Generalist versus Specialist Palliative Medicine

Abstract

The issue of generalist versus specialist palliative care is on the minds of healthcare leaders everywhere. We are amid changing demographics of physicians. The industrialization of medicine is well underway in the US and around the developing world. Is it important to identify patients who benefit the most from specialist palliative care, given that it is currently a limited resource? Should we step out of standard practice and redesign palliative care using principles of population management? The COVID pandemic rapidly introduced virtual palliative care consults. Is it a better way to promote wide access to specialty palliative care? Looking forward, should we promote ways to advance primary palliative care and reserve specialty palliative care to patients who will benefit most from this level of care? These questions, and others, are considered in this transcribed discussion between leading physicians in the field.

DR. von GUNTEN: This series of roundtables for the 25th anniversary of Journal of Palliative Medicine aims to highlight topics that are important to people in the field. We want to illustrate those areas where there are strong opinions or emotions or holes in the research evidence. I want you to imagine we are just sitting around a table in the doctor's lounge at the hospital. Roundtable discussions have an extraordinary impact because people want to listen in to physicians chatting.

DR. PERIYAKOIL: I have been starved of national collegial discussions ever since the pandemic. This is just fantastic.

DR. PANTILAT: The last time any doctor was in a doctor's lounge was about 25 years ago. At least I have not been in the doctor's lounge.

DR. von GUNTEN: The issue of generalist versus specialist palliative medicine is on the minds of not just every program director, every service chief, and every head of the hospital. We are in the midst of changing demographics of physicians. The industrialization of medicine is well underway. What are you all thinking?

DR. PANTILAT: This is something that is very much on my mind and lots of people that I talk to. The good news is the “tide has raised boats.” The general knowledge among my colleagues about palliative care issues, whether it is pain management, having a goals of care conversation, or psychosocial support, has gotten a whole lot better. People in the hospital are a lot sicker these days, and there are many more issues for us to deal with. To my mind, one important question is, where is specialty palliative care most valuable? Who are the patients who benefit the most, given that it is a limited resource? Up until now we just wait for patients to come our way. Somebody calls us and we go take care of the patients. We are a very reactive service. I think where we are headed is needing to be much more proactive. On any given day, there are patients out there in the hospital who need our care more than the people we have been asked to see. I think we really try to target the patients who will most benefit from this very intensive and very specialized service.

DR. FISCHER: We have a reality that there are not enough specialists. As we continue to grow specialty programs, specialty training fellowships, we have to accept that some kind of primary palliative care is going to be part of this picture. We should be thinking about it in a tiered way. If everyone is getting primary palliative care, then what are the triggers that bump it up to that specialty level? In terms of critical things such as quality of life and symptom management, the studies show these are the harder needles to move in the more diluted interventions.

When I think of primary palliative care, I think it is starting the goals of care conversation, starting to talk about prognosis, starting to do some of that advance care planning. When it comes to the complicated symptom management, that is where the data show us that specialty palliative care makes the biggest impact. I do not want to open the can of worms too soon, but what outcomes are we measuring? The elephant in the room is where does advance care planning fall into that mix? I will just drop that and pass to Tim.

DR. QUILL: You do not know what you do not know. That is a big problem because there are a lot of physicians who are in specialties that are not palliative care or generalists or hospitalists. Some of them do very excellent palliative care, but many also think they know a lot more palliative care than they do know. If we assume that they are going to be doing a great job until they ask for help, I think there are some problems with that. Their threshold to ask for help may well be too high and not too low. And if it is too high then there is a lot of patients who have pressing palliative care needs who will be lost in the shuffle. How do you learn how to do sophisticated palliative care if you think you are already doing it? It is very hard to figure out what you do not know and what you need to know unless you are being observed in some way.

DR. von GUNTEN: I remember David Weissman, the founding editor of Journal of Palliative Medicine, coined the term the “ignorance-arrogance” paradox. If you think you know it and you do not, there is very little window to learn unless somehow that window gets opened.

