Palliative care has become a critical issue for patients and families during this COVID-19 pandemic.
The role of palliative care is multifold and includes symptom management, end-of-life care and expertise in goals-of-care conversations. There has been an effort to develop educational resources during the pandemic to increase palliative care capacity for clinicians who are not familiar with this area but who might be called upon to provide palliation. The need to educate health care workers in the midst of a crisis reveals a weakness in our training of physicians. A recent study published in the CMAJ indicates that the majority of undergraduate and postgraduate medical trainees do not complete a palliative care clinical experience during their training, exposing an interesting dichotomy: although palliative care is an important part of the pandemic response, the majority of our physician workforce is not trained to provide it.
Even outside the confines of a pandemic, access to palliative care in Canada is woefully inadequate, with fewer than 1 in 6 Canadians able to access home palliative care in the last year of life. Inequitable access is based on many factors, including geography, culture, socioeconomic status, language and diagnosis. The consequence of this fragmented access is that most patients receive palliative care only in the last month of life, in an emergency setting or in a hospital, with significant subsequent distress to their caregivers. Although opportunities for palliative care training have increased over the years, they are still insufficient to address the broad national need.
To tackle these access issues, all physicians need to know the basic skills inherent in providing palliative care: basic pain management, addressing common symptoms, managing end-of-life care and facilitating a serious illness conversation about values and preferences for current or future care. If these are not taught, practiced and valued in medical training, the onus falls on a small number of individuals to take on these responsibilities. This is further heightened in the midst of a global crisis.
COVID-19 has fundamentally disrupted the undergraduate medical curriculum at all Canadian universities. Workplace-based learning for clerks is on hold and course schedules are being modified to ensure the required competencies are met prior to graduation. This time of disruption and upheaval in medical education is an ideal time to think outside the box about clerkship training as we know it, to let go of preconceived notions of what clerkship training should look like.
Considering the innovations underway in this environment of unconventional medical education delivery, it is imminently achievable to address the relative lack of mandatory palliative care training. In the past, the argument against providing these experiences involved a similar refrain that the curriculum is too crowded and there is no room for additional clinical experiences. With the COVID-19 pandemic shedding light on the current gaps, the question is: Can we as a society afford not to give medical students these critical learning experiences?
Some programs, such as family medicine, have recognized the value of palliative care and have made a commitment to mandatory experiences for all residents. Others, like medical oncology, have developed mandatory palliative care experiences for residents. However, most other residency programs do not have required palliative care exposure. This type of training should be widely provided to general internists or surgeons, to name a few. All physicians will surely be faced with a patient with palliative care needs, so why not prepare them to address those needs? The Canadian Society of Palliative Care Physicians has established primary palliative care competencies for all undergraduate and postgraduate training. These competencies are ready and waiting to be adopted by willing programs and universities.
This pandemic should be a call to leaders in medical education across the country: all physicians, no matter their specialty, need to learn how to deliver the basics of competent and compassionate palliative care to benefit the Canadian public at large. The provision of mandatory medical education won’t solve the pernicious and significant palliative care access issues we face in Canada but it is a very good place to start.