Music is one of the things in my life that has most reliably gotten me into and kept me out of trouble. Having played in bands for decades, I see parallels with the practice of medicine. As a hospitalist and a palliative care pediatrician, I would like to apply lessons from music to consider how general palliative care (provided by all clinicians) and specialty palliative care (provided by board-certified physicians) can work together in harmony. Music (like medicine) thrives through collaboration, benefits from specialized knowledge, and begs to be shared. As we consider this comparison, I am going to use songs and albums as examples. If you do not know these songs, I hope you will pause and go listen; it just might be one of the nicest parts of your day.
Palliative Care Takes a Band
The medical team, like a good band, should come together to create something more than the sum of the individual parts. I think of the Beatles as one of the great bands of all time. Each member was incredible, and together they made music that continues to be relevant, loved, and copied decades later. Some misguided souls think only of John and Paul, forgetting the guitar work of George and the drums of Ringo that completed the unmistakable music they created as a group. Just as great bands need every member, great palliative care relies on a team of generalists and specialists.
In the July issue of this journal, I read, to my great shock, a piece entitled “Why Palliative Care Shouldn’t Exist” by Dr. Rebekah Diamond.1 The article displayed a few of the misunderstandings that have hampered generalists and specialists working together. The first is that specialist care in some way removes the need for generalist palliative care, the second is that the presence of specialist palliative care will weaken skills in other providers, and the third is that a provider should be able to do all things on his or her own without reliance on specialists. Like most knowledge, palliative care belongs in the hands of every provider. Pediatricians work as generalist infectious disease doctors when they treat an otitis but understand the need for specialty consultation in particularly difficult scenarios. We are all generalist cardiologists as we listen to heart sounds and review electrocardiograms of the children we admit. This does not mean that we are electrophysiologists or plan to perform cardiac catheterizations on our patients. Every specialist is also required to have general knowledge of other fields and defer to those fields at times. Good pediatric palliative care providers understand that honest communication, good symptom control, and focus on what is most important starts with generalist palliative care. Every provider is a key band member in the music of palliative care.
Getting Things Right Sometimes Takes a Specialist
At the 60-second mark of Buddy Holly’s hit “Everyday,” there is a celesta solo. The celesta is not, and has never been, a rock instrument. It is an instrument invented in the late 1800s that resembles the glockenspiel. It is most often used in classical music (think Tchaikovsky’s “Dance of the Sugarplum Fairy” from The Nutcracker). That said, “Everyday” would not be what it is without this brief ethereal solo. Yet this solo was not played by Holly or his band. Vi Petty, the soloist, sat in on this recording but was never heard on another Buddy Holly song. Countless other examples could be found of an instrument (Brian Wilson on the theremin in “Good Vibrations”), solo (Brian May’s gut-punching guitar tone in “We Will Rock You”), or production (George Martin’s role in the evolution of the Beatles and the album as an art form) elevating great into classic. The same can be said of specialized palliative care: when it is needed, it can improve everything. Palliative care specialists hold useful expertise and are aware of when to step in and when to hold off.
Gladwell2 famously wrote about the “10 000-Hour Rule” for becoming an expert.3 Whether or not you put stock in this principle, it is logical and true that people can improve with practice and exposure to certain situations. Specialist palliative care is often useful for rare but important events that happen in a children’s hospital, the community, or the clinic. These include working through decisions with families who may not share the same view of a situation, managing symptoms that are refractory to the generalist provider, ensuring that decisions about care translate across the continuum, and helping a family consider how to talk about serious illness with each other and those they encounter. It may include none of those things or many more.
Palliative care teams have been recognized by the American Academy of Pediatrics (AAP),4 the Children’s Oncology Group, the American Heart Association, and others as vital in providing the best and most complete care possible. When the AAP and other bodies say that every child deserves access to quality palliative care, this is not the same thing as palliative care teams seeing every child. Revisiting our comparison with other specialists, if an infectious disease service saw every child with an ear infection, our colleagues would not be able to keep up with the demands on their limited time. Just as you do not want a band member unleashing a loud solo right in the middle of a verse, palliative care specialists work hard to make sure they are seeing the right patients at the right time and for the right reasons.
Good Things Are Worth Sharing
One of my purest joys in life is to hear or tell someone about great music. When I share new music with a friend, I will often think about their interests, background, and life. As we share our palliative care skills, we would be well served to keep the same factors in mind. The AAP includes education as a responsibility of every palliative care provider. This field touches medicine so broadly that I am confident it belongs in the core competencies of all physicians.
Whenever I encounter a learner who does not think that palliative care will be a part of their practice, I think back to my medical school interview process. I sat down with a faculty physician who asked me what my father did. I answered that he was a lawyer, and the professor said that he came from the same background. When the professor asked me why I did not pursue law, I offhandedly said that I did not like paperwork. The professor laughed as he motioned around his office, which was covered in paperwork waiting for his attention. My naivete is reflected in any student who thinks he or she will not need palliative care skills. It is my mission to show the future interventional radiologists, pathologists, orthopedic surgeons, and (of course) hospitalists that generalist palliative care deserves a place in their tool box right along with skills related to infectious disease, cardiology, neurology, and the many other disciplines they take with them into their future careers.
I think of a recent interaction I had with an intern who had never run a medical care conference, which is a generalist palliative care skill. As many hospitalists know, these meetings can be a great opportunity to bring all parties together for the good of the child. They can also devolve into an unwieldy mess. Using a simple algorithm published in this journal,5 I was able to sit down with this resident and talk about what she would do to lead a successful meeting. It was a stressful case in which emotions were high and medical issues complex; however, this resident performed impressively and walked away feeling confident that she could do it again. Generalist and specialist palliative care skills are teachable, useful, and much wanted by the residents with whom we interact.6
Palliative care specialists and generalists can influence their colleagues through informal learning that happens over the phone or at a nursing unit, through didactics in small or large settings, or through writing articles such as this one. Generalists and specialists looking to increase their palliative care skills also have opportunities to continue learning through professional organizations, certificate programs, and workshops. Just like the veteran musicians who maintain a steady habit of practice, there is always something for us to improve in ourselves and teach others.
Buddy Holly croons a sentiment that rings true to the progress of palliative care: “Everyday, it’s a-gettin’ closer, goin’ faster than a rollercoaster.” As the field evolves and progresses, both generalist and specialist providers will be enriched as they work with one another. By recognizing the power of collaboration, the importance of specialized knowledge, and the need for continuous education, we are making a future in which we are all “with the band.”
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POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.