DR. PERIYAKOIL: How would we do this if we are a business? What we do now is what Steve talked about, which is by serendipity. There are patients who need palliative care, but do not know enough about the specialty, so their level of knowledge is very low. There are [nonpalliative] physicians in the middle who think that only some patients need palliative care services. They do not know much about what we do. Yet, they are the ones who are the traffic cops of who gets the service. Imagine if air traffic was like this, or any other high-risk business that is not even as high risk as health care, how would it work? We need to step out of the reactive model and think about proactive population management strategies. Do only the things that only you can do. And what is that? That is the question.

DR. von GUNTEN: We are referring to the sociology of medicine. When physicians ask for help, consultation etiquette requires you to respond—not to tell them to help themselves. The real customer of palliative care, including specialist palliative care, is the referring physician. Is he or she happy with the service? If there is enough demand, particularly in a U.S. supply and demand market, there will be more specialists. The salaries will rise to meet the demand. If the surgeons demand more palliative medicine because it is exceedingly important to them, they will get it. Where I have been working, the salaries of palliative medicine physicians have more than doubled in five years, purely on the basis of meeting supply and demand issues. This is what happens in the American economy in general, if there is high demand and low supply, the price goes up. But I see this in conflict with the cognitive allocation of resources model which you have been describing. The two models compete.

DR. PANTILAT: Part of the challenge is that it is not clear within any institution how the market works. In any one institution, the decision makers about staffing, including palliative care services, are aware that, unlike neurosurgery, the work that we do is not bringing in net revenue. And it is very hard for us to relative value unit (RVU) our way through our salaries. The case for palliative care is a quality, safety, and support of staff argument. Sometimes it is a utilization argument as well although I think we do have to be cautious about that one.

I think the challenge is how we grow from being a little boutique service knowing that there is tremendous demand out there in the world. We do great work with the few people we see. We are like this little boutique hotel. It is great, but you cannot have a big conference at your hotel. So how do you become the Four Seasons Hotel? Right? That is a different set of issues that you have to make the case for. I agree with you that getting your colleagues to make the case for you is really the best.

DR. QUILL: We have to break the mold. The number of people who really need soup-to-nuts palliative care consultation is relatively small. We could have the role of teaching, helping facilitate the people on the front lines providing basic palliative care, whether they be primary care docs, hospitalists, or other subspecialists, and be a backup and/or advising system for them. Unfortunately, that generates zero income for us if we serve patients in that way. Yet, I think that approach should be a big part of the future of palliative care because that skills up those already providing care, and it is much more cost-effective for providing basic palliative care than having yet another entire palliative care team involved in every case. Full palliative care team involvement would then be reserved for the more complex cases where the palliative care needs are more complex and difficult.

DR. FISCHER: When I get a call after hours my blood pressure goes up. “Ugh, am I going to get called in?” When it is just a question from one of the hospitalists, “How do I do this?” I feel a sudden shift from mild panic/annoyance to being excited and walking someone through how to do this. It is some of the most satisfying work. We need to teach people how to take those calls and teach people to do this, because a lot of the questions are fairly navigable. Often what they need is some language or ways to approach a difficult situation. Often they do great, at least initially. If not, then we can come in the next day or so.

The teaching piece of it is not compensated. Yet, it is a huge part of what we do. At our institution, we are involved in the medical school as well teaching all the resident learners who come through. That feels like an important impact. Many of our palliative care physicians also work on hospital medicine or in geriatrics or in other parts of medicine. As difficult as that can be to put your feet in both worlds, it is when you are in that other world where you can, I think, make the most impact of shifting people toward a primary palliative care mindset.

DR. PANTILAT: What are the foundational skills that a health care provider should have? What are the communication skills and symptom management skills? We made palliative care knowledge part of the core competencies for the subspecialty of hospital medicine. Although I cannot vouch for the kind of training that everyone gets, at University of California, San Francisco (UCSF), our medical students and our medical residents and even more broadly now in the department of surgery and so on where we have faculty in palliative medicine who are also specialists in other areas and are doing the teaching, I think you see a real difference and a change in the skill sets. Raising the boat.

