Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

The Sydney Institute of Palliative Medicine Registrar Training Program

An Interview with Kristen S. Turner, MB, BS, FAChPM, and J. Norelle Lickiss, MD, FRACP, FRCP (Edin)

[Citation: Turner KS, Lickiss JN. The Sydney Institute of Palliative Medicine registrar training program. Innovations in End-of-Life Care. 2002;4(5): <www.edc.org/lastacts>]

Introduction

The Sydney Institute of Palliative Medicine (SIPM) which began at Royal Prince Alfred Hospital (RPAH) is the academic arm of a cluster of teaching hospital-based palliative care services in Sydney, New South Wales (NSW), Australia. The Institute has several programs: the registrar training program, an international program, a humanities program, and a research program.

The registrar training program is the most developed of these programs and consists of 12 to15 linked training positions in three Area Health Services. The state of NSW is divided into geographic regions; in each region the Area Health Service provides health services for that region's population. Some Area Health Services also provide tertiary level services for residents outside the Area, and RPAH is such a centre. The registrar program started more than 15 years ago with three positions in one Area Health Service, and has gradually evolved to its current configuration.¹

In NSW, palliative care is practiced in three main contexts: specialist inpatient units (or freestanding hospices), hospital consultative services that mainly give advice to other specialist teams within the general hospital, and community consultative services that provide advice to general practitioners caring for patients at home or in residential care facilities. In the three Health Areas involved with the SIPM program, the palliative care services are organized on an integrated Area-based model.^2,3 In this model, patients may move between home, hospital, or specialist inpatient unit according to their needs and be cared for by the relevant arm of the palliative care service at those locations.

Goals of the Training Program

The goals of the training program are as follows.

• Offer clinical training for future specialists in palliative medicine.
• Provide clinical training for a variety of other doctors, in the hope that their training will make a long-term impact on the quality of end-of-life care that they provide.
• Assist the individual trainee to realize his or her potential as a palliative medicine doctor, whatever the future context of his or her practice.

Types of Trainees

The program is mainly aimed at doctors in postgraduate years (PGY) 4-8; such trainees are called "registrars" in Australia. Prior to 2000, the only formal clinical training in palliative medicine available for those not specializing in internal medicine in Australia was the 2 to 3 year SIPM certificate program. An external examiner, usually Professor Geoffrey W. Hanks from the United Kingdom, assisted in assessment of trainees completing this certificate.

Doctors wishing to specialize in palliative medicine in Australia may now do so in two ways. One method is by specializing in internal medicine and pursuing a three-year subspecialty program in palliative medicine within the Royal Australasian College of Physicians (RACP). This subspecialty has been in existence for more than a decade. The other option has only come about in the last two years; it is now possible to undertake three years of advanced training with the Australasian Chapter of Palliative Medicine after obtaining a fellowship from another college, such as the College of General Practitioners or from another clinical specialty.

A variety of trainees are included in the SIPM program, which features and welcomes professional, ethnic, and cultural diversity. Represented are career palliative medicine trainees from both training tracks, trainees in other specialties of internal medicine (e.g., medical oncology, geriatrics, respiratory medicine), and trainees of other specialties, such as radiation oncology, pain medicine, and family medicine. Other unaccredited trainees are accepted during most years for skills enhancement. The registrar program also attracts trainees from outside Australia who are planning a career in palliative medicine.

At most of the hospitals within the program, there are also other Junior Medical Officer (JMO) positions in palliative medicine, available as one choice in a series of three-month rotations through various specialties. These include Resident Medical Officer posts (PGY 2 & 3) and Medical Registrar positions (PGY 3-5 streamed in internal medicine). These JMOs are given clinical instruction and are welcome to attend the formal teaching program. Many of the doctors applying for the registrar program will have had some experience as a JMO in a palliative medicine post. Such experience is often the basis of a decision to follow palliative medicine as a career.

