Since 2010, I have been actively engaged The Personal Caring Initiative at Mayo Clinic Health System and I have given a lot of thought to the future of caring for seriously ill people and spent many hours in front of diverse audiences talking about health care and palliative care. Most recently, I have created a model of a paradigm shift in medical care that I think exemplifies a paradigm shift in medicine to reintroduce healing to the medical mandate to provide better care for seriously ill people and those they love. Often when speaking about this I receive questions about why it is necessary to change how palliative care is funded and I have applied simple restaurant guide techniques to explain the palliative care financing problem. Perhaps this is helpful to you.

The Current Medical Model
The current model of care is one that is problem based and represented on the left side of the table below. For each diagnosis is a corresponding treatment. This has largely been the success of the last several decades of medical discovery and improved treatments. Thankfully, these discoveries have been made and have resulted in improved therapies and ultimately in increased longevity. All of these developments are wonderful, however, today people living
The Disease Treatment Model and the Lived Experience of Serious Illness

with multiple diagnosis's are at risk for a new modern medical problem. Namely, they are at risk for increasing burden of disease, burden of treatment, difficult and increasing symptoms, and declining function. Despite how we train medical professionals, the Best Care Possible, isn’t the sum total of the treatments for seriously ill people. I observe learners competing to make the longest problem lists and corresponding treatments. The same students struggle communicating with people about their hopes, fears and overall goals. How do we ensure equal attention to the biology of disease and the lived experience of the patient and family?

The Paradigm Shift
In clinical situations, where the sum total of the treatments doesn’t add up to the best care or even increased longevity, the medical mandate has to explore the right side of the table. Preferably the medical mandate would represent both sides of this table. Attention to the goals of the patient and family start to guide which therapies will contribute to the goals they have defined for themselves. Expert symptom management accompanies their goals to enhance their quality of life. The right side of the table is largely representative of palliative care. The entire table represents a concurrent approach to seriously ill people as a partnership between palliative care and other disciplines. Palliative care and the right side of the chart largely represents the long lost art of healing which took a backseat to medical discovery in the last many years however, once again healing is regaining importance as the success of medical discovery has rendered many suffering from the ill effects of co-morbid illness and strenuous treatments. Changing the way we practice and educate next generations is foundational to this paradigm shift and palliative care must lead the movement.

The Restaurant Guide to Funding Concurrent Care
Quite simply, if we had to apply dollar signs to the chart above the diagnosis column would get maybe $$$$. The treatment column would get $$$$-$$$$$$ depending on the treatment. In contrast the entire right side of the chart would get maybe a half a dollar sign, even though patients and families really value what is offered in a healing, goal based approach to care. Necessity and financing are why healing has taken a backseat to medical developments. Now we see a surge in the development of palliative care to reintroduce healing to the seriously ill and perhaps the dollar signs are going to be distributed to ensure all seriously ill patients received concurrent problem based and goals based care, with increased quality of life and increased longevity as Temel’s study showed lung cancer patients live better and longer when both sides of the table work concurrently. I am no medical economist, obviously, however it would appear that the future of palliative care funding would result in a reasonable number of dollar signs to match the value of increased quality of life and longevity in the face of increasing symptoms, declining function and knowledge of the frailty of life and possibly the approaching end of life.

Cory Ingram, M.D.
Assistant Professor of Family and Palliative Medicine
Mayo Clinic, College of Medicine

Medical Director – Palliative Care
Chair of the Palliative Medicine Specialty Council
Mayo Clinic Health System