Chair's Column: The Launch of the Palliative Medicine Subspecialty
Addressing Two Key Departmental Guiding Principles
As we are all well aware, things have changed in healthcare over the past decade or two. Most of our patients are now living well into their 80’s if not 90’s and beyond, and thus with multiple chronic conditions. As a University that trains the largest proportion of internal medicine specialists in Canada, it behooves us to ensure that our educational programs are adjusted to these changes to ensure our graduates are equipped with the skills required of them for the future. Key skillsets required for the future include competency not only in the acute disease management, but also the integrated inter-disciplinary chronic healthcare management of people living with multi-morbidity such that our efforts maximize the patient’s quality of life and address preferences for care.
Towards our strategic goals to, “ensure the perspectives and experiences of our patients and their families drive our work,” and, “align physician training to meet future population needs” – much is happening. Too much, in fact, to relate in one newsletter! Suffice to say that under the leadership of our Vice –Chair, Education, Arno Kumagai, substantial attention is being paid on how best to accomplish these goals for our trainees and our patients. You will hear more about this in the near future. In this planning includes how best to ensure our training programs address cross-cutting population needs, such as aging, mobility, obesity, integrated care with primary care providers, better use of digital technologies in healthcare, and palliative care. It is this latter competency that I wish to address here.
This coming July 1st, we will be welcoming the first two residents (out of a total of four across Canada) into the newly established Royal College residency training program in palliative medicine. I’d like to give a shout out to our colleagues in PGME for providing two new residency positions for this program, and for the hard work and perseverance of James Downar, Camilla Zimmerman – both profiled in this newsletter – together with their colleague Jeff Myers from Family and Community Medicine for getting this program up and running. We are super excited and look forward to welcoming these first trainees.
Under the capable leadership of program director, James Downar, and interim departmental division director, Camilla Zimmerman, I have no doubt that this program will grow fast and furious! In partnership with our colleagues in the Departments of Family and Community Medicine, Anesthesia, Psychiatry, Pediatrics, Radiation Oncology, Surgery and perhaps others, the plan is to create an inter-departmental Division of Palliative Care/Palliative Medicine that, like Critical Care, has the potential to lead nationally and internationally in the clinical care, training and academic advancement of this field.
Over the past months, I have very much enjoyed meeting with the folks who make up the critical clinical ‘front line’ in palliative care. They are currently largely working in the cancer and long-term care settings, but increasingly their ranks are infiltrating other areas, such as solid organ transplant (lung failure) and cardiology (end-stage heart failure). These brilliant individuals have taught me that palliative care is not only about end of life care for cancer patients and not only for people late in the course of their disease when death appears imminent. Rather, palliative care is about ensuring an appropriate balance of attention to ‘cure’ versus ‘care.’ In her editorial within this edition of DoM Matters, Camilla Zimmerman, sums up the role of palliative care with a quote from 19th century physician Edward Livingston Trudeau, “to cure sometimes, to relieve often, to comfort always.” Currently, comfort measures are too often introduced late – too late – in the patient’s disease course. As we strive to place our patients’ needs and preferences first and to prepare our trainees for the future needs of the population, a residency training program that will serve to advance skills and knowledge in this field couldn’t have come at a better time.
As I think about the conditions that a rheumatologist would see, there are so many slowly progressive, chronic conditions – like scleroderma and interstitial lung diseases – where optimizing patients’ quality of life is the goal of management. Yet, the extent to which we have equipped our trainees with the skills to attend to the management of symptoms, like breathlessness or chronic pain, and to engage in end of life discussions, is unclear. I am confident that most programs do a great job, but I am sure there is still room for improvement. I, personally, look forward to learning more from our colleagues as this program advances.
An important next step in the evolution of palliative medicine at the University of Toronto will be to conduct an environmental scan of who in our department is already doing this work. I think there are likely many who may be interested in being part of the establishment and development of an inter-departmental division. So let me take this opportunity to invite you to let James and Camilla know if you have an interest (clinical, research, educational) in ‘palliative medicine’ and would like to get involved. This is an exciting new beginning and we need and want all hands on deck!
I want to end as I started, however, with a bit of a digression. In her editorial commentary, Camilla describes her ‘circuitous route’ to palliative care. In this respect, she exemplifies what is often a life-long journey to find the career in medicine one wants to follow. I, too, started in family medicine but realized it was not the right fit for me. I, too, fell into qualitative research methods unexpectedly and somewhat against my will, but am much better for having done so.
At the PGY-2 retreat in the fall, we talked with trainees about laying out the roadmap for their future. We encouraged ‘taste-testing’ along the way – the old ‘try it, you may like it’ and figuring out not only what you may be good at, but also what you are passionate about. Camilla’s career trajectory illustrates this path of self-discovery beautifully. Although she describes her career path as a, ‘tortuous, seemingly unending, journey,’ it led her to where she is now, leading the first Division of Palliative Medicine in the country and, with James Downar, ensuring that our trainees will be equipped to address the palliative care needs of their patients in the future.