Although we are giving people better skills, we are not turning them into specialists, that is not our job. They do have a better skillset and are more comfortable in doing some of this work. I appreciate what Tim said, “Do you know what you don't know?” Maybe you do not. But to the extent that you have a better skillset in these different areas to address some of the sort of core issues that does help patients a lot.

DR. von GUNTEN: Of all the teaching I have been involved in, the fundamental outcome is, “Oh my God, you all do this so much better than we do. Yeah, you've taught us the skills, but I'm going to consult you because I want my patients to get the best. Why do they want me or my staff fumbling around when they can have you and your team, Charles?” When people are on the equivalent of an island, alone, they call you Stacy saying, “Whoa, what do I do?” You respond, “All right, I'm not there, but I can talk you through it.” Particularly in community medicine, when the star neurosurgeon says, “Look, I cannot have this neurosurgery program without really strong palliative care” or when the transplant surgeon says, “We cannot have a transplant program without a really muscular palliative care program,” they get what they ask for. Economically, it all gets bundled together.

I think our own mindsets influence this. The mindset of scarcity. “There will only be a few of us.” “We can't just live on our own RVUs.” “We have to teach, do research and take care of patients.” Those are all scripts in some ways that create narrow boundaries. Those scripts limit where our field could go. If we were thinking in different ways, with a mindset of abundance, I think we'd get different outcomes.

DR. PERIYAKOIL: I want to play devil's advocate. There are multiple messages. “There are only a few people who need really subspecialty palliative care.” “We need to do better with education.” “Primary palliative care is something that everybody else should be doing.” If you think about this as a scalable population health model, there should be a single unified message, right? And a single unified product.

Imagine the hospital CEO listening to this conversation; it is very polyphonic. “We need more education, we need more troops, we need more money, you all should do better, you all should consult us earlier.” The CEO is busy. She has five seconds. Tell me the one thing you want, what would that be? It is a marketing issue, right? What is the one thing that we want to accomplish before the 50th birthday of Journal of Palliative Medicine?

DR. PANTILAT: I often wonder about how the other specialties look at this. Do the cardiologists get together to talk about who is getting a cardiology consult in the hospital or who is getting an infectious disease consult? I do not think so. That is not what I hear from my colleagues that they are worried that there is somebody with a heart failure exacerbation and oh, you did not call us, how come you did not call us? I am glad you did, but where are the other patients that we need to see? I think there are some interesting lessons for us in that.

As folks in palliative care, we have a strong interest in the issues that we think about for people with serious illness. Their symptoms, their goals of care, and their psychosocial and spiritual support. Those are things that really matter to us, just like cardiologists care about hypertension, but cardiologists do not want to see all the people with high blood pressure. They only want to see people with really, really, really difficult to control high blood pressure. And what is the parallel for us? The worry that I have is that there are lots of people out there who do need to see us who are not seeing us. The answer is not for cardiologists to see every person with high blood pressure. And the answer is not for a specialty palliative care team to see everyone with serious illness.

DR. von GUNTEN: I use the cardiology analogy, too. All of us as physicians learned how to manage heart failure and the basics of rhythm disturbances from cardiologists. Every trained physician has the skills to manage garden variety cardiology problems. Whether you see a cardiologist or not, kind of depends on your setting. If you are in rural Maine, family medicine or general internal medicine sees an extraordinary range of things, because the specialists are just not around. In the standard urban setting, everybody who is on a little bit of Lasix is seeing a cardiologist to manage their heart failure, whether or not they should. No one is saying, “Oh, you're mild, your primary care provider should manage this.”

I think the business model of health care in the United States is so important to understand. The term industrialization means that the people who do it all the time are the ones who do it the best. As I understand the studies, specialists do give better heart failure care than generalists, no matter where you look. Even though you could say they should be reserved just to the very difficult ones, the outcomes are better. And that is why all the gatekeeping kind of fell apart because there is a demand for the specialists to do it. The supply grows in urban settings. And that is how basic cardiology is given. Although our field is new, I do not see a reason why those same forces would not apply to us, including our teams.