Description of the Training

Training occurs in the three main service contexts with three main types of rotations: specialist inpatient units, hospital consultative services, and community consultative services. In addition, there is a more specialized term involving pediatric and gynecological oncology and the opportunity for career palliative medicine trainees to rotate through a hospital pain service. Trainees rotate through successive placements every three to six months and stay within the program for periods varying from six months to several years. Care is taken to individualize each trainee's program as far as possible within service requirements. Career palliative medicine trainees in Australia are required to spend at least six months in each of the three major service contexts. Trainees preparing for hospital-based practice usually have a higher ratio of terms in hospital consultative services, and those preparing for community-based careers more community terms. Family medicine trainees usually train for three months in an inpatient unit, followed by three months in a community consultative service.

The training program consists of supervised clinical training, with a strong emphasis on forming a partnership between supervisor and trainee, who share joint responsibility for a busy clinical caseload. The size of the caseload is considered important: the post needs to be busy enough to provide sufficient clinical material and the opportunity to develop time management skills. Overwhelmingly busy posts may not permit the thorough clinical work required for learning at the specialist level. Case loads vary from post to post and over time, but are on the order of:

• Inpatient units: 12 to 25 inpatient beds per registrar, 250 to 400 admissions per year per registrar, average length of stay 10 to 20 days, with 20 to 45 percent live discharge rate
• Hospital consultative services: 250 to 600 new patients seen in consultation per year per registrar
• Community consultative services: more difficult to capture because of differences in data collection but approximately 200 new patients per year per registrar or 80 to 100 cases "on the books" per registrar at any one time

Most consultations address complex clinical situations, commonly involving unrelieved pain (nearly half), other symptoms causing difficulty, or assistance with total medical management.⁴ Rich and varied experience is available, enabling the trainee to expand on knowledge of the natural history of disease of a wide range of cancers and other advanced nonmalignant conditions. The trainee is guided through the vagaries of symptomatology, difficulties in clinical decision making in the face of treatment dilemmas, and the response of persons and families to tragedy, often in complex cultural contexts. The consultation usually opens the way for ongoing shared care over days, weeks, or months, with the referring doctor often remaining in charge of the case, seeking assistance when required. This pattern may vary according to the context of practice. Most patients die within a few months of referral, but about a third are alive at one year. Like the clinical service, the training includes terminal care, but extends beyond this to wider concepts of palliative medicine.

The trainees usually visit hospital patients daily, whether being seen in consultation or in the inpatient unit. In Australian practice, in addition to the registrars, the senior doctor (Attending Medical Officer or Consultant) sees all referred patients at least two or three times per week, and more often if needed. Patterns of care are more variable in the community and visits are more often episodic. The consultant aims to see all community referrals at least once, preferably on a joint supervisor/trainee visit. Due to the time-consuming nature of organizing such visits, more supervision is given through case discussions.

Registrars and senior staff are rostered on-call: training in after-hours work is thus provided. SIPM expects each trainee to receive 8 to 10 hours teaching/supervision per week, consisting of formal teaching sessions, journal club, clinical meetings, teaching ward rounds, and discussions about patient management at other times. Content and teaching are also enriched by the humanities program and the perspective provided by the international program, which has focused on both developed and developing countries. The key values of the SIPM guide this educational program. These are: respect for the value of the individual, recognition of the value of the last phase of life, respect for fundamental ethical principles, and respect for spiritual dimensions of care.⁵

The clinical caseload provides the context for a spiral learning system, in which the same ground is covered again and again, at higher and higher levels of complexity. The trainee develops a broad grasp of palliative care, gradually building competence by repeated exposure to patients, calling for the application of a wide range of skills with adequate supervision, and opportunity for retrospection and reflection. Such a system risks boredom by its repetitive nature; this is avoided by the diversity afforded by relatively large clinical services.

The process of clinical consultation is an ideal vehicle for problem-based learning: solutions to clinical problems often require the acquiring and drawing together of knowledge from other disciplines, as well as mainstream palliative therapeutics. Palliative therapeutics can be reduced for some purposes to a simple empirical system such as the WHO analgesic ladder for cancer pain relief, but education involving precise definition of pain mechanisms in each patient leads to a more adequate approach to assessment and more comprehensive management of that pain.⁶

Role of Supervision

Although the trainee may work with more than one consultant in a particular post, a main supervisor is always appointed and available. The main supervisor and the trainee develop a partnership, with daily clinical contact; a relationship of clinical apprenticeship, as opposed to solely distance or information-based learning. This model is conceptually based on the two etymological dimensions of the word "educate," that is, "to lead out" and "to nourish."

