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The Palliative Lens By Andrew Esch My 18 year old son recently applied for a secured credit card from his bank. For those unfamiliar with the concept, a secured credit card is essentially training wheels for credit. You deposit your own money with the bank, and that deposit becomes your credit limit. In my son’s case, he wanted to deposit $500. His credit limit would be $500. If he failed to pay his bill, the bank already had the money. This arrangement seemed about as risky

The Palliative Lens by Andrew Esch She is 37 years old. Metastatic ovarian cancer. Neuropathic pain that feels like someone poured gasoline into her feet and lit a match. She came to clinic with her dad. I don't remember everything about the medications we discussed that day. I don't remember the exact dose adjustments or the details of the plan. I remember her father. He sat quietly beside her. Not saying much. Just listening. Watching. Waiting. The way fathers do. There are

The Palliative Lens Andrew Esch According to the WHO, globally, only about 14% of individuals who need palliative care currently receive it. The remaining 86% go without access to these essential pain and symptom management services, which greatly improve the quality of life for patients and their families However there is a strange thing happening in palliative care. The house is on fire, and we keep giving awards to the people carrying buckets. Every conference, every p

The Palliative Lens by Andrew Esch Anna “I feel like cancer has taken most of my life the last two years.” Anna said that to me recently. Not dramatically. Not angrily. Just honestly. To clarify, she was speaking in plural. Three cancers. Not one cancer with recurrence. Three entirely separate cancers. The kind of history that sets the mood in a room before anyone even speaks. The kind of history that reminds you immediately that biology does not care about fairness, timin

The Palliative Lens by Andrew Esch There is something about hockey that never really leaves you. You can go years without lacing up skates. You can move away. Get older. Become a physician. Raise kids. Lose people you love. Carry responsibilities that the teenage version of yourself could never have imagined. And then suddenly it is Game 7 in Buffalo. And somehow all of it comes roaring back. This playoff season has felt bigger to me than hockey. Bigger than the Buffalo Sabre

The Palliative Lens By Andrew Esch, MD Dawn My cousin Dawn died unexpectedly April 18th. Even now, writing those words feels strange. Abrupt. Incomplete. Like the sentence itself should continue. Because that’s what sudden death does. It interrupts not only a life, but everything around it. There is no final chapter. No slow realization. No gathering around the bedside. No last conversations where families say the things they’ve been rehearsing quietly in their heads for ye

The Palliative Lens By Andrew Esch, MD Nancy My patient, Nancy, didn’t mean to wound me. “You’re a good doctor,” she said. Then she paused. “But my first palliative care doctor… he was my favorite.” There it was. Clean. Uncomplicated. Honest. And it stung more than I expected. Not because she was wrong, but because of how quickly my mind went to comparison. Scorekeeping. Ego dressed up as professionalism. I’ve been doing this long enough to know better. Still, I felt it. Then

THE PALLIATIVE LENS By Andrew Esch, MD It’s the question that undoes me. Not the physiology. Not the prognostication. Not the moment when I say, “I'd like to talk to you about the future.” This. “How do I tell my kids?” Nathalie A few weeks ago, I said goodbye to Nathalie. She was 44. She had daughters. Old enough to see it coming. Young enough that it will mark them forever. We talked about everything we’re trained to talk about. Pain. Symptoms. Time. I can do those convers

THE PALLIATIVE LENS By Andrew Esch, MD Let’s stop pretending hospice just needs “reform.” It doesn’t. The modern hospice benefit has drifted so far from its original purpose that honest people should stop talking about tweaking it around the edges. It should be ended. Not because hospice as an idea is wrong. Hospice, at its best, is one of the most humane concepts in modern medicine. But the benefit we built around that idea has become something else entirely: bloated, distor

THE PALLIATIVE LENS By Andrew Esch There’s a moment most of us don’t talk about in healthcare because we know we can’t, at least not honestly. It’s not on rounds. It’s not in a QI meeting. It’s not in the social media posts we write about equity, access, or “transforming care.” It’s the moment something happens to someone you love. And suddenly, you’re not navigating the system like everyone else. You’re calling someone. A colleague A specialist you trained with A medical dir

