Feb 1, 2017

Q&A with James Downar: Department of Medicine's First Palliative Care Program Director

Respirology, Education
James Downar
By

James Downar

James Downar
1). How did your focus turn to palliative medicine?

I initially trained in internal medicine, and was planning to study critical care. I decided to do an elective rotation in palliative care in order to improve my knowledge of pain management, and I really enjoyed it. Many people imagine that palliative care is depressing, but I found it very rewarding to work with people whose concerns were less focused on survival than on comfort. Controlling pain, dyspnea or even constipation may seem like minor issues to us at times. To patients with advanced disease, it is often the only thing they care about, and they are so happy and grateful when you can fix their symptoms.

I wanted to do double training in both palliative care and critical care, which had never been done before in Canada. I was very lucky to have the support of both program directors (Drs. Dori Seccareccia and John Granton), as well as Dr. Kevin Imrie, my program director in internal medicine. To date, roughly ten people have completed the same double training across Canada, and many more practicing ICU physicians are exploring extra palliative care training as an option for their future.  

2). When palliative medicine became an accredited subspecialty of medicine, did that seem like an organic or natural progression considering the size of the Baby Boomer population and the fact that that generation is living longer with more complex conditions?

The recognition of palliative medicine as a subspecialty by the Royal College of Physicians and Surgeons of Canada was a recognition of many changes that are taking place in medicine and society. Clearly, Canadians are getting older and living with more chronic, complex illnesses. They are also appreciating the importance of symptom management, and increasingly demanding access to timely care that is focused on quality of life rather than quantity of life. The Royal College also recognized the need to expand the evidence base in palliative care, which would require a larger academic group within a palliative care community that has been traditionally focused on teaching and service provision.

At the same time, the Royal College observed that many other countries have recognized palliative medicine as a subspecialty, and so they saw the value in doing so here in Canada as well. The new subspecialty will present some challenges, but I think that it will result in a more rapid integration of complex illness into palliative care, and conversely, a more rapid integration of palliative care competencies into other subspecialties.

3). Up until recently, palliative care was a “focus” rather than a recognized subspecialty. As an accredited training program, what will residents now learn in a formalized setting that they wouldn’t have learned (formally) before?

There will be some similarities in the core training of subspecialty residents, who will spend much of their first year learning core competencies on palliative care consultation, inpatient, outpatient and home care rotations (much of which will be cancer-focused). However, since the palliative management of non-cancer illnesses involves many of the same principles as the non-palliative management of these conditions, the second year will involve intensive training in end-stage, non-cancer illness (e.g. heart failure, end-stage lung disease). Trainees will go to specialized services and clinics to learn how to manage end-stage illnesses from the subspecialists who manage them every day (e.g. cardiologists who specialize in heart failure management). There will also be a strong academic component, and more protected time to complete a scholarly project under the supervision of one or more supervisors. We are aiming to train people who will join the academic community, building our evidence base or developing new models of disease management that will enable more Canadians to benefit from a palliative approach to care.

4). What are you most looking forward to with respect to being palliative medicine’s first program director?

I have been the program director for the conjoint residency program in palliative care in the past, and so I know that it can be both challenging and rewarding to be a program director. I enjoy teaching and mentoring residents, but I also enjoy working with the program committee to develop new approaches to educating and assessing our trainees.

 I am looking forward to helping develop and grow the new subspecialty program into an established training program that will attract strong residents and turn out exceptional palliative care physicians and academics. Of course, there will be challenges to overcome. In our first few years, we will need to endure some growing pains as we find the best educational experiences for the trainees, especially in non-cancer. We will also have to adapt to the Royal College’s new Competency Based Medical Education framework of training and assessment. We are well-positioned to overcome both challenges, as the University of Toronto has some of Canada’s foremost experts in the management of end-stage disease, and our division head (Dr. Jeff Myers) has led the development of a national set of Entrustable Professional Activities for Palliative Medicine.

I am deeply grateful to everyone in the palliative care community who has helped to get our subspecialty program ready to receive its first trainees in July. I will also thank the Department of Medicine staff who have been instrumental in preparing the necessary documents and paperwork to secure Royal College accreditation. This was a real team effort and I look forward to overcoming future challenges alongside this exceptional group of people.