Most surgeons are familiar with the Accreditation Council for Graduate Medical Education’s core competencies. However, many likely view them as an onerous set of requirements that have no tangible impact on their day-to-day surgical practice. When I talk to my surgical colleagues about palliative care competencies for surgeons, typical responses include: "That doesn’t apply to me, I don’t treat cancer patients" or "I don’t do much end-of-life care."
The fact is, palliative care isn’t just for cancer patients or those at the end of life. In 2003, the Surgeons Palliative Care Workgroup of the American College of Surgeons (ACS) established core competencies in two basic elements of palliative care—pain management and communication skills—to be essential for all surgeons. Rather than seeing these as yet another list of "to do" items, these competencies represent the very essence of what it means to be a surgeon.
The good news: Many surgeons routinely demonstrate proficiency in these core competencies without even thinking about it. It is time for us to take our rightful place among the better recognized members of the palliative care community. We are, as described by Dr. Charles von Gunten, Provost of the Institute for Palliative Medicine, primary palliative care providers. According to his definition, primary palliative care refers to the "basic skills and competencies necessary to relieve pain and other distressing symptoms." The application of basic palliative care principles to surgery is a fundamental component of good surgical clinical care.
Palliative care is provided throughout the course of a patient’s care, from diagnosis to the end of life. Surgeons are routinely engaged throughout the spectrum of care. Before a knife is ever raised to skin, surgeons utilize their communication skills to establish the covenant that forms the basis of every surgeon-patient relationship. Furthermore, it is through competent and compassionate communication that surgical plans are formed. Every surgeon is familiar with the process of informed consent which is the truest demonstration of surgical communication competency as we discuss a proposed procedure and its anticipated benefits (and risks) in a way that is patient specific, patient focused.
Unfortunately, recent literature suggests that our non-procedural colleagues do not always recognize or appreciate the communication that occurs between a surgeon and his/her patient. This lack of understanding is manifest in an editorial in the by Amy S. Kelley, "Treatment intensity at end of life – time to act on the evidence" (Lancet;2011;378:1364-5), in which she states: "... surgical procedures are highly reimbursed and, therefore, surgeons and hospitals are often financially motivated to operate regardless of the patient\'s preferences or goals. " In other words, there is at least the perception of surgeons as practitioners who "cut first and ask questions later."
Our first challenge is that we need to increase awareness regarding surgical communication competency to other members of the patient’s care team. It is our responsibility to inform other clinicians about these communications lest we continue to be regarded as technicians who operate without regard for patient preferences or goals.
The second palliative care core competency for surgeons is pain management. Surgeons are uniquely aware of the complexities of pain experienced by our patients. We are routinely called to apply surgical procedures for the relief of pain and, in the process, create pain (albeit temporary in most cases). Therefore, relief of suffering represents a core principle of surgical care and the responsibility to provide adequate pain control is ours primarily. Unfortunately, basic principles of pain management are often not routinely taught during surgical training.
Our second challenge is that we need to rededicate ourselves to excellence in pain management. "Surgical Palliative Care: A Resident’s Guide" is a free resource published by the Educational Division of the ACS that includes essential information on pain and other symptom management as well as a variety of key aspects of palliative care relative to surgical trainees and practicing surgeons alike.
Competencies in communication and pain management not only represent the two basic elements of palliative care for all surgeons, they embody the very basis of excellent surgical care.
Bridget N. Fahy, MD, FACS is an Assistant Professor of Surgery with Weill Cornell Medical College and an Attending Surgeon with The Methodist Hospital Department of Surgery. Her clinical practice is divided between the surgical management of solid organ malignancies and palliative care. She recently earned board certification in Hospice and Palliative Medicine. In addition to her clinical practice, she also serves as the Physician Leader of the Bioethics Program at The Methodist Hospital. Dr Fahy has no conflicts of interest to disclose.