Yesterday, September 19, 2006 the American Board of Medical Specialties (ABMS) voted unanimously to establish a new medical subspecialty of Hospice and Palliative Medicine. This action follows similar approval on June 26 of this year by the American College of Graduate Medical Education (ACGME).What does this mean? At the simplest level, this new medical subspecialty now has the same formal status as, say, Cardiology or Oncology. In my opinion, this is to be celebrated. Subspecialty status has both symbolic and practical importance. Symbolically, such status represents legitimacy within the world of traditional medicine. This buys us a “seat at the table.” Practically speaking, subspecialty status will open up new funding streams for training and research that were previously unavailable. For example, Medicare dollars may be used to support fellowship training in palliative medicine. Hopefully, we will see rapid growth in the number and quality of palliative care programs in our country.
Good news though this may be, the potential ramifications for the broader social movement of hospice and palliative care in the United States are complex and worthy of consideration. Is this just a big deal for physicians or might it have deeper implications for other disciplines and for the broader hospice and palliative care movement?
In considering the possibility of subspecialty status, physician leaders in palliative care have recognized the obvious advantages such status brings. However, many have also worried about potential downsides. Does legitimization mean “co-opting the revolution,” to borrow a now antiquated phrase, - denying the history of hospice? Put bluntly, is subspecialty status a “sell-out” to the system? Personally, while I think there is a risk that we will forget our roots, I also think the risk is worth it. I may be wrong, but in this case I think we have a better chance of changing the system if we are part of the system. (Foolish optimism on my part, perhaps.) A second question that has arisen is, ‘In creating a subspecialty, does this mean we are saying that only those physicians certified by board examinations can practice palliative care.’ Put another way, does this mean we are creating a “monopoly on suffering?” Hopefully, the answer to this is, no. As I argued in a recent editorial, (Hallenbeck, J. Palliative Care Training for the Generalist – A luxury or a necessity. J. Gen. Int. Med. 2006; 21(9):1005-6.) I think most palliative care can and should be done by non-specialists. Palliative care must be woven into the overall fabric of Medicine. However, I also believe there is a role for the specialist in particularly difficult cases. Equally or more important, specialists can and must serve as educators, researchers, and leaders, who can ‘work the system’ for broader, lasting change.
So, if I am cautiously optimistic, as I am, what is there to worry about? I am worried that what has been to date a relatively united movement directed toward improving care for the sick and the dying will become fractured. With subspecialty status new associations of largely hospital-based palliative programs are inevitable. The question is – will the movement continue as the “hospice and palliative care movement” or will this development force a schism between hospice and palliative care? There are grounds for concern. State and national hospice organizations have generally added “and palliative care” to their titles, but are they really taking palliative care seriously? Are they recruiting and supporting palliative care programs into their organizations or are these really hospice organizations with the addition of “and palliative care” as a politically correct, pro-forma act? On the flip side, some in palliative care look to be at risk of forgetting that science without art, without soul, is just technique and ultimately sterile. In my opinion while some differentiation between hospice and palliative care is inevitable, even desirable, hospice and palliative care still need each other. The world of hospice needs the improved knowledge, skills, and access that palliative care will bring. The world of palliative care needs hospice as a system of care for the dying, but also as a keeper of a treasured legacy – that whatever this work we do is all about it must not be narrowly and solely defined in terms of medical practice. Our work must be conducted in clear awareness that is this is just one service among many in which people strive to help other people.
So, while I have some concern, this is a time for celebration and, when in doubt, we should be optimistic! I’m optimistic that subspecialty status will mean that:
· we will learn better ways to alleviate suffering
· that we will have more and better-trained clinicians able to alleviate suffering
· new programs and organizations will evolve that will enable us to provide this better care
· we will have improved access to the tens of thousand of Americans, who currently suffer unnecessarily because palliative care (and in turn) hospice are not available or even considered as options
· the overall quality of care we deliver will improve
And that strikes me as a very good thing
Happy Birthday!
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