In my third week in this position, today is the first day that I have reviewed four patients. The fact that the emphasis while discussing goals and expectations, has been on the functional status is definitely a positive.

Each of these reviews makes me think about the requirements of my role as a specialist. The fact that without latching onto the lowest common denominator of pain, proving the role for palliation in the contemporary hospital setting might prove to be an uphill task. Gasping for survival, and looking for a sense of profundity, I take recourse to my internal medicine credentials in order to escape the impostor syndrome.

The fact that I found myself supporting a brief escalation of care to the ICU for one of these patients without any pre-existing comorbidities. then does not come as a surprise. This patient has been admitted for evaluation of fever and my discussion also touched upon the fact that thromboprophylaxis might be considered essential for inpatients (and tachycardia might be the most common clinical finding) and further went onto touch upon use of markers of invasive fungal infection such as galactomannan and beta 3 glucan, and whether Mini-BAL was available. While, this adds on my long held argument that Internal medicine is essential for understanding and participating competently in the goals of care discussion with the primary team (especially when ceiling of care is being discussed), it might also be seen as a reminder of the fact that clinical needs are not always complex, merely from the ethical point of view, that medical complexity might be more prevalent than one is willing to acknowledge. It is well known that the indication for an ICU admission might dictate prognosis and that an indication like respiratory failure might have better outcomes than say renal failure and metabolic acidosis complicating septic shock.

The other interventions concerned discussion of feasibility of further cancer directed treatment in glioblastoma multiforme and involved understanding the utility of bevacizumab in the Multicentric, recurrent setting. Given that the debate of its impact on overall survival remains unresolved, would it be indicated in a situation where anti-edema measures are not being used? What outcome measures are we chasing in someone with a poor performance status and multiple comorbidities? How do we measure quality of life in someone who is paralysed, with a pressure sore, is oxygen dependent and has multiple comorbidities? Would increase in progression free survival be a valid outcome in this scenario? Well, most of my advice to this patient, involved going back to the basics – a realistic advice on outcomes, an honest acknowledgement of the continued intensive nursing needs and the poor outcomes if escalation to ICU-based care was considered? But more importantly, the crux of my discussion relied on the understanding that Bevacizumab might have a questionable role in those not on anti-edema measures (which might need to be considered first, in preference to targeted therapy).

There were other referrals too, where I made the translator provided to me, a bit uncomfortable about the ethics of truth telling and one where I am still trying to convince the team that morphine use when buprenorphine transdermal is being used for baseline pain, is to be considered safe.

I have often wondered whether I will make for a better consultant, assistant professor or both? What if a setting provides you with a taste of both. Put simply, does your approach to the patient change depending upon the depth of his pockets or his political connections? Is that an essential skill in the business of surviving modern medicine – the use of social capital to decide the quantum of response?  

The thinking palliatrist does not abandon internal medicine or oncology; rather, he maneuvers around them. Prognostication and ceilings of care discussions derive their moral valence from an accurate understanding of disease biology and therapeutic possibilities. The ethics of limitation cannot be separated from the science of intervention. If palliative medicine wishes to be more than the medicine of pain alone, it must remain grounded in the disciplines from which it emerged while retaining the courage and foresight to ask what outcomes are truly worth pursuing.

Cite as – Arora, R. D. (2026). Mindful critique (MC9) Bend around the curve – How much of internal medicine and oncology doth make a good palliatrist?. Zenodo. https://doi.org/10.5281/zenodo.21131729

Disclaimer
Every attempt has been made to safeguard the identity of patients referred to in the vignettes and any circumstances arising out of this moral treatise are completely unintended on the part of the author. The author does not intend to cause any harm to another individual’s or organization’s reputation and has tried his level best to ensure that identities are fiercely protected.

Palliative medicine is a relatively young subspecialty whose intellectual and clinical boundaries continue to evolve. In the absence of definitive texts to address contemporary questions, artificial intelligence tools mainly Anthropic (Claude) have been employed to support deeper conceptual exploration, challenge assumptions, and improve clarity of expression. They do not replace critical scholarship, clinical experience, or editorial judgment. Final responsibility for all interpretations, factual accuracy, originality of synthesis, and the quality of the published material rests entirely with the Founder and Editor.