Next step in palliative care education in India : full-time residential courses for professionals
I write this from the background of the Indian context; but this could well be relevant to much of the developing world.
Look back at the development of palliative care in India: from its birth as a hospice in Mumbai in 1986, to its acceptance as an essential part of National Cancer Control Program in 1991, to its establishment in many of the regional cancer centres, to its spread as a community oriented network in Kerala, and to a reversal of the downward trend in opioid consumption in the country. Some of us palliative care workers tend to pat ourselves on our backs – till we are taken aback by someone like Dr Jan Stjernswärd who points out that all considered, the progress is “disappointing”.
When the blinders fall from our eyes, we see the disappointing bits. The policy exists, but only on paper. Oral morphine reaches less than 1% of the needy, even now. The vast majority of institutions treating cancer patients have no palliative care services. There are many states in India which even now have not even a single palliative care facility. It is easy to blame the red tape and the Government, but the fact remains that the medical and nursing professions at large, have not accepted palliative care as an essential part of health care.
We realize very clearly that education of professionals is essential for development of palliative care in India . Many pioneering institutions conduct education programs. But there is a lot of confusion. Who should be the target audience? What should be the minimum objective of teaching programs? Should we just do sensitization programs and leave the professionals to learn more by themselves? How about “foundation courses” of a week to fortnight duration? What exactly do we achieve in these courses? How can we expose nursing and medical students to palliative care? And how do we attract young doctors to take up palliative care?
Perhaps there are no easy answers to these questions. Perhaps we need all sorts of programs. Sensitization programs, no doubt, attract some people to the “new” concept. But didactic teaching seldom changes practice. Undergraduate curricula are already overloaded to the bursting point, and any attempt by a new discipline to muscle in, is resisted. Well, even if the curricula are amended, who is available to teach palliative care anyway?
I think it is time to develop full-time residential courses in pain and palliative care for professionals. That will develop a corps of teachers for tomorrow. Hopefully they will form a critical mass not only to ensure quality palliative care for people who need it, but also to help in integrating palliative care into routine medical practice. And by offering opportunity for career advancement, such courses should attract young professionals.
In Amrita Institute of Medical Sciences in Kochi , Kerala in India , we have started a two year diploma program for doctors – the Diploma in Pain and Palliative Medicine (DPPM). This is the first and only such university-approved course in the country. It started in January 2004, the course is designed to develop the trainee in terms of knowledge, skills and attitude both in palliative care practice and teaching. One does not need to be a specialist to apply; the course is open to any general practitioner. Three residents are taken in every year; for this we got an average of 20 applicants last year and this. Applicants go through a screening process which includes a written test aimed at assessing knowledge and a viva voce to assess attitude. Once selected, the trainee works as a full time resident and earns while he learns - just as in most other postgraduate programs in the country.
In the first six weeks of the course, the trainee goes through a basic training which introduces him to the whole spectrum of pain and palliative medicine. There is a structured training program for the whole two year period, which includes a mandatory rotation through oncology and geriatrics and some elective rotations including one month at another center. In addition to periodic internal assessment, there is a final examination conducted by the university – designed to assess knowledge, skill and attitude.
The Medical Council of India has not yet approved Pain and Palliative Medicine as a separate discipline; that is one obstacle yet to be surmounted. There are other concerns. Will the development of such “specialists” change the art of palliative care to just another mindless technical specialty with too much medicineand too little care? This is something that we will have to guard against. Will there be enough employment opportunities for those who qualify? We hope so; but efforts at generating government policy and at ensuring opioid availability at the national level must continue concurrently.
IAHPC has supported this program with its faculty development grant in 2004. Many visiting professors from the west spend their own time and money to come and teach at this course on a regular basis. Dr Robert Twycross did a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis of the course for us recently, and such periodic evaluation, we hope, will help to maintain quality. Mrs and Dr Peter Kirk have provided a bursary to assist the students at our courses.
The first batch of these full-fledged palliative care physicians should qualify at the end of 2005. We look forward to them being major forces at effecting change for the future of palliative care in India . We also look forward to many more institutions developing full-time residential courses and developing a critical mass of palliative care professionals.
Dr Rajagopal is a member of the Board of IAHPC and Professor of Pain and Palliative Medicine
Amrita Institute of Medical Sciences
Kochi , Kerala 682026
India
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