Palliative Care

Adaptability is the surgeon’s best friend


 

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At my semiannual palliative medicine fellowship evaluation, I was asked, "What is your best strength?" and after a few seconds I said, "Adaptability."

Often, the most profound thoughts come spontaneously before habit interferes. As a practicing cardiothoracic surgeon for more than 16 years, my transition to palliative medicine and a hospice fellowship required the ability to reinvent myself, to embrace new ideas, to let go of old routines, and to accept new possibilities. In other words, to adapt to change.

During my surgical training I was most impressed with surgeons who could think calmly and rationally on the fly. As surgeons, we all understand the benefit of preparation and how contingency planning optimizes safety. But we also know from experience that no matter how well prepared you think you are, something can and almost invariably does happen that is unintentional, unanticipated, and unplanned that sabotages your preparation. So, too, is it with life.

I would never have predicted at the start of my career as a cardiothoracic and vascular surgeon that I would change, at midcareer, to palliative medicine. I am not going to explain all the events that pushed me to make a change, but suffice it to say I came to the proverbial fork in the road. I could have continued down the same path, frustrated and unhappy, but comfortable with my routines, or I could stop feeling sorry for myself, stop complaining, adapt to the changes, and go in a different direction. I chose the latter. I do miss the exhilaration and teamwork of surgery, but I have replaced it with the more profound collaboration of the palliative inter-disciplinary team that includes nurses, chaplains, social workers, therapists, and patients.

The most frequent question I am asked when people find out that I used to be a heart surgeon is why I changed careers. It’s really not as crazy as it seems. Fundamental to both surgery and palliative medicine are evidence-based options and patient-centered, informed decision making.

Historically, palliative care has had limited acceptance by the surgical community except at the end of life in an actively dying patient, but through the efforts of a few visionaries, palliative surgical care is now valued and deemed worthy of incorporation into general surgical residency training. During the past year I have been introduced to this interdisciplinary approach that improves the quality of life of patients and their families. Because this approach assesses and supports physical, psychological, social, and spiritual needs, it needs to occur with, not after, other appropriate medical treatments.

There is good empiric evidence that the earlier palliative medicine is involved in medical treatment, whether potentially curative or not, the quality of care improves: Caregiver, patient, and family satisfaction increases and resource utilization improves no matter what the delivery setting. These are very compelling data, and they validate the role of palliative medicine in a changing paradigm of health care delivery.

My vision for palliative medicine includes complete integration throughout the trajectory of all chronic illness, especially heart failure, cancer, and dementia, where coordination of care is critical and has been historically fragmented. Palliative medicine is increasing its role in acute care with improved symptom management and early consultation in the emergency department and ICU where better communication with the care team and advance care planning can help define goals of care and limit inappropriate and unwanted treatment.

The adaptability that is so crucial for patients and their families to adjust to progressive and critical illness is the same quality we need as practitioners to accommodate them. I challenge all my surgical colleagues to have the courage and wisdom to change, and to allow the integration of palliative medicine into your practice where and whenever possible.

Dr. Strzalka is a Fellow in Hospice and Palliative Medicine, Section of Palliative Medicine and Supportive Oncology, Taussig Cancer Institute, Cleveland Clinic.

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