The network of posts offers differing levels of responsibility and supervision. A rotation is organized wherever possible to allow gradually diminishing levels of supervision as the trainees' skills increase. The main supervisor is responsible for the smooth running of the particular training position, assessing the trainee, and giving feedback. Trainees are assessed using a formal tool every three months, with an informal feedback session halfway through each rotation. The supervisor is the first point of contact for trainees to discuss whatever difficulties they may be facing. In addition to imparting clinical wisdom, a good supervisor also assists with the mentoring and professional development of the trainee. The program is organized to support the trainees' personal growth. In the course of this training, existential questions frequently challenge trainees. Trainees are encouraged to develop their own strategies for self-care: a variety of opportunities are provided, such as external clinical supervision and critical incident debriefing as well as informal strategies such as peer support and camaraderie. Learning to accompany one's fellow human beings on their final journey remains a serious exercise.

All supervisors are practicing palliative medicine specialists, and the majority have received formal clinical training in palliative medicine themselves, many of them through the SIPM program. Having experienced the program, most have an ongoing interest in registrar training. Supervisors are encouraged to improve their skills by attending appropriate educational programs such as supervisors workshops run by Royal Australasian College of Physicians, and SIPM has hosted events, such as the 1998 "Training the Trainers" program led by Dr. Ruthmarijke Smeding and Dr. Ruud Oderkerk, leading educators from The Netherlands.

Evaluation of the Program

Every three months, the trainees evaluate the training program using an anonymous feedback survey. The survey includes questions regarding what they have learned, the quality of teaching and supervision received, whether their expectations have been met, and general comments. In 1995, an unpublished evaluation was conducted to try to ascertain the trainees' views about the program. The following reasons, among others, were given for its popularity:

• teachers committed to developing an appreciation of the specialist body of knowledge of palliative medicine, and expounding it in a clinical setting
• supervised experience of the most difficult and complex clinical problems
• experience in the different settings available in an integrated service
• training within a diverse group of peers, each valued for contributing their own particular strengths and traditions

What Former Trainees Are Doing Now

Roughly one third of the doctors trained have chosen palliative medicine as their career specialty. In NSW about 20 former trainees are in positions of leadership, such as heads of services or departments. They practice in the full range of previously mentioned clinical contexts with some doctors preferring to specialize in one context, while others have positions that may require them to work in two or three contexts. One trainee with a background in pediatrics has become a specialist in pediatric palliative medicine. Many of the trainees have remained in Sydney; however, some are practicing in rural areas, and others have moved to other parts of Australia. The international trainees have all returned overseas to a variety of positions that use their skills in palliative medicine.

Perspectives on the Program More Than 15 Years On

The Australian health system is largely a public health system with a modest private sector. Senior medical staff in teaching hospitals, particularly in the non-procedural specialties, are usually in salaried positions, with no fee-for-service confines. This system allows the clinical freedom to meet the patient's needs with appropriate referrals and the cost of consultation is not carried by the patient. Palliative care services and medical training positions have been able to expand in this climate, in a way that may not be possible in a fiscally competitive health system such as that in the United States.

The SIPM palliative medicine training program first flourished in the late 1980s at a time when there was rapid development of the speciality of palliative medicine, signalled by increasing numbers of textbooks, conferences, and journals. Specialty training programs were established around the same time in Australia and the United Kingdom. Importantly, and at the same time, the Australian national government became interested in palliative care and began to offer incentive funding for palliative care services, which assisted the funding of salaried medical training positions. It should be noted that the program was not formally planned, but evolved creatively as a dynamic entity in response to external circumstances (resources and opportunities) and internal pressure (expanding interests and vitality of staff and trainees). In Australia, there is usually no separate payment to hospital-based clinicians for teaching and training doctors (or medical students); most of this work is done in the course of clinical appointments and responsibilities.

Major Challenges

The development of palliative care in Australia has been complex.⁷ The major challenge of the mid-1980s was sustaining the time and energy required for the essential one-to-one teaching in a partnership model. The principal teacher, who had an academic background as well as experience in oncology, was also a heavily burdened clinician and head of service, as there were few doctors practicing in this field at that time.

