After years of leading palliative medicine departments, as a Fellow of the American Academy of Hospice and Palliative Medicine, I’ve had countless conversations that start the same way. A colleague in the hallway says, “Oh, palliative care—that’s so important. You all are so nice.” Or a hospital administrator tells me, “We wish we could give you more, but resources are tight right now.” Or my personal favorite: “Palliative care is great, but this patient isn’t ready for that yet.”

Each time, I smile and nod, but inside I’m thinking: I used to say the same things before I came into palliative medicine, because once upon a time, I also had no idea what we actually do.

So let me tell you. Not because I need validation, though I won’t lie, recognition would be nice, but because our patients deserve better than a health care system that treats palliative medicine as optional, soft, or somehow less clinical than other specialties. It’s time for a culture shift, and it starts with understanding who we really are and what we bring to the table.

We are clinicians: deeply trained, broadly expert

Let me introduce you to teams through the years: We have physicians who completed grueling residencies in internal medicine or family medicine, then chose to do additional fellowship training in palliative medicine, earning dual board certifications. Some of us, myself included, have gone on to earn fellowship in the American Academy of Hospice and Palliative Medicine (FAAHPM), a distinction that recognizes sustained excellence, scholarly contribution, and dedication to advancing our field. We have nurse practitioners who’ve been managing the sickest patients in health care for decades, with backgrounds in critical care, oncology, psychiatry, many holding advanced certifications in hospice and palliative nursing (ACHPN, CHPN). We have physician assistants who can rattle off opioid conversions, drug interactions, and disease trajectories in their sleep.

This isn’t training we picked up in a weekend workshop on empathy. This is years, often decades, of dedicated study in the science of suffering and its relief. We’ve mastered complex pharmacology, understand pain physiology, know the intricacies of symptom management in the setting of multiorgan failure, and we can navigate polypharmacy in ways that would impress a clinical pharmacist.

On any given day, my team manages refractory pain syndromes that confound: We treat intractable nausea in patients on 17 medications with failing livers. We diagnose and manage delirium in the medically complex. We titrate opioids for respiratory distress with precision. We anticipate and prevent the metabolic crises of advanced disease. None of this is soft or simple. It requires the kind of clinical acumen that belongs in the same conversation as any other medical specialty.

The breadth of our expertise is staggering.

Here’s what a typical consult looks like for us: A 67-year-old with metastatic pancreatic cancer, heart failure, chronic kidney disease, and diabetes presents with uncontrolled abdominal pain. She’s on a fentanyl patch, but it’s not working. Her primary team wants to increase the dose, but they’re worried about her kidney function and the fact that she seems “a little confused.”

My colleague walks into that room and conducts a complete assessment. They’re evaluating the patient for bowel obstruction, examining for peritoneal signs, assessing neurologically for signs of opioid neurotoxicity versus metabolic encephalopathy versus brain metastases. They’re calculating equianalgesic doses while accounting for incomplete cross-tolerance and renal dysfunction. They are considering whether the patch is even absorbing properly given the patient’s cachexia and thinking about adjuvant medications for neuropathic pain, potential celiac plexus involvement, and whether we need imaging to rule out a surgical emergency.

That’s not hand-holding. That’s clinical medicine.

And when they sit down with the patient and family afterward to explain what’s happening, to help them understand the disease trajectory, to explore what matters most to them, that conversation is built on the foundation of clinical knowledge. You can’t have meaningful prognostic discussions without deeply understanding the medicine. The two are inseparable.

Communication is clinical expertise, not a consolation prize

I need to address something gently: the assumption that because we’re good at talking to patients, we must be doing something easier than “real” medicine.

Let me share what’s actually happening. The communication skills we bring are not separate from our clinical expertise; they’re an extension of it, and honestly, they’re one of the hardest things we do.

When I spend 90 minutes in a family meeting helping a daughter understand why her father’s kidneys are failing and what that means for his prognosis, I’m drawing on everything I know about renal physiology, disease trajectories, treatment options, and outcome scenarios. When my colleague helps a patient weigh the benefits versus burdens of continued chemotherapy, they’re synthesizing oncologic data, performance status assessments, and evidence-based prognostication. When our team navigates conflict between family members with different goals, we’re applying ethical frameworks, understanding family systems and trauma-informed care, and translating complex medical reality into language that honors everyone’s perspective.

This is clinical work. It has measurable outcomes. Studies show it improves quality of life, reduces unwanted interventions, decreases ICU utilization, and sometimes even extends survival. These conversations are interventions, as evidence-based as any medication we prescribe.

And they can be exhausting. They require every ounce of our clinical knowledge plus emotional attunement, ethical reasoning, and the ability to sit with profound suffering, and that work is harder than writing orders. The skills I’ve honed over years of practice, the knowledge I’ve contributed to through scholarship and teaching that led to my FAAHPM fellowship, these aren’t soft skills. They’re expert-level clinical competencies that save lives, reduce suffering, and improve outcomes in ways that are both measurable and profound.

