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Surgeons require additional palliative care education
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Physicians who received no palliative care training appeared considerably more likely to recommend major surgical interventions for patients with advanced cancer, according to study results published in Surgery.
Richard Bold, MD, chief of surgical oncology at UC Davis Comprehensive Cancer Center, and colleagues surveyed 102 surgeons and medical physicians who treat patients with advanced cancer who had symptomatic surgical conditions. Researchers assessed respondents’ palliative care training and surgical decision-making.
The researchers hypothesized that surgeons would have less palliative care training and, thus, provide more aggressive treatment recommendations.
Surgeons reported fewer hours of palliative care training (median, 10; interquartile range [IQR], 2-15) during residency, fellowship and CME combined than medical oncologists (median, 30; IQR, 20-80) and medical intensivists (median, 50; IQR, 30-100; P < .05). Twenty percent of surgeons reported no palliative care training.
Survey respondents who had no palliative care training recommended major operative intervention significantly more frequently than those who had undergone 40 hours or more of palliative care training (P = .01).
“These findings highlight the need for greater efforts systemwide in palliative care education among surgeons, including incorporation of a structured palliative care training curriculum in graduate and continuing surgical education,” Bold and colleagues wrote.
HemOnc Today spoke with Bold about the differences in the amount of palliative care training among survey respondents, as well as the clinical implications of the findings.
Question: How did the study come about?
Answer: This study is a 10-year follow-up to our original publication published in 2005 in Archives of Surgery. The specialty of palliative care was just emerging at the time of the first study, and the differentiation between palliative care and hospice care really was beginning to be well-defined. Our initial survey aimed to identify the landscape for surgeons taking care of patients with advanced malignancies. During the past decade, there has been real development of the concept of palliative care as a specialty and how it can be integrated into patient care. We wanted to see if there were any changes in decision-making among a variety of physicians who help treat patients with advanced malignancy.
Q: How did you conduct the study?
A: Our first study was limited to surgeons. We expanded our scope to medical oncologists, intensivists and palliative care-trained physicians. We surveyed these physicians with a 32-item questionnaire that addressed palliative care training and four clinical vignettes about patients with advanced cancer and symptomatic surgical conditions.
Q: What did you find?
A: We found a significant difference across specialists in the amount of palliative care training and education they receive. Unfortunately, providers, intensivists and surgeons still do not receive a lot. The other big finding was that the amount of training one has in palliative care really affected how aggressively they wanted to treat patients with various symptomatic issues outlined in the clinical scenarios presented. The less training someone had, the more likely they were to recommend an aggressive intervention.
Q: Can you elaborate on the key differences in the amount of palliative care training received by various groups of physicians included in th is study?
A: There were two key differences in the training surgeons receive compared with the other physicians surveyed. First, surgeons received far fewer hours of education about palliative care during training, as well as through CME. Second, 20% of surgeons surveyed had no palliative care education. All medical oncologists and medical intensivists had at least some training, including during residency and fellowships, as well as through CME. This gap in education among surgeons starts in residency but, unfortunately, it persists throughout their career.
Q: What are the implications of these findings?
A: It is certainly unreasonable to make all clinicians who are involved in treating patients with cancer into palliative care specialists. However, the most important part of what we are learning is the critical role that palliative care specialists have in terms of participating in decision-making and approaching things with different input in terms of different outcomes. As a surgeon, the biggest way I have to treat patients is with surgical interventions, but specialists and palliative care are part of the complementary team in terms of other options for symptomatic relief for patients with advanced malignancy. Detailed training in palliative care for surgeons may not be feasible, but at least some education about how palliative care specialists integrate goals of treatment with recommended interventions can be accomplished easily.
Q: What should be done to expand palliative care training?
A: Decision-making for these patients should come from a team-based approach that balances the benefits and risks of an intervention. Over the past decade, we have seen the expansion of palliative care training, but we are learning that this needs to be integrated in a structured fashion for those specialists who treat patients with advanced malignancy — not only medical oncologists, but anyone who can be involved in addressing symptomatic issues, particularly at the end of a patient’s life.
Q: Is there anything else that you would like to mention?
A: With the aging population in the United States and the advances in oncology treatment, we are going to see many more long-term cancer survivors. It is estimated that cancer will become the leading cause of death by 2030, so this will become a more frequent issue across all specialties. Even if we do not have integrative palliative care training across all specialties, we should at least recognize the benefit that specialists who are trained in palliative care offer to facilitate the team-based decision-making for these patients. – by Jennifer Southall
Reference:
Bateni SB, et al. Surgery. 2018;doi:10.1016/j.surg.2018.01.021.
Galante JM, et al. Arch Surg. 2005;doi:10.1001/archsurg.140.9.873.
For more information:
Richard Bold, MD, can be reached at UC Davis Health, 4900 Broadway, Sacramento, CA 95820; email: rjbold@ucdavis.edu.
Disclosure: Bold reports no relevant financial disclosures.