DR. QUILL: But it is nuts to do this, right? Because then you are going to have a team of specialists attending to every system that a person has. And it will not be one person, because of course you need a multidisciplinary team of specialists for every organ system and so forth. I mean, it is a crazy way to do health care. And I am not sure the evidence is as strong as you suggest that is better care. It is going to be more treatment, maybe not more care, and maybe not better outcomes, because there is going to be a lot of unnecessary stuff going on. So there is a lot of real downsides to this model that we have created, that works really well for somebody who has got multiorgan failure, and is in the intensive care unit (ICU) and you really can maybe benefit from somebody attending to every organ system. But for the 95% of people who have a little of this and a little of that, maybe a lot of that, they do not need this level of intensity. And in fact, it is probably not just expensive, but harmful.

DR. FISCHER: To your earlier question Steve, is ID or cardiology sitting around thinking about this? No, but primary care is. Family medicine is thinking, how do we manage a population for health?

That makes more sense to me. Even though we may think of ourselves as a specialty field, I think we are more aligned in a lot of ways such as geriatrics or primary care in thinking about the whole person, and thinking more about models of care than, do we need to see everyone with hypertension, or do we need to see everyone who is going to die? Which means everyone!

DR. QUILL: This may need to be a model of going on rounds on a regular basis in the more acute parts of the hospital, where you are not actually consulting, you are just along for the ride and seeing things where your eyes see things that are different than other eyes see, and maybe that contributes to other people seeing those things. I think that may be a piece of the puzzle where this needs to go.

DR. FISCHER: We have a joke on our service that if you walk down the hall and make eye contact with a pulmonologist or a transplant surgeon, they say, “I remember you guys, you were helpful. And suddenly they give you a consult in the next 24 to 48 hours.” So, we have started doing something similar, Tim, going on rounds once a week with a given service here or there. That is fallen off a little bit during the pandemic time, but just to kind of show our faces. “Oh yeah. I remembered you guys.” They start looking at their list and thinking more critically about who may benefit a little earlier, a little further upstream.

DR. PANTILAT: You can always generate more consults. You give surgery grand rounds and suddenly you get five consults the next day. And there is a time limited effect of that, but then you give it again and then low and behold, there are more people to see. But what we have seen is in part, people titrate their cases, based on how busy we are. If they hear, “Oh we're really busy. I don't know if I can get to your patient today” they back off. They monitor what we are able to take and how sick someone needs to be for us to really engage with them.

There is a kind of steady state that teams reach based on their capacity. If you do not exceed your capacity, it is difficult to demonstrate that there is excess need. Quantifying how many consults you turned down or how many extra consults might have happened is impossible. It is challenging to right size our services.

The other point about primary palliative care versus specialty palliative care is the challenge of people who are less sick. It is just harder to show that you make them better. So if you say primary palliative care is for people who are less sick, it is hard to make them a whole lot better. If they have a good functional status and they are coming to see the palliative care nurse on their way to work, I do not know how much more I am going to improve their quality of life and reduce the symptoms that they do not already have. I think we make it harder to demonstrate good outcomes. You see the best outcomes are where the people are the sickest.

I have sometimes wondered with the advances in lung cancer how would Jennifer Temel's study look today in a situation where maybe the mortality rate is quite a bit different? And would the study have to be longer? Would you have to choose even sicker patients? And I think in some ways, advances in medicine are maybe making it harder for us, or at least we have to be more thoughtful and careful about the populations that we choose. We certainly saw that in some of our studies, looking at people with heart failure, for example, even hospitalized patients. Most people with heart failure who are short of breath in the hospital get better, because the cardiologist in the hospital is doing a really good job of treating their shortness of breath.