We’ve pioneered a new model of leadership.

Here’s something I’m particularly proud of: Palliative medicine has figured out something that much of health care is still wrestling with. We’ve built a truly interdisciplinary model, and we’re better for it. Across this country, there are a handful of palliative medicine programs led by extraordinary nurse practitioners who bring decades of clinical expertise and visionary leadership. I’ve watched colleagues who are APPs build programs from the ground up, shape institutional culture, develop innovative protocols, mentor new clinicians, and advance the science. Some of the most respected voices in palliative medicine throughout the world are nurses and NPs who’ve dedicated their careers to this work.

This isn’t about “lowering” standards; it’s about recognizing that expertise and leadership capacity aren’t determined by degree type. In my own program, I learn constantly from physicians, APPs, nursing, chaplains, speech therapy, and so many others. A speech pathologist with 20 years experience knows things I’ll never know and can often be the earliest observer of the trouble to come. A PA who’s managed thousands of complex symptom cases has expertise that deserves equal weight in clinical discussions.

Our interdisciplinary model (physicians, NPs, PAs, social workers, chaplains, pharmacists, etc., working as genuine colleagues) is our greatest strength. We make better decisions because we draw on diverse perspectives. We provide better care because different team members bring different gifts. And we model the kind of collaborative medicine that health care desperately needs more of.

When other specialties tell me they can’t imagine an NP leading their department, I find myself thinking that’s unfortunate because leadership is person-specific, not discipline-specific. I’m part of an organization that sees this in me, and I am thankful everyday to be here.

The organizations fighting for our field

I’m grateful for the work that organizations like the American Academy of Hospice and Palliative Medicine (AAHPM), the Hospice and Palliative Nurses Association (HPNA), and the Center to Advance Palliative Care (CAPC) are doing to broaden knowledge, improve awareness, and increase accessibility to palliative care. These organizations are on the front lines of advocacy, education, and research that’s transforming how health care thinks about serious illness care.

CAPC has been instrumental in helping hospitals develop and strengthen palliative care programs, providing the tools and resources that have allowed hundreds of institutions to launch services. AAHPM advances the field through research, education, and policy work that elevates standards of practice and ensures our specialty continues to evolve based on evidence. HPNA has championed the role of nurses in palliative care, recognizing that excellent end-of-life care has always depended on skilled, compassionate nursing.

These organizations understand something critical: Palliative medicine can’t reach everyone who needs it unless we build awareness, train more clinicians, and advocate for policy changes that support our work. They’re changing the conversation at a national level, and their work matters enormously.

The challenge we’re facing: too few of us for too many patients

Here’s something that keeps me up at night: Palliative medicine is one of the smallest medical specialties in the country, yet the need for our services is growing exponentially. Our aging population, the increasing prevalence of chronic serious illnesses, and the growing recognition of palliative care’s value have created a demand that far outstrips our capacity to meet it.

We’re facing a provider shortage that should concern everyone in health care. There simply aren’t enough fellowship-trained palliative medicine physicians, board-certified palliative NPs and PAs, or specialty-trained nurses to care for all the patients who could benefit from our expertise. And the pipeline isn’t filling fast enough.

Why? The reasons are complex and interconnected. Palliative medicine fellowships are often underfunded and competitive. Reimbursement models don’t adequately support the time-intensive work we do, making it harder for institutions to build robust programs with the resources we need. The persistent misunderstanding of our specialty (the “it’s just about death and hospice” misconception) discourages some clinicians from considering it as a career path. And the work, while deeply meaningful, is emotionally demanding in ways that can lead to burnout without adequate institutional support.

We’re losing potential palliative care clinicians to other specialties where the work feels more valued, better supported, and less stigmatized. Meanwhile, millions of patients are experiencing symptoms that we know how to manage, facing difficult decisions without the guidance they deserve, never having conversations about what matters most to them because there’s no palliative care team available. This isn’t sustainable. If we don’t thoughtfully address the culture that undervalues palliative medicine, if we don’t invest in training programs and supportive work environments, if we don’t shift the perception of our specialty, we’re heading toward a significant gap in care for the seriously ill. The demographic trends are clear, and we need to act now.

The culture change we need

I’m hopeful that we can shift the narrative around palliative medicine. I dream of a day when we’re consulted at the time of serious illness diagnosis, not when patients are imminently dying. When adequate resources (office space, support staff, dedicated clinic time) reflect the value of our work and allow us to reach more patients. When families don’t have to wait weeks to see us because our teams are stretched too thin.

The evidence is compelling. Early palliative care involvement improves outcomes across the board. Yet in many hospitals, we’re still working to establish ourselves as integral partners in care rather than optional consultants.

