Recently, I had the pleasure of exchanging emails with a future palliative care physician. She was interviewing palliative care physicians in Ontario on their model and style of practice. The interview was scheduled for 60 minutes but lasted close to 90. Clearly, I had a lot to say.
This physician was kind enough to send an update to her interviewees while preparing her final report and I came across this line: “There are just not enough palliative care specialists to go around.”
I was so triggered by this comment that I had to write her back and explore this further.
First, I fully support building primary level capacity through education, coaching and mentoring. Primary level palliative care refers to care provided by generalists, not specialists. For example, it would be the care provided by a family physician or oncologist that has basic competencies in palliative medicine.
Second, she is not wrong. We do not have enough palliative care specialists to go around.
But inherent in that statement is that we CAN’T train enough specialists. And that is where I get triggered.
The argument that we cannot train enough palliative care specialists to meet the demand is what Dr. Danielle Martin of Women’s College Hospital refers to as a “healthcare zombie.” A zombie is something that you just can’t seem to kill without a good, clean headshot. So I am here to deliver that head shot.
Let us start with some facts.
An easy estimate is that about 1 per cent of Canadians die each year. If we assume that every patient who dies in a given year would benefit from high-quality palliative care, this would mean that 370,000 Canadians and 140,000 Ontarians would benefit from palliative care every year.
Current studies show that the majority of palliative care is only provided in the last month of a patient’s life despite mounting evidence that providing earlier palliative care improves patient outcomes and even prolongs survival.
A Canadian Society of Palliative Care Physicians (CSPCP) staffing model suggests we need one palliative physician for every 100 palliative care patients.
A 2015 Institute for Clinical Evaluative Sciences report suggests Ontario identified 276 physicians practising mostly palliative care. Of these, 135 were women, 265 practised in urban locations and 145 worked part time. A current review of this work is looking at whether this number has decreased and how many of these physicians are approaching retirement age. Based on Ontario’s population of 14 million, this translates into one palliative care physician for every 50,000 people.
A national survey by the Canadian Medical Association in 2014 identified 1,114 respondents as “palliative medicine physicians.” Of these, 132 were focused practice family physicians, 51 were specialists and 931 were identified as “other.” Based on a population of 37 million, this would represent one palliative care physician for every 33,000 people.
The CSPCP estimates we need twice as many palliative care specialists.
This bold statement is still an understatement.
Clearly, our palliative care physician population is woefully inadequate from a provincial and national standpoint. We must also examine how and how many palliative care physicians we train.
Currently, there are only five Royal College training programs across Canada and while there are more PGY3 programs, many only have one spot available per year and some of these positions are not offered every year.
Furthermore, while many medical schools have a division of palliative medicine (usually organized under a department of family medicine, oncology or internal medicine), some medical schools do not (looking straight at you, Western).
Now, let’s look at the current state of undergraduate and postgraduate medical education.
A recent study published in the Canadian Medical Association Journal shows conclusively that most doctors graduate without even basic competencies in palliative care. This is due, in no small part, to the fact that palliative medicine needs an academic home in our medical schools. It needs a department that can span the entire education lifecycle of physicians starting in undergraduate studies, advancing to postgraduate residency and providing continuing medical education for established physicians and finally establishing a hub for research and academic endeavours to occur.
A CMAJ article from 2012 describes palliative care training in Canada as substandard.
The CSPCP once again points out that in addition to not addressing the immediate shortfall of palliative care specialists, most medical schools dedicate fewer than 10 hours to this training. It recommends expanding the core palliative care training provided to all doctors.
Given the above, I can confidently state that to say we can’t train enough palliative care physicians is an assumption, not a proven fact. And we all know what happens when we assume. The argument that we cannot train enough palliative care physicians reminds me of an article from the Onion. Each time there is a mass shooting in the United States, the Onion publishes an article with the headline “No Way to Prevent This, Says Only Nation Where This Regularly Happens
The link to palliative care? We say we can’t train enough palliative care physicians despite the fact that we aren’t even trying. Nor have we ever tried. While the United States recognized palliative medicine as a specialty in 2006, Canada only did so in 2014. While we enjoy looking down our nose at American health care, this is one area where they are lapping us and it isn’t even close, my friends.
Can you imagine another area of medicine saying that we can’t train enough doctors to meet patient needs and being OK with that?
Imagine if we said we couldn’t train enough . . .
- Surgeons to operate.
- Oncologists to give chemotherapy and radiation.
- Nephrologists to supervise dialysis.
- Obstetricians to deliver babies (oh wait…)
The comment about obstetricians is deliberate. Most intrapartum care in Canada is provided by obstetricians, midwives and some family physicians yet medical students and residents get substantially more exposure to intrapartum care than palliative care over the course of their undergraduate and postgraduate education. Does anyone think an oncologist or nephrologist should graduate without at least basic competencies in palliative medicine, including pain and symptom management and the ability to have effective goals of care discussions?
One possible solution I proposed at the Family Medicine Forum in 2016 was to consider repurposing some rotations during family medicine residency based on the resident’s interest in certain fields or areas of practice.
Perhaps we are not even asking the right question. Many of the arguments around training palliative care physicians orbit around “who should be doing palliative care?” Isn’t the better question “what do patients and families want?”
Most patients and families would say that access to high quality palliative care is their goal. If we are to be truly patient-centered, wouldn’t the best approach be to train enough specialists to meet the demand, ensure all physicians are trained with basic competencies and mandate that all medical schools have a department of palliative medicine to function as an academic home to advance research and training?
So, why aren’t we doing this?