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The Future of Palliative Care



by: Olivia Gamboa, MD (@Liv_g_g)

As palliative care providers, we are lucky to be a part of a relatively new and growing field.  This provides us with both an innovative energy and the opportunity to shape what our specialty will look like in the coming years.  Concurrently, medicine as a whole is at the precipice of many sea changes in therapies and care models brought about by improved analytics (most notably artificial intelligence) and novel biotechnology.  The confluence of these technological currents means that new trends in practice are emerging quickly.  These are my thoughts about the possible directions our specialty will take and the opportunities (and challenges) this will present over the next several years.

Disclaimer: I’m just a palliative care fellow who likes to muse about these things.  These predictions do not necessarily reflect the views of my institution and are not projections nor certainties and should not be taken as such.  And remember, as Yogi Berra opined, predictions are hard to make, especially about the future.

  1. We are going big...data.  The clever use of technology to both create and to deftly analyze patient data has great potential to improve our practice.  Imagine machine-learning algorithms that can mine patient records for information that dramatically improves our prognostic capabilities.  Or the ability to use apps or wearable technology to trend pain scores remotely and in real-time.  Or the ability to virtually compare your patient to thousands or millions of similar patients to discern a priori which pain medications will be the most effective for them.  I could go on.  Some of these use cases already exist.  Though these technologies bring challenges regarding privacy and potential for bias, the advances of digital data-gathering and artificial intelligence hold great promise.  If used well, they will give us an ever-increasing ability to plunge into the noise of medical data and emerge with useful signals that will improve the care we provide.  
  2. We are going everywhere.  Many health systems are rolling out or enhancing home-based palliative care and will continue to do so very proactively.   The expansion of this trend will allow us to bring the advantages of a home-based, team model of care to patients who are not eligible for or elect not to be on hospice. The increasing use of telehealth will also offer a way to reach more patients in more places by removing the costs and physical challenges of making it to an in-person appointment.  Improved sensors and other technologies will be able to help the physician perform a remote “physical exam” or at least gather information that previously required an in-person visit.  I predict that telehealth visits will become so common that they are the default option within a decade.  Additionally, there is increasing institutional and evidential support for our embedment in specialist services other than oncology.  I think that this trend will be most prominent in cardiology, nephrology and surgery.      
  3.  We are going to do more procedures...or at least refer to other people who do.  Leaving aside that many of us consider family meetings to be the most complex of all procedures, advances in imaging mean that doing procedures outside a hospital setting is increasingly feasible.  Since your average Jane can now buy an ultrasound probe that can attach to her smart phone or tablet for $2000 (or less for a subscription-based model), the idea of doing a paracentesis or a nerve block at a hospice patient’s home isn’t completely crazy.  It remains to be seen if these advances will usher in the paradoxical-sounding new sub-specialty of Interventional Palliative Care.  
  4. We are going long.  The promises of new treatment modalities for cancer, in particular immunotherapy, mean that the long tail of survivorship is getting much longer.   I predict that in the coming years we will increasingly be in the happy position of considering the cancer “off-ramp” and how we can best support the unique needs of the growing population of long-term cancer survivors. Conversely, the fantastic success of novel therapies in some patients will leave behind a less fortunate subpopulation who face increased isolation and depression when these treatments do not work as well for them as for others.  We will need to figure out how to best support these patients as well.   
  5. We are getting popular.  Spurred by a desire to connect more with the human side of medicine, medical students, residents and practicing physicians are increasingly interested in palliative care, either as a career choice or as a skill set they bring to another specialty.  In the longer term, the increasing use of artificial intelligence (AI) for some of the more routine legwork in medicine means that the fields in which physicians do more subtle and emotionally complex work (ahem) will begin to stand out as the most promising career choices for young physicians.  As such, I expect a growing emphasis on primary palliative care in medical school and residency curricula as well as growth in the number of applicants to fellowship programs.  This mismatch between this increasing demand and the relatively constrained supply of trained physicians will provide PC physicians with better opportunities and perhaps better salaries.  Through all of this, we as a specialty will carry the attendant responsibility of continuing to thoughtfully build programs, provide primary palliative care education and find other ways to extend our services to all that need them.    

So there you have it.  Though these trends are coming on fast and may change our practice in unpredictable ways, I believe the future of our specialty will be the result of crafting a shared vision rather than moving towards an immutable destiny.  We will have the future that we work towards--so we owe it to ourselves and our patients to thoughtfully envision what we would like it to be.

Olivia Gamboa, MD

Comments

Joanne Lynn said…
I'd encourage you to remember geriatrics also -- including rehabilitation, durable medical equipment, complicated family and social supports. The numbers of frail and disabled elderly persons will quickly eclipse conventional "palliative care" patients. Some will have indolent cancers, some will suffer neurological degenerative illnesses, many will die with frailty of old age (and so on). The skill set is a bit different from hospital-based goal setting and pain relief. And the reimbursement is, for now, much worse. But that's where the large numbers will be
Peg Graham said…
THANK YOU Joanne Lynn, for mentioning Durable Medical Equipment as a data point. We know that the current generation of DME - and the restrictive practices/policies surrounding it- need a reset. DME is often overlooked when we talk about aging in place, yet it is essential for so many people whose aging includes mobility-related disability.

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