Here’s what I hope we can build together:

• Early partnership: Involvement at the time of serious illness diagnosis, not at the end of life. We can help manage symptoms, coordinate care, and support patients through treatment. We’re here for the whole journey.
• Recognition of clinical expertise: When we round together, I hope you’ll notice the assessments we’re making, the subtle clinical observations, the sophisticated pharmacology. The board certifications, the fellowship designations, the years of specialized training, these represent real expertise.
• Support for interdisciplinary models: When an experienced NP leads a palliative care program, she deserves the same resources, authority, and institutional support as physician leaders in other specialties.
• Acknowledgment of our clinical contributions: A thoughtful family meeting is clinical work. Symptom management in complex patients is clinical work. Helping someone experience comfort and dignity during serious illness is some of the most important clinical work in health care.
• Adequate resources: Palliative care teams need appropriate staffing, space, and support to do this work well. The return on investment is there: in reduced ICU days, fewer unwanted interventions, shorter lengths of stay, and yes, in the immeasurable value of reduced suffering. If we want to avoid a significant shortage of palliative care providers, we need to make this work sustainable and valued. I am really lucky to be in an organization that sees me for what I bring to the table, who value my work and treat me with kindness and respect. I have physician leaders who partner with me and do not treat me like an afterthought. I am fortunate but aware we all have similar struggles.
• Making this specialty attractive to the next generation: We need students to see palliative medicine as an exciting, intellectually rigorous, clinically sophisticated field where they can make an enormous impact. That starts with how we talk about the specialty and how we support the clinicians already doing this work.

Why this matters to me

I fell in love with palliative medicine because it allows me to practice medicine the way I always hoped to: attending to the whole person, using all of my clinical skills, making a genuine difference in people’s lives during their most vulnerable moments. I get to solve clinical puzzles that would challenge any specialist. I get to sit with people through their hardest days. I get to work alongside brilliant colleagues from different disciplines who teach me constantly.

But I also fell in love with what palliative medicine could be: a model for how health care should work. Interdisciplinary. Patient-centered. Built on both cutting-edge clinical science and deep human connection. Recognizing that expertise comes in many forms and that the best care happens when we work as true colleagues.

I came into this field with a clear mission and intent: to treat and care for every patient the way I would want the person I love the most to be cared for, and to do so with an emphasis on reducing human suffering in somehow, everyday. And I accomplish this in a lot of different ways: shared moments of humor, psychosocial support, hug for a patient/family/caregiver who is struggling, other days it is complex clinical medicine and on the best days, it’s all of the above.

The journey to FAAHPM recognition wasn’t just about personal achievement; it was about deepening my commitment to advancing this field, to mentoring the next generation of palliative clinicians, to contributing to the scholarship that will improve care for future patients. That’s what drives all of us in this specialty: the knowledge that we’re building something bigger than ourselves. We’re making progress. More institutions recognize our value. More colleagues understand what we do. More patients receive palliative care earlier in their illness journey. But we still have work to do, and we need more brilliant clinicians to join us.

To my fellow palliative care clinicians

I see you. I see the physician managing complex pain while fielding calls from multiple services. I see the nurse practitioner patiently explaining prognosis, meeting a family where they are. I see the PA troubleshooting medication regimens at midnight, the social worker holding space for grief, the chaplain sitting in silence with someone who has no words left.

Your work is extraordinary. Your clinical expertise is profound. Your compassion is matched by your competence. Whether you’re working toward your board certification, maintaining your ACHPN credentials, or have earned fellowship recognition in our academy, you deserve recognition, resources, and support.

Keep doing the work. Keep advocating for your patients. Keep showing your colleagues what excellent medicine looks like. Keep mentoring students who might fall in love with this specialty the way we did. We’re changing the culture one conversation, one consult, one beautifully managed symptom at a time. And we need more people to join us in this meaningful work.

To everyone else in health care

I’m inviting you to see us differently. We’re not an optional add-on. We’re not here just to talk about death.

We’re expert clinicians with broad, deep knowledge managing some of the most complex patients in your hospital. We’re specialists who’ve earned our place at the table through rigorous training and years of experience. Many of us carry dual board certifications and fellowship distinctions that represent decades of dedication to mastering our craft. We’re colleagues who can make patients’ lives better if you’ll involve us early and trust our expertise.

The next time you work with palliative care, I hope you’ll pay attention. Notice the clinical assessment, the pharmacological sophistication, the diagnostic reasoning. Ask us questions; we genuinely love teaching what we know. Involve us before patients are in crisis. And recognize that the person managing that patient’s care might be a nurse practitioner with palliative expertise.

When you encounter students or residents who express interest in palliative care, please encourage them. Tell them it’s intellectually rigorous, clinically sophisticated, and deeply meaningful work. Help build the workforce we need.

Our patients deserve comprehensive, expert palliative care as a standard part of serious illness treatment, not a last-minute afterthought. And our teams deserve recognition for the sophisticated clinical work we do every single day.

Patricia M. Fogelman is a nurse practitioner.