Should palliative care be a specialty?: YES

Joshua Shadd

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Raising the Bar in End of Life Care
Joshua D Shadd

Published on: 29 July 2008
Subspecialties In Family Medicine: A Question of Values
Aaron M Orkin

Published on: 28 July 2008

Published on: (29 July 2008)
Page navigation anchor for Raising the Bar in End of Life Care
Raising the Bar in End of Life Care
Joshua D Shadd, Palliative Medicine Physician
Dr. Orkin’s critique of my argument is quite right – I provided a positivist answer to a normative question. My only defense is that the original question which I was asked to address was ‘Is palliative care a specialty?’ Only after my submission was the question changed to ‘Should…?’
The editors were right to change the wording. ‘Should’ is the question with which we need to grapple. My answer is still y...
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Dr. Orkin’s critique of my argument is quite right – I provided a positivist answer to a normative question. My only defense is that the original question which I was asked to address was ‘Is palliative care a specialty?’ Only after my submission was the question changed to ‘Should…?’
The editors were right to change the wording. ‘Should’ is the question with which we need to grapple. My answer is still yes, though my argument is different. Our ultimate goal must be to improve the care of people with palliative needs. In the long run, this involves not only knowledge translation (i.e. helping all providers to employ best practices) but knowledge generation (so that best practices 50 years from now are better than best practices today). In every field of medicine, knowledge generation comes primarily from those engaged in the field full time. Therefore, one piece of a broad strategy to improve palliative care would be to encourage physicians to engage in palliative medicine full time, and to enhance the knowledge and skills of this cadre of physicians. It isn’t about title. It is about raising the bar.
What happens if we don’t? One of two things: either the bar will not be raised (which will be a disappointment for every Canadian at risk of dying), or it will be raised by someone else within the Royal College alone (which will be a disappointment to those who see Family Medicine as the beating heart of palliative care). Should palliative medicine be a specialty? Yes, because the bar needs to be raised, and we need to take a leading role in raising it.
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Competing Interests: None declared.
Published on: (28 July 2008)
Page navigation anchor for Subspecialties In Family Medicine: A Question of Values
Subspecialties In Family Medicine: A Question of Values
Aaron M Orkin, Resident, Family Medicine
Dr Shadd’s argument in favour of palliative care as a subspecialty hinges on a tautology: that any area of medicine is either a specialty/subspecialty or not a specialty/subspecialty. His argument can be reduced to the following statements:
• Family medicine is a specialty (as declared by the CFPC in 2007).
• All specialties contain subspecialties.
• Therefore, Family Medicine has subspecial...
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Dr Shadd’s argument in favour of palliative care as a subspecialty hinges on a tautology: that any area of medicine is either a specialty/subspecialty or not a specialty/subspecialty. His argument can be reduced to the following statements:
• Family medicine is a specialty (as declared by the CFPC in 2007).
• All specialties contain subspecialties.
• Therefore, Family Medicine has subspecialties.
• “Subspecialty” has a clear definition (under the Royal College of Physicians and Surgeons).
• Palliative care fits the definition of a subspecialty.
• Therefore, palliative care is a subspecialty.
However, this is not really a debate about whether palliative care fits into a RCPSC definition, especially since this definition has not been adopted by family physicians or integrated into family medicine training or organizational structures.
Should palliative care be a specialty? This is a normative question: a question of values, a question of how things ought to be. It is not a positive question: a falsifiable question, or an issue of definitions and categorization. Dr Shadd’s positivist answer to a normative question assigns palliative care to the set of subspecialties, but he offers no cogent argument for or against the question at debate. Just because the CPFC has asserted that family medicine is a specialty – just because family doctors may now carry contradictory titles like “generalist specialist” – does not de facto lead to the conclusion that family medicine must have subspecialties.
If we are to properly address the pressures to now introduce family medicine subspecialties, family physicians will have to identify and articulate the meaning and value of generalist practice. We will have to engage with normative questions: Should family medicine have subspecialties? What would we call them: subspecialist-generalist-specialists? What would family medicine subspecialties mean for the spirit and affirmative practice of generalism? What motivates our discipline to engage in the fracturing of medicine and the denaturing of health care into ever smaller pieces?
Is any of this a good thing?
Are we all still practicing family medicine?
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Competing Interests: None declared.