Excellence Is a Staffing Decision

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The Palliative Lens

By Andrew Esch, MD

Somewhere along the way, we stopped designing palliative care programs around patients.

We started designing them around vacancies.

A physician position goes unfilled for six months? Build a nurse-led program.

Can’t recruit a physician? Start with social work.

Need to show activity? Launch an advance care planning initiative.

The problem is that none of those are palliative care.

They’re adaptations.

Sometimes necessary.

Never sufficient.

We have become remarkably good at building workarounds for the workforce we wish we had instead of building the workforce our patients actually need.

Serious illness doesn’t wait for the right referral

The patients we care for don’t present with one problem:

• They have pain that requires opioid rotation.

• Delirium that develops overnight.

• Nausea.

• Dyspnea.

• Goals of care that change after a CT scan.

• Family conflict.

• Depression.

• Existential suffering.

  
  

And often, all of those in the same afternoon.

This is why palliative care was never intended to be a collection of isolated services. It was designed to be interdisciplinary because serious illness is interdisciplinary.

• The physician doesn’t replace the nurse.

• The nurse doesn’t replace the social worker.

• The social worker doesn’t replace the chaplain.

But neither can any one discipline replace the physician when complex medical decisions must be made in real time.

That isn’t hierarchy.

It’s simply recognizing that each member of the team brings expertise that the others cannot.

We have confused access with comprehensiveness

I understand why organizations build nurse-led or social work-led programs.

• Recruitment is difficult.

• Budgets are tight.

• Demand is overwhelming.

  
  

Doing something feels better than doing nothing.

But we should be honest about what those programs are.

• They improve access.

• They do not create a comprehensive palliative care service.

If a patient needs opioid conversion, management of refractory symptoms, prognostic counseling, treatment recommendations, or immediate medical decision-making, there still has to be a physician available who practices palliative medicine at a high level.

Otherwise, we’ve simply added another stop before the patient reaches the care they actually need.

Advance care planning is not the destination

Perhaps no example illustrates this better than the explosion of stand-alone advance care planning programs.

Advance care planning matters.

I’ve spent countless hours having those conversations. They are among the most meaningful moments in medicine.

But somewhere along the way, the conversation became the product. Advance care planning was never supposed to replace palliative care.

It was supposed to occur within it.

When organizations measure success by the number of documents completed instead of the number of patients whose suffering has been relieved, we’ve lost our way.

• A completed form doesn’t treat pain.

• It doesn’t manage refractory nausea.

• It doesn’t help an oncologist decide whether another line of chemotherapy aligns with a patient’s goals.

• It doesn’t support a frightened family at two o’clock in the morning.

  
  

Advance care planning is one skill within serious illness care, not the entirety of serious illness care.

When we reduce palliative care to paperwork, we unintentionally diminish the specialty we have spent decades trying to build.

Stop hiring résumés. Start hiring physicians.

I’ve heard leaders say they “need a palliative care doctor.” I think that’s the wrong question.

Every fellowship graduate has the credential.

• Not every fellowship graduate builds programs.

• Not every fellowship graduate earns the trust of oncologists.

• Not every fellowship graduate teaches.

• Leads.

• Innovates.

• Communicates.

• Or inspires a team.

  
  

There is a profound difference between hiring a physician who practices palliative care and hiring a physician whose professional identity is to advance palliative medicine.

The latter sees problems before everyone else:

• Builds systems.

• Develops future leaders.

• Earns referrals because colleagues trust their judgment.

• Makes everyone around them better.

  
  

Those physicians are harder to find.

They’re also worth every penny.

Because exceptional physicians don’t simply see more consults. They elevate an entire program.

Design for excellence, not adequacy

Healthcare has become comfortable asking, “What’s the least we can build?”

I think we should ask a different question.

“What would our patients deserve if this were our own family?”

The answer probably isn’t a fragmented collection of programs created to compensate for positions we couldn’t fill.

It’s a physician-led interdisciplinary team where nurses, advanced practice providers, social workers, chaplains, pharmacists, and physicians practice together, each at the top of their expertise, each indispensable, and each making the others better.

That’s not the most inexpensive model.

It is, however, the model that serious illness deserves.

Our patients don’t experience their suffering in silos.

We shouldn’t organize their care that way.