Palliative Care’s Real Power Skill Is Systems Translation

Two things landed in my reading queue this spring.

First, a Cornell study by cognitive psychologist Shane Littrell, published in Personality and Individual Differences, finding that workers most receptive to buzzword-heavy corporate language scored lower on analytic thinking, cognitive reflection, fluid intelligence, and a simulated workplace decision-making task. NPR's All Things Considered did the rest of us a public service by getting Littrell on the air to explain it.

Second, a Harvard Business Review piece arguing that "soft skills" should be rebranded "power skills" — listening, empathy, trust-building, dialogue — because those skills shape execution, culture, and whether organizations actually solve the problems in front of them.

You can read those two findings as opposites. I read them as two halves of a problem palliative care has been fumbling for years.

Our allergy to corporate-speak is mostly well-earned. We have also, as a field, allowed our highest-leverage (see what I did there?) work to be coded as "soft" — by the system, by other physicians, and, most uncomfortably, by ourselves. The result is that we get funded like a service line that's nice to have, when we are critical clinical experts.

The work needs an accurate name. I have one: systems translation.

The work the system keeps misnaming

Start with the patient.

Patients and families in palliative settings consistently want the same things: open and honest information, empathy, clear language, professionals who take responsibility, and recognition that family caregivers are part of the care, not adjacent to it. They also want clinicians to pace truth to where they actually are — emotionally and cognitively — because truth without timing can land like assault. That pacing is judgment. That is expertise. That is also a place where structural inequity shows up early and often: language access, health literacy, prior trauma with health systems, and the cumulative wear of being misread by clinicians all change what "open and honest" requires.

Then the family.

Any clinician who has run a serious illness conversation knows that "the family" is usually a stack of conflicting interpretations. One person is protecting the patient. Another is protecting themself. Someone heard the prognosis and could not take it in. Someone else translated guilt into demands for more treatment. Someone else is talking to ChatGPT on the side. The NEJM Videos in Clinical Medicine piece on family meetings teaches the meeting like a procedural skill, and a 2026 systematic review in Patient Education and Counseling found preliminary evidence that structured family meetings improve family psychosocial outcomes — while flagging that the evidence base is still uneven and the conduct of meetings still varies wildly.

That last caveat matters. The procedure works when the team can actually do it. That is a training problem, a workflow problem, and a culture problem before it is a communication-skills problem.

Then the team.

Palliative care works when disciplines translate across one another rather than orbit in parallel. Nursing sees one set of facts. Social work assesses another. Chaplaincy hears things no one else hears. Physicians bring prognostic synthesis, medical authority, and the ability to speak fluent consultant when the room requires it. The National Consensus Project's 4th edition Clinical Practice Guidelines place communication, care coordination, caregiver support, and interdisciplinary process at the center of quality palliative care across all eight domains. That is the job description.

Then the institution.

Health systems talk in beds, days, readmissions, denials, throughput, handoffs, and whatever phrase someone smuggled out of an MBA slide deck this quarter. Someone has to convert "she is terrified of becoming a burden to her daughter" into a plan that changes what gets offered, what gets documented, which consultant hears what, and what does not happen by inertia. Someone has to turn a fractured family conversation into a care plan that survives the weekend. That is systems translation too — the part of the work that is easiest to underprice because it leaves the cleanest paper trail when it succeeds and the loudest one when it fails.

Why physicians still flatten this expertise

Part of this is an old prestige map.

Procedures look like expertise. Medication changes look like expertise. Declaring the plan looks like expertise. Sitting with uncertainty, metabolizing emotion, translating competing narratives, and building a plan the rest of the team can carry forward gets coded as supportive work — even when it prevents the next 72 hours of confusion, the next bounceback, or the next ethics consult.

Physicians are not outside that hierarchy because we chose a field that imagines itself more enlightened than the rest of medicine. We carry the hierarchy with us unless we actively file its edges down. That includes me. The position I occupy in a palliative team meeting comes pre-loaded with weight I did not earn in the room.

