Are We Building Workarounds to Replace Workforce?

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 feature.

That was the treatment.

And yet if we are honest about where the field is right now we are quietly moving away from the very model that made us successful.

Today, only 41% of hospital palliative care programs have all core disciplines represented.

And nearly 1 in 5 programs report no dedicated physician staffing.

Read that again.

We are scaling access to palliative care while simultaneously removing pieces of the intervention that made it effective in the first place.  No other specialty would tolerate this.

Imagine cardiology without cardiologists.

Oncology without oncologists.

Trauma teams built on “whoever we can recruit this fiscal year.”

But in palliative care, we call it innovation.

Or flexibility.

Or my personal (least) favorite “right-sizing.”

Let’s be honest about what’s actually happening.

We are trying to mass-produce a workforce we don’t have. So instead, we are redesigning the care model around scarcity and hoping the outcomes still look like the studies.

And maybe they will.

But maybe what we’re really doing is slowly teaching health systems that you can get “close enough” palliative care without building the teams that patients and families were promised when this field earned its reputation.

If palliative care is team-based medicine, and the data say it is, then this isn’t just a workforce conversation.

It is a quality conversation.

It’s a truth-telling conversation.

And it’s a “what kind of field do we actually want to be?” conversation.

Because patients don’t get randomized trials in Palliative Care.

They get whatever version of us shows up in the room.

We Built Workarounds Instead of Workforce

If you step back and look honestly, you can see it.

Instead of saying:“We need more specialty-trained palliative physicians and advanced practice clinicians”. We often said:“Let’s build programs that work around not having them.”

Heck, entire consulting industries now exist to help systems design care models around workforce gaps.

So now a patient is less likely to engage with highly trained, interprofessional teams and more likely to find:

·      Care pathways.

·      ACP-only programs.

·      Remote triage models.

·      Fragmented consult structures.

·      Task-shifting without diagnostic authority or integrity.

Some of this came from necessity. Some from funding realities. Some from workforce shortages that were (and are) very real.

But necessity should never become identity.

I’m Tired of Hearing “We Can’t” and “That’s Not Realistic”

Let me say this plainly.

I am tired of hearing that it is “not realistic” to have qualified, specialty-trained palliative clinicians available to patients. We would never say that in cardiology. We would never say that in oncology. We would never say that in pulmonary or critical care.

We don’t tell heart failure patients,“Sorry, it’s not realistic to have cardiologists, but we built a really strong workaround.”

We don’t tell cancer patients,“Oncologists are hard to find, so here is a system that approximates oncology.”

And yet in palliative care, we sometimes act like expecting specialty-level clinicians is aspirational instead of standard. Shortage does not equal justification for permanently lowering the bar.

Shortage means:

• Build pipelines

• Fund training

• Change payment models

• Prioritize workforce development

Not:

• Redefine the specialty downward

Ask Yourself This

Would you go see:

• A cardiology practice without a physician?

• A pulmonology program that cannot assess, diagnose, intervene, and prescribe?

• An oncology program that only offers advance care planning conversations  but no medical management?

Of course not.

It would sound absurd.

And yet, in palliative care, we normalized versions of exactly that.

Not because our colleagues aren’t excellent. But because we built models that sometimes remove the medical specialty from specialty palliative care.

Patients Are Telling Us Something (If We Listen)

At my cancer center, patients come from all over Florida, and often beyond, to see subspecialty physicians. They are not traveling hundreds of miles for an ACP conversation.

They are coming for:

• Complex symptom management

• Medication management across organ systems

• Prognostic synthesis

• Risk–benefit decision support

• Real-time medical judgment in serious illness

  
  

They are coming for palliative medicine, not just palliative care.

Both matter.

But they are not the same thing.

The Narrative Drift

We became so focused on the “palliative CARE” narrative, and I understand why, that we sometimes lost something critical:

We are a medical subspecialty:

• We diagnose.

• We prescribe.

• We intervene medically, psychosocially, and spiritually.

• We manage complex physiology across disease states.

• We sit in the hardest medical gray zones in healthcare.

That is not something to apologize for.

That is something to build around.

This Is Not About Turf

Palliative care only works because of the team.

But teams work best when:

• Everyone practices at the top of their training

• Medical complexity is owned by medical specialists

• Supportive care is layered, not substituted

  
  

We don’t strengthen care by weakening teams.

Why This Happened (And Why It Made Sense At The Time)

Let’s be honest about the drivers:

• Workforce shortages

• Payment structures that reward conversations more than complexity

• Health systems needing “a palliative presence” quickly

• Misunderstanding of what specialty palliative medicine actually does

• The false dichotomy of “medical = cold” vs “care = compassionate”

  
  

We filled gaps because patients needed something.

But “something” should never become “the standard.”

What Clinicians Can Do Right Now (Actionable Steps)

1. Stop Apologizing For Being A Medical Subspecialty

Language drives policy and funding.

Say:

• “Specialty palliative medicine consult”

• “Complex medical symptom management”

• “Serious illness medical co-management”

Not just:

• “Goals of care”

• “Supportive conversation”

If we describe ourselves as conversation services, systems will fund us like conversation services.

2. Track And Show The Medical Complexity You Manage

Administrators fund what is measurable.

Start tracking:

• Opioid rotations

• Refractory symptom rescue

• Polypharmacy reduction

• ICU avoidance tied to medical decision making

• Rapid titration cases

• Transitions from futile escalation to targeted care

  
  

Show value as clinical medicine, not just satisfaction scores.

3. Push Locally For Training Pipeline Growth

   
   

You don’t need to solve this nationally to matter.

Ask:

• Does our hospital sponsor a fellowship?

• Can we expand one slot?

• Can we co-fund with oncology or ICU?

• Can we support loan repayment or recruitment packages?

  
  

Workforce grows where institutions decide it matters.

4. Design Programs For The Workforce You Should Have Not The One You Don’t

When designing new models, ask:

“If we had full specialty staffing, what would this look like?”

Then build toward that, even if in phases.

Stop locking scarcity into permanent program structure.

The Upbeat Part (Because There Is One)

Here’s what gives me real optimism.

More clinicians are pushing back on the idea that excellence is “not realistic.”

More leaders are saying:

• Workforce is infrastructure

• Interprofessional teams matter

• Specialty training matters

• Teams need medical depth, not just breadth

• Access should mean access to the right level of care

  .

The Bottom Line

Patients with serious illness deserve:

• Not workarounds.

• Not stripped-down versions of specialty care.

• Not programs built around what we don’t have.

They deserve the real thing.

• Highly trained specialty palliative medicine.

• Fully supported interdisciplinary care.

• And systems designed to scale excellence, not replace it.

We don’t need to choose between compassion and clinical excellence.

Palliative medicine is both.

And always has been.