A Diamond in the Rough

Gemstone cutting is a precise and laborious technique by which a multifaceted, highly valued crystal is brought forth from a rough-appearing irregular stone. It is a learned skill, concentrated in the hands of individuals who have acquired the necessary expertise through apprenticeship and practice. Cutting a diamond—the hardest of gemstones—requires even more specialized knowledge, tools, equipment, and techniques because of its extreme difficulty. When we speak of a “diamond in the rough,” this metaphorical phrase reminds us that highly valued diamonds are quite ordinary appearing at first, and that their true structure and beauty is only revealed through a process of cutting and polishing.

This metaphor came quickly to mind when considering this month's issue of the Journal of Palliative Medicine—let me explain. We all peruse the contents of our research journals for new truths we can use in practice. Not surprisingly, we focus on topical content we can use—pediatric palliative care providers seek research enrolling children, hospice clinicians read studies from their setting first, and investigators and educators who focus on pain management may prioritize an opioid clinical trial over a study of spiritual caregiving. But I invite you to look at this issue of the journal differently.

Palliative care is a diamond in the rough, partially cut. Thanks to the past decade or two of high-impact research, few health care providers within or outside our field question its value. Facets have emerged and shine with the clarity that comes from uncovering a crystalline structure. For example, intensive community and outpatient palliative care improves satisfaction, symptom control, and quality of life while reducing intensity of health resource use.^1–4 We can say with confidence that hospice and palliative care do not shorten life in serious illness, and may even prolong life for patients with certain cancers or with heart failure.^3–6 Yet for those of us engaged daily with clinical palliative care, we are well aware that we face uncertainties and gaps in the evidence that should guide our treatment. Those are the facets still hidden in the rough stone.

As you read the pages of this issue of the journal, take a look at every article and think about the compelling array of skills and tools investigators apply to bring hidden gemstones into the light. First, validated interview instruments are tools that allow for quantitative analysis of the human experience. Palliative care is intended to improve patient and family-centered outcomes, so we require these measures in order to learn when and how we succeed. Investigators like Wells-DiGregorio use rigorously designed questionnaires to capture elements of bereavement such as complicated grief, posttraumatic stress symptoms, and depression. ⁷ From this carefully conducted prospective study we learn that setting-specific care may be required to improve bereavement outcomes for families. Second, some investigators have the wisdom to recognize the questions that cannot be compressed into numeric summaries; thankfully they understand and use the tools of qualitative research. In this issue, Periyakoil reports on an extraordinary mixed methods study with interviews in seven languages, allowing the voices of a culturally diverse group to inform our efforts to expand access to care. ⁸ Szekendi and colleagues use qualitative interviews to report on potential solutions to access as described by experts in health policy. ⁹ Third, reports on innovative forms of treatment expand our therapeutic options. Read the study of music therapy by Oechsle and colleagues, and consider the skill necessary to design an intervention, recruit patients to try it, and evaluate the potential benefits. ¹⁰ In addition, this issue illustrates the valuable tools required to conduct systematic reviews, health services research, and educational research.^11–12

It is our good fortune to practice in a time of increased investment in the tools of research. Federal dollars are at work through the National Institute of Nursing Research in a major investment in the Palliative Care Research Cooperative Group in order to promote new clinical trials, investigator development, and expanded awareness of measurement tools. ¹³ Private philanthropy and foundations are investing in the Center to Advance Palliative Care, promoting rapid dissemination and implementation of evidence into practice. ¹⁴ The National Palliative Care Research Center and the American Cancer Society provide career development and pilot research awards to catalyze the science of palliative care.^15,16 Palliative care is by necessity interdisciplinary, and concerned with the patient as a whole person. It will take skill, time, and patience to gain the answers to key questions we ask every day in patient care—but keep reading!