Careers in Palliative Medicine

If training full-time in a numbered post, it takes four years to gain a certificate of completion (CCT) in palliative medicine. Trainee numbers in palliative medicine have increased from 135 (in 2001) to 243 (in 2012) and about 30% train flexibly. 149 palliative medicine trainees responded to the recent RCP 2011 survey (response rate 59%). The vast majority work an on-call rota rather than a full-shift rota, with just over 50% receiving a pay banding of 1A or 1B. Compared with other specialties, palliative medicine trainees spend proportionally more time doing ward work (52% of their time, compared to 46.6% for geriatric medicine trainees).

The survey revealed that 74% of palliative medicine trainees felt positive about going to work in the morning (one of the higher figures compared to other specialties). In comparison to most other medical specialties, there is a much higher proportion of female trainees in palliative medicine, at about a 1:5-6. Specialties with a similar gender bias include clinical genetics.

During 2012-13, for the 34 CCTs awarded, 25 (67.6%) were in substantive posts, and 7 (20.6%) were in locum consultant posts. During 2011-12, 34 CCTs were awarded, with 20 (59%) in substantive posts, and 4 (11.8%) in locum posts.

The estimated Royal College of Physicians workforce requirements are 2 full-time equivalent consultants for a population of 250,000, which represents 505 full-time equivalent posts across the UK. According to the Specialty Advisory Committee workforce data for 2012, there are 409.6 full-time equivalent palliative medicine consultants in the UK.

Consultants

Why do we need consultants in palliative medicine?

There is a growing need for consultants in palliative medicine. With population growth and a larger percentage of elderly people, the number of patients nearing end-of-life is increasing. Patients with advanced diseases are also living longer and needing more specialist palliative care.

There is increasing referral of patients with diseases other than cancer to specialist palliative care. The complexity of medical treatments and co-morbidities in advanced disease is rising, and there is a national focus on improving the quality of end of life care services.

What do consultants in palliative medicine offer?

Consultants in palliative medicine provide medical leadership to multi-professional specialist palliative care teams. They work in acute hospital, hospices and in the community; often enabling continuity of care by working in more than one setting. Their core roles cover the following five areas:

• Clinical expertise
• Leadership of palliative care services
• Clinical governance
• Education
• Research
Consultants provide clinical expertise in several ways. For example:
• they assess complex symptoms from an understanding of the underlying pathology
• they assess and support patients who are dying and their families
• they formulate evidence-based and individualized management plans
• they advise other clinicians on ethical decision making and symptom control “Palliative physicians work within specialist palliative care teams assessing and treating patients with difficult symptoms and complex psychosocial and spiritual problems” [RCP London]

In addition consultants are expected to demonstrate leadership in a variety of contexts. For example:

• clinical and operational leadership of palliative care teams
• strategic leadership for service development
• supportive leadership and appraisal of specialty, staff grade and associate specialist (SSAS) doctors

What appeals about Palliative Medicine?

If delivering high-quality, multi-disciplinary, patient-centred care interests you, then palliative medicine could be the specialty for you.

As a trainee, you will learn to care for patients with a great range of illnesses, of all ages and in all settings, whether at home, in hospital, or in a hospice. You will learn to think on your feet, apply theoretical and scientific knowledge and blend this with empathy and pragmatism.

As a small and dynamic specialty, there is ample opportunity to help shape the future by becoming involved in collaborative research, quality improvement and education during your training

A day in the life of a Palliative Medicine consultant

I work 4 days a week as have 2 young children, so the day starts with playing with them and then rushing out of the house to work. I’m in by 8.30 and then catch up on emails and see how the Palliative Care Unit that I work on has changed overnight.

Two mornings a week I do a ward round on the palliative care unit when we encourage relatives to attend (if the patient wishes) so everyone feels involved. One morning a week we have a pan-Northumberland MDT when we video-link to the more remote areas to discuss complex patients across Northumberland.

At the MDT the Macmillan nurses frequently ask me to see patients either at home or in my clinic. I get phone calls throughout the day asking for urgent advice or home visits.

One day a week I work as an Honorary Senior Clinical Lecturer in Palliative Medicine for the medicine undergraduates from Newcastle University, so time is spent preparing, planning & delivering teaching. I also do lots of teaching for the doctors at the hospital and GPs in the community.

In my leisure time(!) I work as the Honorary Secretary for the Association for Palliative Medicine coordinating responses to national consultations from NICE, DoH, RCP etc. My job is very varied and that is what I like.

No two days are the same and you never quite know how a day will pan out.

Palliative Medicine SHO

A day in the life of a Palliative Medicine SHO

My day usually starts at 9am with a multidisciplinary handover – encompassing physiotherapists, chaplaincy, nursing and occupational therapists. In this we briefly discuss issues which have cropped up overnight, and updates on discharge planning. Following this – dependent on the day I either attend the Consultant-led ward round this involves – presenting cases to the consultant and discussing management plans, or seeing patients myself, we split the ward in 2 usually – so I care for about 8-10 patients, I enjoy doing these reviews as it gives me the opportunity to act autonomously and form a relationship with my patients – allowing access for more difficult and challenging discussions.

My afternoons are frequently spent chasing jobs from the morning, making phone calls to GP’s to discuss discharge plans/gain further information, family discussions and updates – these can often take some time and be quite emotionally tiring – due to the nature of discussions, however they can also be extremely rewarding, bringing families together and paving ways for a “good death.”

We frequently can get community admissions from a GP or McMillan Nurse – for patients who require admission for symptomatic control or end of life care. These cases can be quite complex and can involve detective work- finding out nature of disease, prognosis and treatment plans, thorough clerking and consideration of investigations before deciding on the most appropriate management plan – liaising carefully with the patient and their families. My day ends at 5pm following a mini-handover with nursing staff of the changes made to plans and any updates made throughout the day.

Palliative care is an extremely rewarding job – offering the opportunity to deal with both chronic and acute conditions – allowing for that “buzz” of adrenaline in the acute situations such as a terminal bleed or seizure. Whilst allowing you to build relationships with patients and have the aspect of continuity of care. Given the nature of Palliative Care – there is so much variety in presentations, symptom management and types of families encountered – no two days or patients are alike!

Palliative Medicine within general practice

Palliative care within general practice

Dr Laura Bennett, Salaried GP and Medical Officer at Shakespeare Hospice

My interest in Palliative Medicine started at Medical School when we had a brief taster session at the local Hospice in Penarth. This led me to request a Palliative Medicine rotation as part of my GP training. I really enjoyed the multi-disciplinary teamwork, and the opportunity to spend a greater amount of time with each patient – getting to know them as a person, their concerns and expectations so that a holistic approach could be taken with their management. I am now working as a salaried GP but have been able to pursue my interest in Palliative Medicine by doing monthly on calls at the local Hospice inpatient units; weekly sessions as a Medical Officer at a local Day Hospice, and undertaking the Diploma in Palliative Medicine at Cardiff University.

There are lots of opportunities to explore an interest in Palliative Medicine within General Practice. These include becoming the practice and/or CCG lead for Palliative Care; taking on a Macmillan GP role, or working as a medical officer at a local Hospice. If a patient wishes to die at home then the GP will be the clinician responsible for coordinating their care. This involves working closely with the patients Macmillan Nurse to ensure they have the appropriate support, and also symptom control management e.g. anticipatory medications. With the number of patients with end stage non-cancer diagnoses increasing it is important to take a palliative approach in their management and pro-actively discuss advance care planning. The skills required in Palliative Medicine are invaluable for General Practice, and it makes for a great portfolio career if you decide to combine both interests.