“The biggest mistake that people make in putting together palliative care services,” concurs Dr. von Gunten, “is thinking that the patient is the client. That isn’t true. It is the person requesting the consultation—meaning, the referring physician or the managing service. The patient is the secondary beneficiary.
“The language we use—‘my patient’—is fundamental to the practice of American medicine,” explains Dr. von Gunten. You have to respect that. If you go to someone’s home, you don’t redecorate it because you don’t like their taste. You do not comment on their choice of draperies or their choice of food. The same applies to medical consultations.” (See “Consult Etiquette for Palliative Care Services,” p. 33.)
Oncologists generally feel “very possessive” about their patients, adds Dr. von Gunten. Even though oncologists are technically also consultants (to the patient’s primary care physician), the pattern in American medicine is that oncologists treating patients acquire the status of a primary care physician. “So,” he says, “you treat them with that kind of respect, which means that you ask permission before you do things, and you don’t disparage what they are doing—either to their faces or to their patients or to other bystanders like nurses.”
Dr. Lawson agrees that oncologists often have a strong personal bond with their patients. “These personal feelings are often reciprocated by the patients and families,” he says. “Accepting another person [the hospitalist as palliative care consultant] into the equation can be difficult at times, even more so while the patient is still in the hospital and the oncologist is still around.”
The palliative care program at Emory is consult-driven. “The doctor has to agree to us getting involved, so I don’t get into territorial issues,” says Dr. Grossman. “When I do get involved with patients, the oncologists welcome me taking care of them and realize the benefit of what I’m doing. They see that my approach is collaborative.”
Dr. Grossman has been able to offer services to oncologists whose patients are receiving chemotherapy and experiencing significant symptoms, such as pain. When hospitalists on the hospital medicine service consult her about cancer patients, she calls the primary oncologist to familiarize herself with the patient’s background and to check if other treatments are available.
Strengths of Hospitalists
Palliative care should be distinguished from hospice or end-of-life care, although it can be concurrent. Palliative care needs—ranging from symptom management to alleviating psychological suffering—can exist at any point along the cancer care trajectory, notes Dr. von Gunten, who was a co-developer with Dr. Pantilat and others of the California Hospital Initiative in Palliative Services program to assist hospitals to develop palliative services.4
Hospitalists, says Dr. von Gunten, already possess some of the baseline skills needed to deliver palliative care: They’re based in the hospital and so have the opportunity to interact with patients and their families; they are experienced in hospital-based management of patients; they are experienced in teamwork with other providers also based in the hospital. The ability to be available to patients and physicians 24/7 is a real advantage in symptom management, says Dr. Lawson.
Because hospitalists by definition care for people who are not their primary care patients, the sophistication and sensitivity about working with one’s colleagues “is already inculcated,” observes Dr. Meier. In addition, “hospitalists understand that their responsibility to and relationship with the patient is only one piece of being a good doctor. Ensuring good care for a patient means very high level and high intensity communications with everyone involved in that patient’s care: all the other specialists, the primary care physician, and the floor team—the social workers, nurses, certified nursing assistants, dietary staff, and rehab and physiatry staff. Unless everyone is reading from the same page, the patient’s care will not be good. Very often, it’s the hospitalist or palliative care consultant who is at the center of the wheel, making sure that all the spokes are getting the same message,” she says.