DR. PERIYAKOIL: Steve, you talked about titrating to the capacity of the team and always running a little high. So that the next time funding is allocated, you do not get credit for what you did not do. But the challenge in that model is burnout, right? You have to walk the tight rope of not burning out the team, and going back to what Tim was saying, if we only saw the people that only we should see, then that brings up the burnout issue as well. Because now you are seeing only the toughest, the hardest cases that nobody else could manage. Over a period of time, the team would get burned out.

I think COVID-19 is the largest social experiment in the past century, right? One day we were all insisting that the only way to do everything is in person at the bedside, eye contact, and therapeutic touching. Then, a week later, the whole hospital was completely empty except for “essential services.” A lot of medicine became virtual. Many of us on the west coast did virtual consults for our colleagues in New York when they were the hotspot. Maybe a portion of palliative care could be like radiology, working remotely, not sitting in a dark room, but sitting in a lovely room with some harp music maybe, where we could be doing remote consults and then identify where you need in-person care. Remote consults entirely would totally burn us out. So, there might be some rotational schedules, right? What has COVID taught us, and how is that going to change our model, is the question. Both for generalist and subspecialist palliative care.

DR. QUILL: COVID has really opened the door to what could be done with virtual consults that are much more limited. You see people, you have great insights, you give the team some great information, and you get out of there. Maybe our in-person presence undermines them doing that work. And them doing that work is a key to their growth and professional development. They are learning how to do palliative care and not just palliative care, but to build a clinician–patient relationship that is committed to many dimensions of illness. The model where you get paid by how much time you spend directly seeing the patient and how much you document in the chart is an okay model. It has some plusses in it, but boy, it really encourages that kind of involvement, even when it is not necessary.

DR. PANTILAT: I think that is something we need to study. When are you in long enough? And when are you not in long enough? I worry where “we're too busy for follow-ups,” so we only do one visit. I worry when you are in the worst possible situation, and you are doing a lot of work and not having the impact that you want. And so, I think this is an important question for us to understand. When can you guide somebody and how much time does it take to do that versus doing it on your own?

With COVID-19 we started using telemedicine in the hospital where it has been a boon to us. Maybe we would have come to that idea at some point, but I do not know when. We have connected with patients and families in a way that we had not done before. It was like a “duh” moment. We should have been doing that, but we were not. In the outpatient setting, it has increased everyone's satisfaction. The patients like it, the clinicians like it.

DR. von GUNTEN: As part of the 25th anniversary of Journal of Palliative Medicine, what studies do we need going forward? As Editor-in-Chief, I notice a certain repetitiveness to some of the articles that are submitted as opposed to pushing the boundaries. What studies would help us in this discussion about specialist versus generalist palliative care? One you are suggesting would be a time-and-effort or a time-and-outcome study. Are there other studies you would like to see so we are not just sitting around with our opinions?

DR. PERIYAKOIL: How about a randomized clinical trial, where people get randomized to maybe a three-arm usual care versus primary palliative care versus subspecialty palliative care and look at outcomes related to patient-reported outcomes, as well as health care system outcomes and cost outcomes?

DR. von GUNTEN: We might be able to approximate that just by looking at Medicare databases, since that is our best coding we have for large populations. Do you think you could back into it without the randomized clinical trial design?

DR. PERIYAKOIL: Huge explorative studies that look at databases are fabulous, and they have a place, but at the end of the day, you do need a randomized clinical trial so you can say we have proved it unequivocally.

DR. von GUNTEN: Steve, you brought up Jennifer's Temel's trial. The big multicenter randomized trial of that intervention fell apart in the Eastern Cooperative Oncology Group because no cancer center had the same ability to deliver palliative care. With a trial of a drug or even a procedure, it does not present the same challenge.

DR. PANTILAT: In addition, in what populations do we have equipoise about the outcome and about the potential benefits between the treatment arms? Who are the patients, or their physicians, who would be comfortable randomizing to usual care and not getting any palliative care at all, or getting primary palliative care for which we do not have great evidence, compared with people where we have evidence that specialty palliative care helps? Some of our successful studies make it harder to randomize to no palliative care. Gosh, is that okay? I am not sure.

