The Things That Haven’t Changed

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 cord that stretched halfway across the room if you were lucky, and absolutely no privacy. Conversations happened in the middle of life, while someone was making dinner or washing dishes.

And yes, I was alive when all four Beatles were still alive.

That last fact is less about music and more about time. It reminds me that I’ve lived through a fair number of medical leadership trends: the Clinton health plan, primary care gatekeepers, MIPS, meaningful use, RVUs, DRGs, dashboards, metrics, mandatory trainings, credentialing that borders on the absurd, reinvention, and declarations that everything is different now.

But at the bedside, has it really changed at all?

The Industry of Change

In my career alone we’ve seen electronic medical records transform documentation, hospital systems consolidate into enormous networks, private equity discover healthcare, and an entire cottage industry of leadership frameworks, productivity models, and management theories rise up around the practice of medicine.

Every few years a new language appears:

• Population health

• Value-based care

• Service lines

• Care redesign

• Telehealth

• Health equity

• Clinical transformation

• 
  

Some of it is useful. Some of it is necessary. Healthcare systems are large, complicated organisms, and they require organization.

But beneath all of it, beneath the dashboards, acronyms, spreadsheets, productivity reports, and consultants, medicine itself has not fundamentally changed.

Not really.

The Core of Medicine

The core of medicine is still a human relationship.

A person who is sick or afraid sits across from another person who has knowledge, training, and hopefully the humility to use it wisely.

That relationship is the soul of what we do.

We can surround it with technology, wrap it in protocols, measure it with metrics, and optimize it with workflow redesign. But none of those things replace the moment when a clinician actually sits with a patient and tries to understand what matters.

Especially in serious illness.

The Questions That Matter

In palliative care, we see this stripped down to its essentials.

We ask patients questions like: “When you think about the future, what worries you most?”

Because patients worry about things that are important to them. They ask questions that no algorithm can answer.

• Am I dying?

• How much time do I have?

• What will this be like?

• Will I be a burden to my family?

• What should I do now?

Those conversations do not improve because of a better spreadsheet. They improve because of trust.

• Because someone listens carefully.

• Because someone explains honestly.

• Because someone is willing to stay in the room when the questions get hard……and the answers get even harder.

  
  

The Most Important Tool in Medicine

For all of the extraordinary advances in medicine, AI, targeted therapies, imaging that borders on science fiction, and the computational power now embedded in clinical decision-making, the most important tool in medicine remains astonishingly low-tech.

Presence.

The willingness to be there. The relationship itself.

Lessons from a Stick Shift

I sometimes think about that old stick-shift car again.

Driving it required attention. You had to listen to the engine. You had to feel when the clutch engaged. If you rushed it or ignored what the car was telling you, things went badly.

Practicing medicine well isn’t so different.

• You can’t automate judgment.

• You can’t outsource empathy.

• And you certainly can’t build trust through a protocol.

Those things are learned through attention to patients, to families, to the quiet signals that tell you what someone is really asking when they say they are “doing fine.”

What Still Matters

Medicine will continue to evolve. It should.

The science will get better. The systems will change again and again.

But the heart of it, the reason people come to us in the first place, remains surprisingly

unchanged.

Good medicine is still good medicine.

And the relationship between a clinician and a patient remains the part of the system that actually makes it work.

Everything in medicine keeps changing.

Except the part that actually matters to patients.