AAHPM — Winter Quarterly 2011
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Ronald J. Crossno

From the Shadows into the Spotlight

Reflection on one’s year-long journey seems to be an appropriate and popular theme in the president’s message each winter. When I recall the past several months, a lot has happened, but I also recognize one predominant theme—that of surprise. Although I knew the year would not be predictable, and I expected to encounter diverse perspectives and people, I hadn’t anticipated how varied the viewpoints related to hospice and palliative medicine would be from insiders and outsiders alike.

I entered this subspecialty for many of the same reasons my colleagues did. There are few fields that allow such a rewarding experience with patients and their families, allowing the practice of high-quality medicine guided by individualized, patient-directed goals of care.

The opportunity to be involved in a field that was still new in the sense that it was not well recognized when I first became involved also had appeal. I recall the days when one did not dare mention working in hospice unless he or she was prepared to be treated as an outcast, at worst, or to do a lot of explaining, at best. But the frequency of these interactions has diminished over time. Today I more often encounter people who have had positive personal experiences with hospice and palliative care. My taxi rides and airline trips are more commonly spent interacting with satisfied individuals rather than explaining what hospice and palliative care is and how it can be beneficial.

The professional landscape has changed to an even greater degree. Here, too, I have been pleasantly surprised that my interactions with other healthcare professionals and government leaders who were once dismissive are not only positive but increasingly tinged with admiration for what hospice and palliative medicine is and has accomplished. I recall my first such experience from several years ago, although I’m not sure our Academy delegation recognized it for what it was at the time. AAHPM was struggling to maintain our representation in the American Medical Association (AMA) House of Delegates. Academy leaders were working very hard to meet the requirements but felt like they were not going to succeed. Our diligence was recognized by AMA leadership, but perhaps more importantly, their leadership recognized the strides made by our field—that hospice and palliative medicine was already a very important aspect of the entire field of medicine, and that our influence was only going to continue to ascend. Based largely on that recognition, AAHPM was granted an exception to allow our continued representation.

Shortly after assuming the Academy presidency, the deputy director of the US Food and Drug Administration (FDA) called me to discuss an impending announcement on proposed opioid regulations. Earlier interactions with agencies like the FDA had occurred because someone knew someone else personally, which was also how things were accomplished in the early days of our field. But this call was a matter of professional protocol, recognizing the importance of our field, including our physicians and unique patient population. To me, this marked an important turning point: The FDA contacted AAHPM and other recognized organizations in our field to seek input and counsel. They knew who to call and why it was critical to share important news in advance, in part to identify any unintended consequences prior to their occurrence.

Another example of increased recognition and growing importance of our field was when AAHPM was invited to send official representation to the American Osteopathic Association (AOA) House of Delegates meeting this past July, during which I was formally recognized and warmly welcomed. In addition to the AOA, several other organizations invited the Academy to participate in key meetings and initiatives over the past year, including the National Quality Forum, the Medicare Payment Advisory Commission, the Council of Medical Specialty Societies, the Pain Action Alliance to Implement a National Strategy, the Collaboration for REMS Education, and the International Transplant Nurses Society.

During the AAHPM Capitol Hill Days event in September, every congressional staffer I met was already knowledgeable about hospice and palliative care. That isn’t to say there weren’t opportunities to educate, but the starting point was well above zero and almost uniformly positive. This is in large part due to the efforts of our collective advocacy efforts at both the state and federal levels. However, it also reflects how hospice and palliative care is starting to be broadly recognized as an important component of the entire healthcare policy agenda.

More recently, while attending a meeting at the National Association for Home Care and Hospice (NAHC), this change in attitude was perhaps even more clearly exemplified. For those unfamiliar with NAHC, it is an organization primarily composed of home health providers across the country, with increasing representation from hospices and home care agencies offering outpatient palliative care services. The hospice and palliative care components seemed—to this first-time attendee of their meeting— to be relatively recent additions to what has traditionally been an organization devoted to home health.

The goal of the NAHC Physician Leadership Forum was to engage internal physician leadership, as well as leadership from across many areas of medicine, such as the AMA, the American Medical Directors Association, and the American Academy of Home Care Physicians, in an effort to promote physician involvement in the home care setting. As I listened to several stories of success from other participants, I was struck by how similar these were to the hospice and palliative medicine experience. It also occurred to me that our experience actually represents a fairly mature model of successfully accomplishing many of the goals other organizations are now pursuing.

I shared with the group of physician leaders at NAHC that it seemed their vision was one of moving sick patients from the hospital setting to the home setting to better manage their care there, and that achieving this would require a complete change in attitudes and priorities. I explained that this is very similar to palliative care, during which patients are commonly moved from intensive care units to other settings where more appropriate care can be provided based on the patient’s goals. I also asked them to try to think of another field that has evolved and succeeded, in a single decade, from having relatively few inpatient services to offering these same specialty services in more than 60% of all hospitals and more than 80% of hospitals with more than 300 beds. This—as we know—is the evolution of palliative care. I also noted some emerging challenges resulting from this growth, including the lack of an expert work force necessary to meet the increasing demand.

How our field achieved success is a story too long for my remarks to any of the groups I’ve had the pleasure to meet during this past year and certainly for this column. But it is a story worth telling, analyzing, and spreading. The NAHC physician leadership group is certainly interested and so are many others.

I used to joke that I entered hospice and palliative medicine because I was inspired by the Timbuk3 song, “The Future’s So Bright, I Gotta Wear Shades.” I don’t mean to minimize the work ahead, but ladies and gentleman, you better have your shades on because our field is now a headliner, having moved from backstage directly into the spotlight. Will we shine brightly, earn good reviews, and remain an audience favorite? That depends on how each of us performs, individually and collectively.

It has been an honor to serve as your Academy president during this year of exciting developments for our profession. I look forward to continuing our important work together in the years to come.