UK, Australia, New Zealand Take Lead in Palliative Medicine

ORLANDO--Half of the problems of patients who are dying are never reported. "Why?" asked Dr. Derek Doyle, a palliative medicine specialist in Edin-burgh, Scotland, "because doctors are not interested." Or at least that’s how patients feel, he said. "Physicians have not yet learned to communicate with patients about problems beyond their disease and its pain," he said at the 15th Annual International Breast Cancer Conference.

In the best medical schools, physicians receive up to 76 hours of course work in palliative medicine, but the mean is 13 to 14 hours, and may be only 1 hour.

Ten years ago, Dr. Doyle and his colleagues met in Brussels with two members from each country in the European Union, plus Switzerland and Sweden, to review a curriculum in palliative care for medical students originally devised by the Association for Palliative Medicine of Great Britain and Ireland. They felt that palliative care had to be made an examinable specialty for it to have credibility in both professional and political circles.

The undergraduate curriculum concentrates on pain and symptom management, psychosocial problems, spiritual issues, legal and ethical issues, communication, and palliative care in different settings. In pain and symptom management, Dr. Doyle said, it is important to develop the physician’s sensitivity to a patient’s problems rather than simply giving them treatment formulas. "It’s not so much a matter of giving the correct morphine dose as of being sensitive to the fact that the pain comes with fear and psychosocial issues that are more difficult to control."

At first a patient only wants relief of pain and that takes about 4 days to achieve. Then 50% of patients cease to report physical problems, but may have psychosocial ones--fears, apprehensions, problems about family and spouse--as well as spiritual problems.

Searching for Meaning

"When I say spiritual, people immediately assume I’m talking about religious concerns," he said. "It isn’t that at all." He said that people are searching for meaning and asking difficult-to-answer questions: Why do I die at 35 leaving four kids? Why do I die when I still have so much to do? Why do I have to suffer like this when I try to lead a good life? Dr. Doyle said that terminally ill patients do not need traditional pat answers, but help from someone who has the same questions and is still searching for answers.

Physicians entering the program are taught by nonspecialists in their preclin-ical years--family physicians, psychologists, and hospice doctors--while in the clinical years, they are taught by palliative medicine specialists.

"In the United Kingdom, where palliative medicine has been a specialty since October 1987, there are now more palliative medicine specialists than there are oncologists," he said. To date, ther are 230 palliative medicine consultants and 110 fellowship training programs. Programs are only open to applicants who have already completed training in internal medicine, oncology, or family medicine. To this training is added a 4-year course of further rigorous study.

During their training, they will see 1,000 to 1,500 patients and also attend courses in management, audit, research, teaching, and bereavement counseling. They must also spend a year "filling gaps in their knowledge of neurology, AIDS, psychotherapy, and family medicine, depending on their background," he said.

All those present at the Brussels conference accepted the recommended pallaitive medicine curriculum, he said. However, not all medical schools have implemented it, and only the UK, Australia, and New Zealand have set up palliative medicine as a specialty area.