Medical News: Looking back on the past year, how has the healthcare system changed and what is the physician community doing to adapt to the changing environment?

Natalie Houghton, MD: The past year has seen an increased focus on addressing opioid abuse and addiction. The physician community has recognized that we need more education on pain management and opioid prescribing practices. Currently the physician community is in a transition period where we’re changing how we view and manage pain. This often leads to increased referrals to specialists, because right now it’s all very reactionary practice. I think in the future we will find a balance and comfort level with opioids–it will just take time.

MN: End of life is a challenging time for families and physicians. How would you like to change the dialogue?

NH: Too often we talk about doing everything vs. nothing, and we even use terms like ‘withdrawing care.’ I think it’s important our dialogue about care at end of life becomes less about what we’re not going to do, and more about what we can do for patients. The dialogue should be about continuing to care for patients, but in a different way now.

It’s always best if conversations about end of life happen before a patient actually approaches that time. Frequently we are having conversations about end of life at a time when the patient is unable to participate and provide guidance to their providers and family members. I would love for physicians to empower patients and families to ask questions and become as educated about their disease process and options for treatment as possible. Ideally the dialogue about end of life would involve patients, families and physicians all working together to base decisions about care on patients’ expressed values and goals.

MN: What recommendations do you have for the physician community as it relates to end of life care?

NH: Don’t be afraid! Embrace death as part of life and recognize that death doesn’t equal failure on the part of the physician. Also, as physicians we are used to being the ones in control. Approaching end of life is a key time to give some of that control to patients and families, as they’re often at a time when they struggle with a sense of loss of control over their health or fate. Giving them the opportunity to direct what kind of care they receive can improve that end of life experience for them. I would also recommend that physicians take the opportunity to seek closure with patients and families. It’s important for all parties involved and can be an amazing gift to patients.

MN: How has the practice of medicine changed over your career? How would you like to see it continue to change?

NH: I have seen an increase in services that aim to improve transitions in care. We know that patients in their last six months of life experience many transitions across healthcare settings. There’s an increasing focus on how we can improve care specifically at that transition out of the hospital and back into the community.

Even in our own organization we have been focusing on growing our community based palliative care services so that we can reach patients at different points in their disease trajectory. We help them plan for their future and provide them with tools to help them be more successful at remaining in the home setting. Telemedicine is becoming increasingly common as well, and can be extremely beneficial to patients without quick access to specialized care.

Additionally, physicians are now able to be reimbursed for having advance care planning conversations, so I’d like to see those conversations taking place on a routine basis in specific populations. State specific forms, like the MOST in Kentucky, are more comprehensive than others, are transportable across care settings, and are physician orders. I’d like to see them used more routinely by nursing homes and ambulatory clinics caring for seriously ill patients.

MN: What are the biggest challenges to practicing medicine in Kentucky? What are the benefits?

NH: It can be difficult to reach patients in rural Kentucky. They have much less access to care and information. The benefit of practicing medicine in Kentucky is that I get to meet some of the most caring families–people who welcome us into their homes and lives, and allow us to support them through the worst of times. Kentucky is a place where the family unit is still fundamental. It gets them through the challenges of caring for a loved one at end of life, and caring for their loved ones is so important to them. That’s something that seems to be lost in a lot of other communities.

MN: What can Kentucky do to create a better environment for physicians?

NH: Creating avenues to provide healthcare information to rural areas is essential. It would also be beneficial to engage the physician community as we navigate the changes to opioid prescribing practices. We’re out there talking to patient and families, and I think we are fundamental to reshaping the culture.