Palliative Medicine as a subspecialty: What's the impact?

Now that palliative medicine is becoming a formal subspecialty of medicine, I would like to see some discussion on how that could change the structure of hospice and palliative care services in the future. What are the practical implications of subspecialty status for your program?

James Hallenbeck MD just did an editorial titled "Palliative Care Training for the Generalist A Luxury or A Necessity?" (J Gen Intern Med; Sep 2006) that poses some framing questions. I expect that Jim will be blogging on these issues in the future, but I want to prime your pump by sharing with you some quotes from that editorial:

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The American College of Graduate Medical Education has just approved an accreditation process for palliative medicine fellowships and the American Board of Medical Specialties is likely to approve palliative medicine as a formal subspecialty later this year. What implications does this hold for generalists interested in palliative care? Clearly, significant overlaps in skill sets and interests exist between the disciplines.

Broadly speaking, management of chronic illness is largely "palliative" to the extent that it is not curative and focuses on helping patients to live with their illnesses. Leaders in Palliative Medicine, working to establish subspecialty status for the field, are acutely aware that most palliative care will and should be provided by nonspecialists. Why then, a subspecialty at all? Certainly, a subset of patients will benefit from care and consultation from physicians, who have chosen to acquire advanced-practice knowledge and skills at a subspecialist level. Equally or more important is the creation of a cadre of leaders, who will develop formal systems of palliative care, such as palliative care consultation teams, who will engage in palliative care research, and who will function as educators of other clinicians. Thus, somewhat paradoxically, one important goal of Palliative Medicine as a subspecialty is to disseminate palliative care throughout everyday practice.

The birth of this new subspecialty is to be celebrated. However, certain challenges are obvious. Where extensive overlap exists among disciplines both collaboration and competition are possible. Some generalists, particularly hospitalists, who are increasingly performing palliative care consultations, may feel threatened by subspecialty status. Eventually, it seems likely that only physicians board eligible/certified in palliative medicine will be credentialed to perform such consults, to the extent this work is recognized as requiring advanced-practice skills at the subspecialist level. Generalists devoting a significant portion of their work to palliative care may wish to consider studying for board certification in Palliative Medicine and becoming subspecialists. It is anticipated that a grandfathering period of approximately five years will be allowed, following formal approval of subspecialty status, wherein physicians may sit for board certification without formal fellowship training. Hopefully, in this evolving process a collegial and respectful relationship between generalists and palliative medicine specialists will be fostered. Subspecialty status for Palliative Medicine means that the field has come of age and represents a distinct body of knowledge and skills which require advanced-practice training. This should be respected. In turn, palliative medicine specialists need to respect the fact that the provision of palliative care is intrinsic to the role of the generalist and, as such should be encouraged and supported. More training of and partnering with General Internists, as admirably modeled in the PCEP program, would go a long way toward enhancing such mutual respect and improving the overall quality of care.

James Hallenbeck, MD, Stanford University, VA Palo Alto HCS, Palo Alto, CA.

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What are your thoughts on these issues? In particular, how will your program adapt to accomodate the new subspecialty?