A continuing major challenge is nurturing the intellectual diversity of those who emerged from the training over a decade ago and are now leaders. Sub-specializing is occurring such as disease or tumor-specific expertise, symptom-based expertise, and other areas of interest, such as health service delivery, education, administration, and research. As a result, variation in the training experience is an issue, and although this has many advantages, it is also more difficult to ensure adequate training in the core of palliative medicine.

The most significant of the many lessons learned over the years is that it is necessary to accept the supervisors' and trainees' limitations, as human beings and professionals. Conversely, it is also necessary to clarify the limits of tolerance for shortcomings: the issue of standards and the poorly performing trainee is always time consuming and difficult. The shortcomings of supervisors may receive less attention, but are equally important. Another lesson learned at cost is that senior staff overburdened with a heavy clinical load have little energy for research and other academic pursuits. Consequently, training in research has been a deficiency in the training program.

Advice for Others

Our closing words of advice to others wishing to embark on training doctors in palliative medicine are as follows:

• Keep the doctor's training in palliative medicine focused on the medicine. The doctor is a key player and needs to be able to provide the interdisciplinary team with excellent palliative medicine knowledge and skills, for no other team member is able to do so. There is temptation for trainees to pursue interests in common with other disciplines; however, this should be secondary to gaining core knowledge and skills in palliative medicine.

• Recruit carefully, particularly for those embarking on a career in palliative medicine. The potential for clinical and intellectual growth is important in future leaders of the field. The motives of the trainee need some assessment.

• Ensure adequate resources to supplement funds for clinical services.

• Ensure a climate of "freedom of spirit," so vital in the age of multiculturalism and for optimal learning to take place.

Conclusion

The number of trained palliative medicine specialists has steadily increased and is now approaching adequate numbers in some Area Health Services in Sydney. In the future, the focus will increase on providing training for doctors who will ultimately practice in other areas of medicine. The clinicians associated with SIPM have always recognized the challenge to educate both palliative medicine specialists and doctors preparing for other careers within the health system.

US recommendations.⁸ concerning improvements needed in end-of-life care include medical education and are noteworthy⁹; some implications have been explored in the Australian context.¹⁰ Much more remains to be done in the field of medical education to improve care of all patients in the last phase, wherever they may be.

References

1. Turner KS, Lickiss JN. Postgraduate training in palliative medicine: The experience of the Sydney Institute of Palliative Medicine. Palliative Medicine. 1997;11:389-394.[Return to International Perspectives]

2. Lickiss JN, Turner K, Gibson S, Ng M, Macaulay P, Formby F, Hartley J. Palliative care in central Sydney: The Royal Prince Alfred Hospital as catalyst and integrator. Journal of Palliative Care. 1993;9(3):33-43.[Return to International Perspectives]

3. Report of NSW Health Palliative Care Working Party. Sydney: New South Wales Health, 1993.[Return to International Perspectives]

4. Virik K, Glare P. Profile and evaluation of a palliative medicine consultation service within a tertiary teaching hospital in Sydney, Australia. Journal of Pain and Symptom Management. 2002;23(1):17-25.[Return to International Perspectives]

5. Lickiss JN. Palliative care for patients with gynaecological cancer: Approach to decision making. In Gynaecologic Oncology Issues GR Di Paola, J Sardi (eds.) in the 8th International Gynaecologic Oncology Society (IGCS) Meeting of Buenos Aires. Bologna, Italy: Monduzzi Editore, 2000:7-14.[Return to International Perspectives]

6.Lickiss JN. Approaching cancer pain relief. European Journal of Pain. 2001;5 (Suppl A): 5-14.[Return to International Perspectives]

7. Lickiss JN. Australia: Status of cancer pain and palliative care. Journal of Pain and Symptom Management. 1993;8:388-394. [Return to International Perspectives]

8. Institute of Medicine, Field M, Cassel CK (eds.). Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press, 1997.[Return to International Perspectives]

9. Lickiss JN. Education for physicians on end-of-life care: EPEC trainer's guide on CD-ROM. Review of the CD. Lancet. 2001;357:1051-1052.[Return to International Perspectives]

10. Glare P, Virik K. Can we do better in end-of-life care? The mixed management model and palliative care. Medical Journal of Australia. 2001;175(10):530-533. [Return to International Perspectives]