Question on intellectual fulfillment of palliative care

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Hello,

I am a 4th year med student going into family medicine. I am considering palliative care but wonder if I would miss "solving the puzzle" of an undifferentiated patient.

Some of my most energizing patient encounters have been when I was having meaningful conversations at important moments, but also when working through a complex or difficult diagnostic workup. I can see palliative care touching such a wide variety of conditions that the breadth of knowledge for disease processes and pharmacology could be quite robust, but would welcome your perspectives on the intellectual side of the specialty.

Thank you,
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[WilcoWorld]

You won't make the diagnosis (often) but there are plenty of puzzles to solve in Palliative.

Occasionally I will make a new diagnosis by bringing a fresh perspective to the case, but that is admittedly not a common occurrence. Differentiating the cause of pain can be quite challenging in patients with complex illness. Thinking through the cause of nausea and selecting a treatment that targets that etiology while not adding side effects can be a very fun intellectual exercise. Also, Palliative is often tasked with coming up with creative solutions to complex situations by "thinking outside the box". Figuring out how to have a goals of care discussion with a patient with locked in syndrome, for instance, is one of the most intellectually stimulating things I've done in over 15 years of clinical medicine.

 

[----x----]

Thank you for your insight - it does seem like no matter the field the novelty of most problems you solve will fade. The thinking you described may well stay fresh in a way other specialties would not (to the same degree) due to the unique circumstances of each patient affecting the regimen and care needed.

 

[WilcoWorld]

Thank you for your insight - it does seem like no matter the field the novelty of most problems you solve will fade. The thinking you described may well stay fresh in a way other specialties would not (to the same degree) due to the unique circumstances of each patient affecting the regimen and care needed.

Certainly true. I still do half time EM. If I'm not teaching, most of my intellectual work is done on auto pilot, or "system 1".

When I'm teaching, and have to articulate your thought processes, it can still be stimulating to explain why my differential for monocular diplopia is different than for binocular diplopia, etc.

All that is to say, I wouldn't avoid a specialty because you think it may become less stimulating over time - that will happen in any specialty.

 

[ilovecorgis]

IM-trained, soon to be fellow.

One of the most intellectually fulfilling parts of Supportive Care for me is figuring out how to match someone’s goals of care with diagnosis and management of their medical issues. Working up an undifferentiated patient in medicine can feel extremely formulaic once you’ve seen it enough times. I get a lot of extra intellectual fulfillment in learning what matters most to my patients (using my HPM brain) and figuring out how I’ll need to adjust their medical care around those goals (using my medicine brain), so every encounter ends up feeling a bit different and new.

The symptom management component of HPM for me is less inherently exciting, but there’s still a lot of intellectual nuance and creativity needed to find the right mix of interventions to ease a patient’s pain, nausea, or whatever. I also appreciate the (relatively) instant gratification component symptom management offers when you succeed, especially when you work in inpatient palliative.

 

[Entadus]

Leading a large tumultuous family meeting can often pose a technical challenge, although I guess it depends on your definition of 'intellectual' if that scratches the itch, or not.

True we less often get the intellectual satisfaction of making a diagnosis. But we are more often responsible for gauging prognosis, and across a wide range of organ systems. We still use our "doctor brain" to understand and communicate a patient's overall clinical picture, while combining that with more attention to the psychosocial and spiritual factors. Plenty of room to think 'outside the box'.

 

[dchristismi]

Late to the party...
I am EM trained, so know exactly the itch you want to scratch. It's... different. But it can be good.

I have a 100% inpatient hospice practice, and get the intractable disasters which often does mean I'm thinking outside the box or throwing Hail Marys. It's certainly not daily but can be wickedly challenging. Neuropathic pain, especially in the sacral plexus, and Parkinsonian psychosis, for example, tend to be some of the more complicated medical challenges, but as the other mentioned, the family dynamics are where we really shine.

I picked up on a thyroid storm the other day. There wasn't honestly anything I could do about it (she was dying) but it was kind of cool...

 

[WilcoWorld]

Late to the party...
I am EM trained, so know exactly the itch you want to scratch. It's... different. But it can be good.

I have a 100% inpatient hospice practice, and get the intractable disasters which often does mean I'm thinking outside the box or throwing Hail Marys. It's certainly not daily but can be wickedly challenging. Neuropathic pain, especially in the sacral plexus, and Parkinsonian psychosis, for example, tend to be some of the more complicated medical challenges, but as the other mentioned, the family dynamics are where we really shine.

I picked up on a thyroid storm the other day. There wasn't honestly anything I could do about it (she was dying) but it was kind of cool...

Not to derail the thread, but I'd love to hear your insights on managing psychosis in Parkinson disease!

 

[UTsksk]

Pimavanserin?