in palliative care is not optional; it is a requisite.