Abstract
Isubscribe to the New Yorker magazine mostly for the cartoons. They have a unique ability to succinctly capture some “truth” of modern life. The most effective of them trigger both a laugh of recognition as well as a wry wince. An old cartoon from the New Yorker magazine has made the rounds of palliative medicine physician offices. We have permission to reprint it here. I remember seeing this early in my career as a palliative medicine consultant.
The version making the rounds has an added title above it,
I have a framed copy that has sat on my office bookshelf for many years. I speculate the author of the cartoon meant it pejoratively. Poking fun at the doctor who hasn't learned to “tell bad news.” The development of communication science and making that knowledge available through a palliative medicine consultation is a practical way to make the science available to the patients, and their physicians, who need it. In many medical centers, 2/3 of all consultations contain a request to host a “Goals of Care” conversation which usually entails the need to tell the bad news.
Over the past 25 years, palliative medicine has achieved “expert” status; we have become the arbiters and teachers of others. The quality of physician–patient communication about the “bad news” of serious illness has made it to the high-stakes level of health care organization quality measurement. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results have real implications for the financial support of hospitals in the United States. Similar tools are in use elsewhere in the world. Neurologists have been the butt of jokes for generations about their poor patient communication skills. So have critical care physicians, both adult and pediatric—yet they now need these skills. Since it's not just the physician who talks to patients and their families, nurse practitioners, physician assistants, social workers, pharmacists, and others now engage in direct patient care in team settings.
Communication about serious illness can be a part of that team care. The frequency of the “bad news talks” appears to go up during life-threatening pandemics such as the one with COVID-19, at least in the beginning. Specialist palliative care units are places for the “difficult” cases, as well as a product of the skill: efficiency argument that underlies the development of any specialty hospital unit.
Dr. Diane Meier told me in the early days of our field in the United States that a neurosurgeon in her hospital told her the “goals of care” talk was the equivalent of neurosurgery. That is high praise indeed and a mark of the esteem with which we are held by colleagues in the hospital. At the time, I was trying to cope with the tidal wave volume of such requests in the hospital where I was working. Some of the time, it felt the title fit what I was doing precisely—very challenging conversations with very challenging patients and their families—sometimes requested by neurosurgeons. Other times, I felt like a plumber fixing a leaky faucet with a new washer that the managing physician could have done, but knew I could do better, faster, or more efficiently despite the added time and expense. As the demand for our field has grown over the succeeding generation, this conundrum has played out the world over. The same supply and demand arguments that underlie almost all human services now apply to palliative care. Should we teach others to do it themselves? Should we do it if we have enough staff because we do it better, and free others to do what they do best? In the setting of shortages of specialist consultants, the presence of a specialist palliative care team is a recruitment tool and physician satisfier for the institution. When we don't have enough people, such as during the COVID-19 pandemic, do we triage? Such is the state of our field.
Overall, I see this as a mark of success. Now that I have reached the age of 67 years, I can retire from clinical work, as well as my from role as Editor-in-Chief of Journal of Palliative Medicine, knowing that the field has been established. The sociology as well as the science of the field will continue to evolve. Journal of Palliative Medicine will continue to disseminate new information that shapes the field around the world. I am deeply proud of my colleagues who founded the field, and even more proud (like a kvelling grandfather) of those we have trained who will follow us in meeting the needs of patients, their families, their physicians, and the other members of the health care team who say they “couldn't have done it without us.” That has been the reward of the practice of medicine from the beginning of time. How satisfying for me to have played a role in that history.