Palliative Medicine

Background

Palliative medicine is one of the specialties within medicine. Currently there are approximately 252 consultants, 82 (full time equivalent) non-consultant career grade doctors and 201 trainees working in the specialty in the UK, 25% of whom are training flexibly. Some non-consultant career grade doctors combine practice in palliative medicine with part–time work in General Practice.

There remains a shortage of trained specialists in palliative medicine, with a number of unfilled consultant posts across the UK. The number of doctors in training has increased however and it is anticipated that there will be 325 consultants by 2013.

What is Palliative Medicine?

Palliative medicine is a relatively new specialty that was first recognised by the Royal College of Physicians as a specialty in 1987. It has continued to grow in size and influence since that time. Originally borne out of the need to improve the quality of life for people with advanced cancer and with its roots in the hospice movement, the specialty is increasingly relevant to any patient with advanced, progressive illness requiring specialist input to improve their quality of remaining life. This has been endorsed in recent years by the publication of several National Service Frameworks, such as Renal Medicine, Long Term Conditions and Cardiology. Its place within cancer management is described in detail in the NICE Guidance “Improving Supportive and Palliative Care for Adults with Cancer, 2004.”

The holistic nature of palliative medicine encompasses the physical, psychosocial and/or spiritual domains of care and as such, good multi-professional working is fundamental to its success. Palliative care is delivered in a variety of settings, including hospice and specialist palliative care units, hospital and community. Many hospice inpatient and community services sit within the charitable sector, supported by the NHS. Doctors are involved in the direct management of hospice inpatients and outpatients and usually act in an advisory capacity in hospital and community teams. The delivery of education and training to a variety of professional groups to improve the standard of general palliative care runs in parallel with the direct delivery of a specialist service.

Due to the nature of their work, palliative medicine physicians enjoy close working relationships with a variety of colleagues including those in general practice, medical and clinical oncology and other medical and surgical specialties.

Core Competencies for the Palliative Medicine Physician

From the above description of the role, it can be seen that a good palliative medicine physician needs a variety of skills and competencies, including:

• A background in a broad range of medical specialties with the ability to manage general medical problems in the context of advanced disease.
• Excellent clinical skills in diagnosing and managing the physical problems associated with advanced disease.
• Understanding of the evidence base for decision-making.
• Commitment to providing holistic care for patients and their families/carers.
• Skilful working within both multidisciplinary and multi-professional teams.
• Ability to work for patients and their carers across all care settings.
• Highly developed communication skills are needed to handle complex and sensitive discussions with patients, carers and colleagues and to work collaboratively with a number of clinical teams.
• A good understanding of ethical frameworks that underpin decision-making is required.
• Ability to teach/train different staff groups in different settings.
• Skills in developing and managing the service.

Choosing a career in Palliative Medicine

Palliative medicine can be highly rewarding with a good mix of clinical work and opportunities to rely on highly developed clinical skills and judgement. It is a young specialty with new challenges and opportunities allowing for a varied and changing career.

A sense of achievement is provided by the setting of realistic goals of care with patients and carers to improve quality of life. Time to give holistic care is built into the work and is valued by patients and staff alike. Strong team-working with a broad range of expert colleagues provides a supportive working environment. There are opportunities to work in a variety of settings during training. Consultant posts are varied in their structure with the possibility of developing special interests. Influencing the delivery of palliative care across the broader health community by teaching, training and developing services provides good job satisfaction.

Training in Palliative Medicine

As a specialty of medicine, training will usually be from the Foundation stage, through Core Medical Training and then into palliative medicine. Traditionally, doctors have also entered palliative medicine through general practice and the SAC is keen to see this continue. The detailed entry requirements and outline of training can be found in the Palliative Medicine Specialty Training Curriculum.

Updated Jan 07

Due to regular revisions, arising from changes in the training environment and the requirements of the PMETB, the JRCPTB are currently running various curricula for trainees in each specialty.  All relevant curricula are listed at the bottom of this page under Documents.  Use the filter option on the right-hand side, together with the guidance notes below,  to help you select the correct document.  In summary:

• If you are a run-through (Specialty Registrar [StR]) trainee, you will follow the curricula tagged as ST3+

• If you are an ‘old style’ SpR, you are following the curricula tagged as SpR

• If you enrolled prior to 01/01/03, you will be following the original curricula which are no longer available for download, see note below

 
Competence Based Curricula – StRs

PMETB has received the assessment system (blueprint and RITA/ARCP grid) for Palliative Medcine and this has been approved.  

The assessment blueprints show the possible methods that can be used to assess each of the competences in the curriculum. Trainees and trainers should refer to the blueprints for guidance on the appropriate assessment methods for each aspect of the curriculum, and so plan the training programme according to the criteria set by the RITA Decision Aid. It is not expected that all competences will be assessed by all methods, rather that there will be a sampling of competences within a variety of settings, both within formal and workplace-based assessment, from which overall competence acquisition has to be determined.

 Acute care common stem (Medicine) trainees will also follow the ACCS training manual.

Competence Based Curricula – SpR (for trainees enrolling after 1 Jan 2003)

The JCHMT introduced revised curricula for all the medical specialties together with a generic curriculum that applied to all trainees back in 2003. These are competence-based and set out the knowledge, skills and attitudes to be acquired by trainees before they may be awarded a CCT. 

Curricula (for trainees enrolling before 1 Jan 2003)

Assessment methods for SpRs in Palliative Medicine

An outline of methods of assessment and their use in higher specialist training for physicians can be found in the performance assessment section of the website. This information is designed to supplement that for trainees in palliative medicine.

360 Assessment (multi-source feedback)

This should be used to assess team-working skills. Assessments should be completed in year 1 and year 3 (or equivalent for flexible trainees) as a minimum. If there is any suggestion that this is an area where the trainee needs further to develop skills in order to achieve the required level of competence, it should be repeated more frequently to monitor progress against the standards defined in the curriculum and competency framework. The JCHMT has developed and validated the tool available on this website. Some deaneries may prefer to use the system devised for foundation training and this would be equally acceptable.

DOPS

Direct observation of practical skills can be used to assess any of the practical procedures listed in the curriculum. The SAC however has stipulated that, as a minimum, trainees must be assessed on the setting up of a subcutaneous infusion via a syringe driver and abdominal paracentesis, during the course of their training. These can be done using the generic form available on this website, using local guidelines for the procedures. A sharing of local guidelines will be facilitated via a link to the Association for Palliative Medicine website. It is expected that sufficient assessments will be undertaken to ensure competence in at least these two skills before the end of training.

Record of Reflective Practice (RRP)

The palliative medicine SAC, in conjunction with the University of Wales, has developed a tool to encourage reflective practice across various aspects of the curriculum. This does not form a summative assessment like the other methods as it has not been validated as such. However, it does provide opportunities to reflect on practice in a structured way and to receive feedback on this through appraisal. Engagement in the process and satisfactory feedback will inform the RITA and creates an opportunity to provide evidence of thoughtful learning across both clinical and non-clinical aspects of the curriculum. The documentation with full instructions can be found on this site. Feedback to the SAC is welcomed, as this is a new development and will be modified with further experience of its use.

 Record of Reflective Practice forms

Mini-CEX

The mini-CEX may be used from now onwards, while other assessment methods come into routine use.