DR. FISCHER: I would like to take us in a different direction to make sure we talk about it: the need for more inclusivity and diverse populations in our studies. As we were talking about telehealth during COVID, especially in the first wave, we saw tremendous disparities at our hospital. Everybody in the ICU that was sick was a person of color who was oftentimes exposed in a vulnerable situation at work or in a living situation where isolation was impossible. We saw a lot of challenges connecting over telehealth with some of the technology with families. In my own research studying a virtual platform, in our screening we found that none of the patients were comfortable using a virtual platform. We were specifically interested in recruiting Hispanic patients with serious noncancer illness across Colorado. As we switch more toward a technology solution, I worry that we are ensuring that we are being inclusive and that we are not further widening existing disparities.

DR. PERIYAKOIL: I think the digital divide is huge. And then you add disparities, plus the digital divide and people who are using a burner phone and paying by the minute, then being on the phone with the doctor for 15 minutes will literally break their bank. We have to be very careful that we, in a very well-intended way, do not make disparities worse.

DR. PANTILAT: Part of the research need is about access. What kind of access are we creating and who is engaging with palliative care? There is a question about the right patient, meaning are you sick enough? And what serious illness do you have, but also, are we reaching all communities? We know that there are disparities in access, and we know there are disparities in pain management, for example. That is well documented.

We have been doing some of that work of looking at who gets referred, who makes an appointment, who keeps the appointment, and who comes for follow-up. We have found that there are disparities by race, and we are looking at language as well. Then the question is, how do we overcome that? What are the barriers? Is it about virtual? Is it about who we are, or the messages that we are giving? We need to understand that and to create access.

DR. QUILL: We must look at the question about whether you can empower people on the front lines to do a lot of this work with support from us indirectly. If the model requires needing two or three separate consults to get your problems addressed, if you are a poor person or even living in a rural area, it is probably not going to happen. If we are to skill up the clinicians who are on the front lines, perhaps they are the people who need the consults to improve their care for patients they are already seeing.

DR. von GUNTEN: We have moved to the outpatient setting in our conversation. In the specialist model, patients are seeing their oncologist or their cardiologist or their pulmonary doc, then they are seeing the palliative medicine doc. It is two copays. That is a barrier right there.

DR. PANTILAT: My worry is that people who are already disadvantaged get more disadvantaged because there is no access in the rural community to specialty level care, or because there is a financial barrier. And in many ways it is really our responsibility at the system level to try and reduce those barriers. This is about a $20 copay. We need to figure that one out.

DR. PERIYAKOIL: This was an issue that we wrestled with a long time ago and we deliberately set up our palliative care within general medicine clinic so that people are not hit with the subspecialty copay of 50 bucks. And if you see a person in the general medicine clinic, which includes us, then other copays are not there for that day, because you can only get one copay per day.

DR. PANTILAT: We found that for a lot of our very sick patients in the outpatient setting, they did not want to see us on the same day they were coming to their specialists, because it was exhausting and long already. And so they preferred not to see us then and to see us virtually. And then the question is what is the copay on a virtual visit? I think our patient population may be a little different and we have not seen a problem with virtual access. It is not trivial to get yourself over to UCSF. It is not trivial paying for parking here. Maybe parking is free elsewhere, but it is certainly not free at UCSF. Our patients just prefer to do it in some other way.

It begs the question if telemedicine is the same and what is being lost. When we first started using it, I was so enthusiastic about it. I thought this is amazing for everybody. We can have really good conversations and we can do symptom management. And now I am just wondering, what are we losing?

It is really great to see all of you online. V.J.P., you were saying you were so deprived of human contact. I wish we were in the doctor's lounge, Charles, sitting down together in the same room, having this conversation. And I wonder here what is lost. And what is lost between us as clinicians with our patients.

DR. von GUNTEN: We could probably talk forever, but I want to pull us to a close, what do you want to be sure that people take away as they are thinking about generalists versus specialists and the evidence that we need going forward?

