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Palliative Care Perspectives : Chapter 9: Working the System and Making a Difference : The Importance of Systemic Change

In the United States at the time of this writing, public health is witnessing a resurgence in interest in large part in response to the September 11th attack and a new awareness of the risk of bioterrorism.

Medical education has not stressed the importance of systematic change as a means of promoting health. Young physicians have come to believe that a good doctor is a knowledgeable doctor.5 The doctor who can cram the most facts into his or her head is the superior physician. Clinical skills, both cognitive and procedural, are also highly valued. It is worth noting, however, that historically the greatest effect on health and mortality worldwide resulted not from clinician knowledge or skill, but from systematic changes in sanitation, which preceded not only the discovery of antibiotics but even modern germ theory.6,7 In recent years the notion of public health, focused more on collective well-being than the health of the individual patient, has atrophied to near nonexistence.

Given all this, it is a wonder that positive change in the system happens at all. Fortunately, there are always a small number of people who understand the great importance of improving the system. Although Cicely Saunders was right in suggesting that we should set lofty goals for ourselves, I am sure she would agree that one does not have to become the president in order to make a significant contribution. This book is written for the serious student of palliative care. Clinicians who find their way to palliative care are highly motivated to be of help to patients and families. They cannot help but become aware of how flawed the current health care system is. Here I am suggesting that simply becoming clinically competent in the provision of palliative care, important as this may be, is an inadequate response to the suffering around us. Each of us, regardless of our position, must work to change the system for the better.

Someday I hope a good history of hospice and palliative care will be written. The story is full of heroes (and remarkably few villains). I have had the privilege to know some of the leaders in palliative care, and their work and commitment are truly inspiring. I have been equally inspired by the work of many individuals working at local levels. Let me share one example.

A group of second-year Stanford medical students came to recognize that their preclinical training on topics related to palliative care was seriously lacking. Stanford has a course in the second year called Preparation for Clinical Medicine (PCM), a well-designed course used to jump-start students for their clinical training. These students developed a half-day course on communication - how to share bad news and discuss goals of care - and got this into the PCM curriculum. It was a wonderful thing to see - three second-year medical students teaching a group of faculty, including two associate deans, how to act as facilitators for this course. The course has been positively received. The students went on to publish what they did in a special issue of Academic Medicine dedicated to end-of-life care.8 As any medical school faculty member can tell you, there is nothing harder to change in medical school than is the curriculum. How did these students accomplish this? Beyond their obvious dedication and precocious understanding, their great strength lay in the fact that they were students, not faculty who were advocating for change. Faculty members who push for curricular reform are suspect because expansion of vested interests is often viewed as turf-building. The students could not be so accused. Their interest in changing the curriculum was selfless, and they were right to point out deficiencies. To Stanford's credit, the medical school deans listened to the students and were willing to let the students lead the way. At least sometimes there is an advantage to being the little guy.

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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.