“The Best Care Possible” by Ira Byock—A Lesson for All of Us in Cancer Education
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- Cite this article as:
- O’Donnell, J. J Canc Educ (2012) 27: 195. doi:10.1007/s13187-012-0359-7
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As a gift on the very first day it was published, Ira Byock, my esteemed colleague at Dartmouth, gave me an autographed copy of his newest book, The Best Care Possible . I have known and admired Ira for many years now, since the time he was administering the Robert Wood Johnson Foundation’s palliative care portfolio; his work, writings, and, indeed, his very “being” have always been a source of inspiration. In the best of ways, Ira is a man on a mission to change the world. As a matter of fact, the subtitle of this latest book is A Physician’s Quest to Transform Care Through the End of Life. Ira reminds me of Paul Farmer, who was described in the subtitle of the book Mountains Beyond Mountains by Tracy Kidder as being on a “quest to heal the world” . Ira and Paul are cut from the same cloth. My institution was very fortunate to have attracted Ira; he runs our palliative care program magnificently and, more importantly, he uses our center as the home base for his quest. Being with him is a profoundly energizing experience. His passion and dreams for a better future for medicine are contagious.
I have loved the compelling and clear writing in his books, especially Dying Well: The Prospect for Growth at the End of Life  and The Four Things That Matter Most; A Book About Living , AND (see Meghan Duff’s Reflection on the use of “but” vs. “and” in this issue ) I am thoroughly convinced that this new book is his best work yet.
I started reading The Best Care Possible on my overnight flight from Boston to the 25th Anniversary Meeting of the EACE in Vienna, and I just couldn’t put it down. With the rest of the plane dark and mine the only overhead light on as I read voraciously, I experienced a paradigm shift. The book recounts story after positive story about the impact of palliative care on total “care,” and even though I’ve been worshiping at the altar of palliative care for years, a light bulb went on and I realized I may not be “getting” how much more palliative care could do. It IS part of the best care possible…and all the time, even if the patient isn’t in the terminal part of his/her illness! What one does in the best of palliative care is simply part of good (i.e., “best”) care.
The title of Byock’s book comes from the first story, in which Ira is called in consultation to see a healthy, robust, active man and his wife. The man had just been diagnosed with pancreatic cancer. When asked why he (Ira) was there to provide a consultation for palliative care just as things were beginning (haven’t many of us been there at such a moment, trying to explain preparation for death just as a plan to fight for “life” is rolling out?), Ira gave the answer that was the game-changer for me and my paradigm. He said he wanted to help make sure that this patient got the “best care possible,” and duh—I realized that what goes on in palliative care is indeed an integral and necessary part of providing the best care possible. Life is never the same for patients and their loved ones once that diagnosis “cancer” is uttered, and the knock-your-socks-off blow to one’s personhood is mitigated by the skill set that is presented through great palliative care, with the aim of attaining “the best care possible.” Evidence-based technical-scientific care and attention to the body is both essential and not enough. Attention to the soul, the very “being” of a person and their loved ones, is equally essential, and framing the care with an eye toward what the best of palliative care brings is the way to produce the “best care possible.” This doesn’t only occur in illnesses that will cause death in the near term; rather, every illness experience can benefit from the holistic approach of palliative care. Hence, my paradigm shift—every illness needs these skills. In the chapters that follow, Ira recounts story after story, each of which drove his point even deeper, especially the data on the survival advantage of palliative care . At the end, he bemoans the sad fact that our medical system is set up neither to provide this type of care, nor to expect and value it. Ira ends with policy suggestions that would make this type of care happen. Most compelling of all, he urges us to live in community and make love the center of medicine. This is not squishy stuff, but tangible things that will make a difference. Ira points out how the current financing system creates huge barriers to the best possible care. We can work together to help address these barriers.
One of the many reasons I was drawn to AACE and EACE (by the way, the Vienna meeting was awesome!) was that I sensed that by working together, we could provide the best care possible. And the “together” part was demonstrated by the best organization geared toward promoting interprofessional teamwork that I had ever seen. I hadn’t really noticed these things before Ira’s book, however. At the time I joined the AACE, palliative care was almost a gleam in people’s eyes, and through conversations among like-minded colleagues, we began to change the world toward the one Ira so beautifully articulates and envisions. I remember when, at meetings, we used to have conversations about the fact that some cancer patients actually died. Some colleagues actually called us the “fringe” of oncology. Others said we weren’t the fringe, but the “lunatic fringe.” In spite of this fringe designation, I watched as one of my idols, David Weissman, who was also on a mission to embed this in medical care, almost literally moved mountains to create lasting change. He had many others marching with him, but David himself was the disruptive technology bringing about very significant change, almost in the way that angioplasty displaced bypass surgery. Things would never be the same.
Now, even the venerable American Society for Clinical Oncology has come to the religion, and recognized that early and good palliative care must be part of the “best care possible” for cancer patients. Bravo!
AACE/EACE have been at the cutting edge for the long haul, but I feel we must take it one step further to Ira’s vision. Everything we do—from teaching about prevention to actual palliative and hospice care—must be embedded with palliative care principles to provide the “best care possible.” I hope that more of the articles in this journal walk this walk in an effort to help us all get to this ideal state of the best care possible.
I remember when David Weissman and I wrote an article for the ASCO journal called “A View from the Fringe.” David began the article with a story about a question he always asked candidates for the oncology fellowship at his institution: “Just what does an oncologist do?” A frequent answer was that “they give chemotherapy.” This would make smoke come out of David’s ears as he said, “I don’t think so…oncologists care for people with cancer!”
David nailed this, and reading Ira’s book drove the message deeper for me. That is exactly what oncologists do, and we need to do this in a way that produces the best care possible. Get Ira’s book. Have your paradigm changed, and let’s all expect behaviors that produce the best care possible. That will help us to appreciate the “meaningful work” we are privileged to do, and also help our patients, their families, and our colleagues perform, and feel better about, the tasks at hand.