You can see that hierarchy clearly in the qualitative implementation study of the Serious Illness Care Program published in BMC Palliative Care. Teams improved when clinicians stopped treating these conversations as code-status cleanup or prelude to withdrawing care. They improved when nurses, social workers, and advanced practice clinicians had more psychological safety and more ownership. They got stuck — explicitly, in the data — when physicians "expressed negative attitudes toward inter-professional roles by actively blocking the involvement of nurses and social workers in conversations." The authors called that out plainly. We should too.

When physicians medicalize the team's work, the rest of the team's expertise gets flattened into "support." That flattening is not just unfair; it is also expensive. The plan you build without the social worker is the plan that fails shortly thereafter.

Why your best argument dies in the boardroom

The C-suite misses this work for a boring reason. The system counts what it was built to count.

A family meeting that prevents an ICU conflict leaves no obvious billable artifact. A conversation that changes a discharge path before the weekend can look, from a distance, like nothing happened. A social worker who realizes that the "noncompliant" daughter is actually one rent payment from housing instability can change the trajectory without touching the MAR. Systems translation often prevents institutional stupidity before that stupidity becomes visible enough to count.

That is not the same as saying the work has no measurable outcomes. It just means many of us still describe the work in language that fails under fluorescent lighting.

The Serious Illness Care Program cluster randomized trial in JAMA Internal Medicine gives you a cleaner way to talk about it. This was not a vibes intervention. It combined a structured conversation guide, clinician training, patient preparation, workflow reminders, and EHR documentation changes. In the trial, moderate-to-severe anxiety dropped from 10.2% to 5.0%, and moderate-to-severe depression dropped from 20.8% to 10.6%. Anxiety improvement was sustained at 24 weeks. Serious illness conversations occurred more frequently in the intervention arm (96% vs 79%) and happened a mean of 2.4 months earlier in the illness course. Those are not soft outcomes. Those are clinical and operational effects with a real evidence trail.

The implementation study matters here too, for a different reason. It showed that better serious illness communication depended on workflow, team roles, psychological safety, and culture change. In other words, on changing how the system functioned, not on telling clinicians to have better bedside manners. That is operations work. That is the work the boardroom funds when it understands what it is buying.

Strategic bilingualism without capture

Here is where the dialectic gets uncomfortable.

Littrell seems to be right. Empty buzzwords correlate with worse decision-making, and they are particularly dangerous in healthcare because we have so many authority cues — titles, hierarchies, ostensibly visionary leadership — that nonsense can pass for insight without anyone flinching. Every time a "transformation" or "high-value redesign" rolls into our inbox without a definition, the field is being asked to spend cognitive credibility on language designed to deflect it. We should keep flinching.

The HBR power-skills crowd is also right, in their less interesting way. Listening, empathy, trust-building, and dialogue do shape execution and decision quality, and calling them "soft" makes them easier to defund.

The trap is treating those two truths as a choice. They are not. The job is bilingualism: keep the bullshit detector calibrated, and develop enough fluency in the operational register to put our work in language the people who hold the budget can actually price.

The test for whether your translation is honest is whether the language stays attached to specific, observable changes in care. Anchored language that specifies what changes and for whom is translation. Floating language that sounds important but cannot be tied to a measurable difference is the same disease Littrell is describing, just dressed in scrubs.

This is also where the lateral risk shows up. (I have written about this before in the context of how shared decision-making got rebranded into something that quietly hurts the patients who most need it.) Reframing the work in fashionable language is not free. The language you adopt to get funded shapes what you get funded to do. Adopt "patient experience" as the frame and you will deliver patient experience. Adopt "throughput optimization" and you will optimize throughput. Words are not neutral wrappers. They are operating manuals. Choose carefully.

How to name the work in a room full of vice presidents

This is the part you can use.