THE PALLIATIVE LENS By Andrew Esch 4/7/2026 My friend Dave has a mass on his kidney. The kind that looks, and behaves, like renal cell carcinoma. They told him about it in December. His surgery is next week. Not because it needed to be. Not because anyone thought waiting was better. But because of vacations. Because of volume. Because there always seemed to be ten other explanations for why it couldn’t happen sooner. There is a special kind of suffering we create for patients

By Andrew Esch The Palliative Lens THE QUESTION THAT DOESN’T GO AWAY There’s a moment in almost every clinic day where I feel it. It’s not uncertainty, that’s always there. Something more. A quiet, persistent question: Am I helping… or am I just choosing which harm I’m more comfortable with? PAIN IS NOT A NUMBER Pain in serious illness isn’t theoretical. It’s not a slide deck. It’s not a guideline table. It's always fascinated me that we choose to measure somet

By Andrew Esch, MD — The Palliative Lens There’s a particular kind of silence that settles into a clinic room when a patient realizes the timeline they’ve been planning for isn’t the one they’re going to get. It’s not loud. It’s not dramatic. It’s subtler than that. It sounds like: “I was going to retire next year.” “We were finally going to travel.” “I just needed to get through a few more years.” A few more years. I hear that phrase all the time. The Long Game We

By Andrew Esch, MD The Palliative Lens There are a lot of ways to measure whether a place is good to work. Health systems tend to prefer metrics. Productivity dashboards Engagement surveys Annual modules about teamwork narrated by someone who sounds like they recorded it inside a porta potty But the truth is that the real test of a workplace is much simpler. It’s whether people actually want to spend time together. A Place You Want to Show Up To For the last decade and a half

The Palliative Lens Andrew Esch, MD 3/11/2026 A Different Era I’m old enough that the first car I learned to drive had a stick shift and a carburetor. Not the retro, enthusiast kind that people romanticize now. The real kind. The kind where if you didn’t understand how the clutch worked, you stalled out in traffic and everyone behind you let you know about it. I’m also old enough to remember when the phone in our house was attached to the wall in the kitchen. There was a long

The Palliative Lens Andrew Esch MD MBA 3/4/2026 My wife’s uncle Martin is dying. He is here with us in Tampa, he is enrolled in one of our local hospices. The hospice care itself has been a disaster, and that story may come in another blog. Right now it is simply too sad, too emotional, for me to be articulate about it. Today I want to celebrate Martin. Martin is not easy to describe to people who haven’t known him. In many ways, he is an anomaly in today’s world. He is alwa

The Palliative Lens Andrew Esch MD MBA This is written in celebration of the upcoming 2026 AAHPM/HPNA Annual Assembly. There are moments in medicine when you step back and realize that something fundamental has shifted, not with a press release or a dramatic announcement, but quietly, steadily, because a group of people refused to accept the status quo. Palliative medicine is one of those shifts. The first annual assembly was held in 2004 in Phoenix, Arizona and was attended

The Palliative Lens By Andrew Esch, MD Are we approaching the point where health insurance is so expensive that it makes more sense to self-pay? Not “go uninsured and hope for the best.” I mean something more deliberate and more telling: · Pay cash for routine care, imaging, labs, and straightforward procedures · Use a membership model for primary care (DPC or concierge-lite) · Carry catastrophic coverage for the true financial disasters — ICU stays, cancer,

The Palliative Lens By Andrew Esch, MD 2/13/2026 I have a question. What exactly are we doing? The data that made palliative care credible, the trials, the cost savings, the quality outcomes, the patient and family satisfaction, were not built on having just any “palliative care.” They were built on interdisciplinary palliative care teams. Physicians. Nurses. Social workers. Chaplains. Working together, at the same time, around the same patient. That wasn’t a nice bonus fe

The Palliative Lens By Andrew Esch MD It may surprise some (most) people who have worked with me to hear this: I’m a conservative. Not the caricature. Not the stereotype. Not the version people imagine when they hear the word. Just… me. A physician who believes in patient dignity, responsibility, community, and the idea that medicine is fundamentally about showing up for people when they are most vulnerable. For most of my career, I kept my political identity quiet. Not becau