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Mainstreaming Palliative Care by Dr. Periyakoil and Dr. Von Gunten

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Vyjeyanthi S. Periyakoil, M.D. and Charles F. Von Gunten, M.D., Ph.D. 

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Palliative Care has arrived.

The field has been officially recognized by both the American Medical Association (AMA) and the American Board of Medical Specialties (ABMS).

While this is indeed a time to take great pride in being a palliative care professional it is also
1. The time to take stock
2. Examine where we are
3. Identify where we want to be
4. Plan how best to get there.

As the field of palliative care moves into a new phase in its life cycle it faces some very real threats.

The transition from a young field operating in a few select locations and dominated by a handful of visionaries and pioneers into an established field with a presence in every health care institution and run by pragmatic clinicians is a challenging one.

This gap or chasm between these two stages in the life cycle of the field is an important one and must be the primary focus of any long-term development plan. The field of palliative care in the U.S. is now entering this chasm. Once the field successfully crosses the chasm, it will then emerge as a robust field with a mainstream market and great potential for sustainability (Fig. 1 below).

Why is crossing the Chasm a risky process?

A review of the existing successful palliative care programs reveals the following commonalities:

1. Early programs are often founded and run by charismatic leaders and visionaries.

2. These charismatic leaders have (often against all odds) managed to secure access to a local champion in administration.

3. External grant funding sources are often used to support some of the core program activities.

Thus, these early programs were/are critically dependent on their leaders for sustainability. While this model may work well in an early market it is not one that lends itself to dissemination to a mainstream market. More importantly the skill sets needed for sustainability in a mainstream market are often diametrically opposite to those needed in the early market.

Thus, palliative care will mainstream if and only if new programs can be created and maintained by pragmatic clinicians in a neutral (or even hostile) administrative environment without supplemental external financial support.

A different set of resources are needed in order to help the field make this critical transition (Fig. 2 below).

Resources needed for the successful mainstreaming of palliative care

The Medium

Typically there are two successful paths for most medical subspecialties. The first one is a ‘high-tech’ and the second pathway is a ‘high-volume’ pathway.

High-Tech Pathway:
The specialty has specialized skills that are aimed at solving specific problems. Examples of this pathway are fields like neurosurgery and radiation oncology.

High-Volume Pathway:
A specialty that embraces this path is often able to care for a large number of patients in a short amount of time with the field of dermatology being a classic example.

The field of palliative care has forged a third new pathway.

Palliative care is a ‘high-talk‘ specialty with a major focus on communication skills. This then makes us a low-tech and often a low-volume specialty (conducting crucial conversations with patients with advanced illnesses behaviors of the populations we serve. This then can guide our clinical care, teaching, research, and quality improvement efforts thereby helping us enter the mainstream market.

The Message

When you are asked to ‘Xerox something,’ you know exactly what you are supposed to do. If you want to find information on a topic you ‘Google it.’ Everyone knows a ‘Kodak moment‘ when they see one. Xerox Corporation, Google Inc., and Eastman Kodak Company epitomize the power of the message.

The meaning of what constitutes palliative care is currently subject to a wide variance. Many health care institutions offer palliative care services. At this time, this can mean that these facilities have a part-time massage therapist on staff or it can mean that they have a sophisticated multivenue palliative care program or anything inbetween. The need for standardization, quality and, most importantly, consistency cannot be overstated. The field needs one simple and unifying message, a catch phrase, which can immediately and effectively transfer to the public the meaning of everything we stand for.

The Mentors

When Meriwether Lewis and William Clark set out on their epic journey, they did not stop at the local St. Louis AAA for maps and traveler’s checks.

The “Pioneers in Palliative Care” series is an effort to document the trailblazing trajectories of the field visionaries, analyze their paths, and absorb their wisdom. Palliative care is a young field in need of intense ongoing mentoring. The pioneers who have until now skillfully created and catered to an early market will now need to mentor the young field of palliative care and skillfully guide it first through the chasm into the mainstream market.

The Maintenance

Anyone who has ever started a campfire knows that starting the fire is the easy part. Tending to the fire and maintaining it on an ongoing basis requires a separate skill set. Fortunately, palliative care has the uncanny ability to draw health professionals who have a great passion and commitment to the field. We need to harness this passion to hold ourselves to high standards and rigor in clinical work, teaching and research.

Finally as we get ready to face the new challenges of a growing field, it is critical that we stoke the kernel of inner energy that led to the original movement.

Palliative care is all about the patient.

Our passion for providing quality care for all patients with the aim of augmenting comfort and fostering patient dignity is what drew us to the field in the first place. Despite all the struggles we have faced and will be facing again, we can look back and take great pride in the wisdom of our choice to specialize in palliative care.

Poet Robert Frost summarizes this so very elegantly in the following excerpt from his beautiful poem The Road Not Taken.

Two roads diverged in a yellow wood
And sorry I could not travel both
And be one traveler, long I stood
And looked down as far as I could
To where it bent in the undergrowth, . . .

I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I-
I took the one less traveled by,
And that has made all the difference


1. Moore GA: Crossing the Chasm: Marketing and Selling Technology Products to Mainstream Clientele. New York: Harper Collins Publishers Inc., 1999