If you walk into a strategic planning meeting and say "we're really good at communication," you will get polite nods and no money.

Try language that names what the work changes:

• "We reduce decisional conflict before it spills into prolonged admissions, weekend crises, ethics consults, and fractured discharge plans."
• "We convert fragmented information from patients, families, consultants, and bedside staff into care plans that teams can execute across settings."
• "We improve care-plan coherence before unwanted escalation hardens into institutional momentum."
• "We reduce avoidable suffering by making the healthcare system more intelligible to the people trapped inside it."
• "We support team function by reducing avoidant communication, hierarchy-driven confusion, and moral residue around serious illness decisions."

Same work. Better translation. (Yes, my bullshit thermometer is rising right now, too.)

One more, because it is the one that gets dropped first when these conversations turn budget-shaped: "We reduce the disparities in care experience that show up when the system runs on autopilot." Systems translation is either an equity intervention or it is not the work I am describing. The patients who most need it are the ones least equipped to translate themselves into the system's vocabulary. If your translation only lands for English-speaking, well-resourced families with college-educated advocates, you are doing concierge work and calling it palliative care.

Where I might be wrong

A few places this argument could come apart, in roughly increasing order of how much they would cost it.

The Cornell finding is correlational. Receptivity to corporate jargon and weaker analytic performance travel together; we don't know that buzzwords cause worse decision-making. The mechanism Littrell proposes is plausible — credulity toward semantically empty language tracks credulity in general — but it is a mechanism, not a proof. I am leaning on the finding more than its design technically supports.

"Systems translation" can become its own bullshit. If the term floats free of specific, observable changes in care, it is just a new piece of jargon scoring points against an old one. The discipline has to be on the language staying anchored to operational specifics. If I catch this term being used to defend the same fuzzy claim "communication is important" was used to defend, I will retire it.

Bilingualism has costs that aren't evenly distributed. The clinicians most often asked to translate the team's work into the boardroom's language are also the clinicians with the most institutional capital — frequently physicians, frequently white, frequently male. The team members doing the actual translating across patient, family, and system are often the ones who never get the boardroom invite. If we are not careful, "speaking the boardroom language" becomes one more way physicians take credit for team work. That is not a hypothetical.

The boardroom may not actually be persuadable. There is a version of this argument where palliative care does the bilingual work, names everything beautifully, and still gets funded as an afterthought because the system's incentives are hostile to what we do regardless of how we describe it. I think the bilingualism is worth doing anyway, because the alternative is letting the language be set entirely by people who do not understand the work. But I am not confident.

What this is really about

Funding palliative care matters, and I do not pretend otherwise.

The deeper point is that when palliative care describes itself only in sentimental language, or lets itself be described as "support," it makes the field smaller than it actually is. When it describes itself only in symptom language, it makes the field narrower than it actually is. The work sits at the junction of medicine, family systems, ethics, operations, and culture. That complexity is the point.

The Lancet Commission on the Value of Death argued that dying has become overmedicalized, with families, communities, and ordinary conversations about death pushed to the margins. Palliative care's job is to keep dragging the system back toward reality. Reality includes physiology, yes. It also includes fear, meaning, logistics, conflict, power, equity, and time. Systems translation is one of the things we do to turn that reality into actual care. (I have written more about the team-based version of this work in "Teams, Not Saviors", and about why specialist palliative care's role is counter-cultural translation in "Palliative Care 3.0".)

Some readers will hear "power skills" and roll their eyes. Fine. Their eyes may roll. The budget still matters.

Call it systems translation. Call it clinical infrastructure. Call it the work that keeps values, families, symptoms, and institutions from flying apart on contact.

What I care about is that we stop letting anyone — including ourselves — pretend it is soft.

I am a palliative care physician, educator, and professional strategery expert. Known for turning rounds into rants and rants into teaching points. Rounds & Rants represents my views — not those of any organization or professional membership organization where I hold a role. I don't write on their behalf and they don't vet what I publish.