DR. QUILL: I come back to thinking about how much should we be putting our energy into skilling up the people who are going to do the bulk of the care of patients? How much will we be spending our energy, scaling up their palliative care skills, providing support for them to do the work and really scaling down, frankly, the people we see face-to-face so that we do not create a whole other system to do palliative care. I understand that there are a group of people who have complex palliative care needs, and they probably do need to see a palliative care specialist like us directly. But those are, in my opinion, the exception, rather than the rule. If we are creating a system skilling up the folks on the front line this is a much more cost-effective and probably systems-effective approach.

DR. FISCHER: Although it is not even my place to argue with you, Tim, I do feel less optimistic. As the older physicians retire, I see this new crop of clinicians who think differently. I have not seen that willingness to learn as much as I have hoped to. I do worry that we are going to see a significant portion of clinicians that are going to be, not untrainable, but unwilling to be even open to these ideas. I see the strong role for having a more parallel approach. I am just a little pessimistic about what our society, what our medical school, what our nursing schools do to folks as they are going through learning, both the hidden curriculum and the actual curriculum.

DR. PANTILAT: I would say its “both and” to my mind. I appreciate asking the question, are we in fact a limited resource? How limited a resource is specialty palliative care? We should not just assume. It is a great field to go into, and we should be attracting more people. If the situation was right, we might be able to do that. Whether we could meet all the demand, I do not know. So, I do not want to start there and given that we are a limited resource today, we do need to ask the question, who does benefit the most from specialty palliative care and where should we be putting our energies?

I appreciate what you said, Tim, but I will tell you, it is the rare consult that I think we do not have a role to play. And every day, both in the outpatient and inpatient setting, I think there is at least probably five times as many people who need specialty level palliative care than are receiving it on any given day at my institution. So, I think that demand is out there where people would really benefit and trying to understand that issue. We have been really interested in thinking about what are the palliative care needs those patients have, rather than do they need specialty palliative care? Is it needs for symptom management? Is it needs for goals of care conversations? Is it need for spiritual and psychosocial support? Then, how might we as an institution begin to address those needs that we do not have to do as a specialty team? We can educate others through protocols and guidelines, and what are all the kind of clever ways we might do that?

Just a simple example. We have a comfort care order set in the hospital for people who are actively dying. In the beginning, like way back in 1999, we saw all those patients. You had to call us to use that protocol. Now we see the minority of people for whom that order set is being used. We could look at the quality of care and see if it is as good, but it is pretty good. The nurses have learned a lot since 1999 and the nurses are really good at the bedside. So, I have a lot of confidence in that. Where are those opportunities and how can we study those opportunities to really ensure that people are getting care that maybe we are not the ones doing?

DR. PERIYAKOIL: One important stakeholder group who benefits from palliative care consults we have not talked about is our colleagues. They are often moving really fast, running in isolation, and feeling stressed. Sometimes I think about the question, who is the real patient here? Sometimes, the patient is actually the referring physician or referring team because they are struggling with something. We should think more about it in terms of physician wellness and the burnout epidemic.

As I reflect on the past, we were in the “forgiveness, not permission” mode, where we would tiptoe and do palliative interventions and then say, “oops, I'm sorry, I didn't mean to do this” if the managing service became upset. But we keep doing the same thing. Looking forward, I hope we will go into the “by design, not serendipity” mode, because I feel like we are just drifting along where the current is taking us. Can we grab the oars and start rowing in one direction? I want any palliative care clinician in any facility, be it rural, urban, academic, community, wherever, when they are asked, “what is primary palliative care?” they should say the same thing. If you ask them “what is subspecialty palliative care?” they should say the same thing. If we cannot even get our definitions straight, how are we going to get our gameplay straight?

DR. von GUNTEN: I do feel like I have been sitting at the table in the doctor's lounge, and I am stimulated. I love the variation of ideas. You are articulate, experienced, and willing to share your opinions. And for that, I am deeply, deeply grateful.