Education and training
Specialist training in palliative medicine includes:
- a working knowledge of the similarities, differences and relationships of practice in hospital, community and primary care
- rehabilitation and general internal medicine
- psychological and psychiatric interventions
- social care and the influences and complexities of culture and beliefs on patients’ and families’ views of failing health, dying and death.
Training provides up-to-date knowledge of the pathology and management of a range of malignant and non-malignant, life-threatening conditions.
Doctors with core skills undergo competitive selection into palliative medicine specialty training using a nationally agreed person specification and interview process. Entry to palliative medicine training is possible following successful completion of both a foundation programme and a core training programme. There are five core training programmes for palliative medicine training:
- core medical training (CMT)
- acute care common stem (ACCS)
- anaesthetic training
- core surgical training
- general practice training.
Higher specialty training then builds on these core skills to develop the specific competencies required to practise independently as a consultant in palliative medicine. The training programme aims to develop physicians with a breadth and depth of experience and competence to work safely as a consultant in palliative medicine in any care setting in the UK and within the NHS and charitable sectors.
The purpose of the palliative medicine curriculum is to produce doctors with the generic professional and specialty specific capabilities to manage patients with advanced, progressive, life-limiting disease, for whom the focus of care is to optimise their quality of life through expert symptom management and psychological, social and spiritual support as part of a multi-professional team. The curriculum for specialty training is competency based but is a minimum of 4 years in length. It covers a number of key areas (see bottom of page).
The curriculum is covered through a sequence of posts in a training rotation. Trainees occupy posts that provide experience of palliative medicine in a full range of settings including patients’ own homes, day hospices and hospice inpatient units and other inpatient specialist palliative care units, outpatients and general hospitals. Attachments to oncology, chronic pain services, and other related specialties are available to allow trainees to meet the competencies outlined in the curriculum.
The annual review of competence progression (ARCP) has outlined the targets that have to be achieved for a satisfactory outcome of training each year.
Shape of Training and future changes
The Shape of Training (SoT) review was a catalyst for reform of postgraduate training of all doctors to ensure it is more patient focused, more general (especially in the early years) and with more flexibility of career structure. Shape of Training will change training on palliative medicine from 2022. Doctors will dual train in internal medicine (IM) and palliative medicine with the award of CCT (IM and palliative medicine) on completion of training. The model for physicianly training consists of an indicative 7-year (dual) training period. Candidates will be selected to enter specialist palliative medicine training following completion of stage 1 training in IM, during which there will be increasing responsibility for the acute medical take and the MRCP(UK) Diploma will be achieved. After this, there will be competitive entry into specialty plus internal medicine dual training. A minimum of 3 years will be spent training in the specialty and there will be a further 1 year of internal medicine integrated flexibly within the programme. This will ensure that CCT holders are competent to practise independently at consultant level in both palliative medicine and internal medicine.
This model will enhance the training of palliative medicine physicians, by enabling the management of the acutely unwell patient with an increased focus on chronic disease management, comorbidity and complexity. For palliative medicine doctors, there will be a significant focus on identifying reversibility (or lack of) in acutely unwell patients with life-limiting conditions and in promoting safe management in non-acute settings, eg community and hospice. Enhanced IM skills will also better equip palliative medicine physicians to work as members of the wider multidisciplinary team and alongside physicians in the acute hospital to most effectively manage patients with complex palliative care needs and those approaching the end of their lives.
The model for palliative medicine training will:
- ensure trainee physicians can provide safe, high quality, holistic palliative care in all settings (including acute hospital, ambulatory, community, care home and hospice/specialist palliative care unit) during and on completion of their postgraduate training
- ensure that palliative medicine doctors develop and demonstrate a range of essential capabilities for managing patients with a range of life-limiting, progressive conditions
- ensure that trainee physicians can acquire and demonstrate all of the GMC mandated GPCs including advanced communication skills
- allow flexibility between specialties through GPCs and higher level learning outcomes
- further develop the attributes of professionalism, particularly recognition of the primacy of patient welfare that is required for safe and effective care of those with life-limiting, progressive conditions, and develop physicians who ensure patients’ views are central to all decision making, which needs to be robust, individualised and incorporates a thorough understanding of medical ethics
- ensure that palliative medicine physicians have advanced communication skills to manage complex and challenging situations with patient, carers and colleagues
- provide the opportunity to further develop leadership, team working and supervisory skills in order to deliver care in the setting of a contemporary multidisciplinary team to enable them to make independent clinical decisions on completion of training
- build on the knowledge, skills and attitudes acquired during stage 1 internal medicine training
- ensure the flexibility to allow trainees to train in academic medicine alongside their acquisition of clinical and generic capabilities.
Experience in research is and will continue to be an essential part of the curriuclum and it is important that hospitals provide support and accessibility for trainees to experience related specialties. Trainees can also take time out of programme to spend more time focusing on research. There are a small number of academic training programmes available. Academic clinical fellowships have a different funding mechanism which allows a trainee to set aside 25% of their time to develop academic skills and to prepare and compete for a training fellowship to undertake a higher degree.
The Academy of Medical Royal Colleges (AoMRC) has produced a cost of training document setting out the mandatory costs of training involved in college enrolment fees, examination costs and GMC fees. Published in October 2017, it has been compiled to help pre-specialty doctors make fully informed career selections, with a clear understanding of the mandatory costs of their future training pathway.
Continuing professional development
For doctors working within palliative medicine:
Specialty guidance on continuing professional development (CPD), appraisal and revalidation has been developed and is available via the Association of Palliative Medicine.
For doctors in primary care and other specialties who have responsibility for patients with progressing, life-limiting illness:
There has been considerable development of resources to ensure all doctors can provide good end-of-life care, including the RCP’s Improving end-of-life care: professional development of physicians working party report.
The Department of Health’s End of Life Care Strategy published in 2008 identified three groups of staff with professional development needs in end-of-life care:
- staff who work in specialist palliative care and hospices
- staff who frequently deal with end-of-life care as part of their role, eg secondary care staff who work in accident and emergency, acute medicine, respiratory medicine, geriatric medicine, cardiology, oncology, renal medicine, intensive care, and those who work with patients with long-term neurological conditions
- staff who work within other services and who infrequently have to deal with end-of-life care.
Four areas have been identified as common core requirements for the workforce:
- training in communication skills
- assessment of a person’s needs and preferences
- advance care planning
- symptom control.
Palliative care physicians and specialist teams often have lead responsibility for such education in hospitals.
Professional development for end-of-life care should:
- strengthen multiprofessional teams and promote collaboration between team members
- support the development of effective communication skills through interactive approaches such as simulation, observation and practice with feedback
- use opportunities in routine practice to draw on clinical experiences with a direct relevance to patient care, developing problem-solving and reflective skills
- actively seek engagement with, and feedback from, patients and caregivers to improve understanding of the patient experience
- be embedded into a wide range of educational events such as conferences, workshops and study days, not just those that focus specifically on end-of-life care.
Consultants who provide care at the end of life should incorporate this into their CPD and undertake at least one learning event in end-of-life care within a 5-year CPD cycle. This should be reviewed at their annual consultant appraisal. Joint learning with GPs should be encouraged to further the understanding of each other’s roles and services and to improve coordination of care across traditional boundaries.
The use of e-learning, such as End of Life Care for All (e-ELCA), to support work-based learning should be included where relevant.
- Legal frameworks
- Learning and teaching
- Clinical governance including audit.