Doctors don't like to talk about death, and they often avoid doing so. Most physicians — including me — never studied palliative care in medical school and were rarely trained in how to communicate with patients. By the time I finished residency in 2002, I had to show competency in running Code Blues, inserting arterial lines and performing lumbar punctures, but not a single senior physician had to certify that I could actually talk with patients.
The recent expansion of the field of palliative medicine, with doctors who are experts on having these discussions, is a giant step in the right direction. But the growth of this specialty has not kept up with the need: There are 4,400 such doctors in the United States today, but the need is estimated to be as high as 18,000 physicians. Incentives such as student loan forgiveness, higher baseline salaries and more robust insurance reimbursements would encourage more students to consider the specialty as a profession. But it would take time for society to reap the benefits.
Recently Medicare announced plans to reimburse doctors for having advance care planning conversations with patients. This is an important start. But it's not enough to simply reimburse for these discussions, which are not one-time exchanges but rather a process over time. Neither is it realistic to expect most doctors who have never been trained to have these dialogues to all of a sudden be experts, which studies have suggested is difficult. We need to make sure that these exchanges are high-quality, informed, shared decision-making encounters where patients understand each of their options along with the risks and benefits.
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