How to build a palliative care empire

Lately, I have been listening to a podcast called People I (Mostly) Admire, a series by Steve Levitt and Angela Duckworth. You may know Levitt from his award-winning book Freakonomics.

It is a fun but informative podcast, much in the same spirit as Freakonomics. Guests have included Ken Jennings of Jeopardy, Mayim Bialik of The Big Bang Theory fame and other fascinating people you may not recognize.

They even did a podcast on palliative care in which they interviewed BJ Miller, a California-based palliative care physician who provides a great description of palliative care, the benefits of a palliative approach to care and his hopes for improving uptake of hospice palliative care in the United States.

The podcast got me thinking of people I (mostly) admire.

While it would be easy and predictable to say someone like Dame Cicely Saunders, who started the modern hospice movement, or Balfour Mount, who coined the phrase “palliative care” and started one of Canada’s first PCUs in Montreal, I decided to go a bit Rogue.

One person I (mostly) admire is Sheev Palpatine of Star Wars fame.

Now some of you might know him as the plucky Senator Palpatine when he was on Naboo, the imminent Chancellor Palpatine when he assumed power (thanks Jar Jar) to defend the Republic during the Clone Wars, or as Emperor Palpatine when he ultimately transformed the Republic into the first Galactic Empire.

What I admire about Palpatine is his ability to: 1) identify talent; 2) recruit; and 3) build armies.

Palpatine had a keen eye for talent. In Episode 1, he had already partnered with Darth Maul, perhaps one of the coolest characters in all of the Star Wars universe, especially now that Boba Fett has been taken down a notch by his lukewarm Disney+ series. But Palpatine was always on the lookout for new talent, eventually recruiting Count Dooku and then Anakin Skywalker.

Recently, I had an opportunity to work with two residents rotating through our community hospice program. Like Anakin, Mary Ann and Natan were still in training as Padawans. At the end of their Post Graduate Year 1 (PGY1), they were rotating through our community program and demonstrated a lot of potential. A good palliative care physician has a strong and broad base of medical knowledge, compassion, excellent communication skills and works well in an interdisciplinary team. Mary Ann and Natan certainly have all of these.

When Palpatine suggested to Anakin that there could be a way to even greater power, Anakin was intrigued. Mary Ann and Natan were curious about careers in palliative care and what that could look like. During the rotation and their evaluations, we discussed various options for training, the current environment and what career opportunities could look like in palliative medicine. We discussed the flexibility of a PGY3 that could allow them to have mixed practices that include family medicine and palliative care, as well as the option of simply incorporating a palliative approach into their practices as family physicians. We talked about all of the various care settings in which palliative care is required (home, hospital, hospice, LTC, congregate care settings, etc.) as well as the variety of patients they would care for, ranging from patients with cancer to non-malignant diagnoses such as CHF, COPD, liver disease, ALS and dementia, just to name a few.

Palpatine’s first action as Chancellor was to build a grand army with which to defend the Republic. Now, his army was a bunch of clones from Kamino. In palliative care, what is needed is an army of health-care professionals with at least basic competencies in palliative care as well as specialists and experts with advanced training and knowledge.

Those who showed an aptitude for palliative care, like our two residents, were invited to “come to the dark side” and consider the Post Graduate Year 3 program.

Now, I keep hearing from colleagues that we can’t do this. Yet, we have never tried. I have already written about the deficiencies in medical training, both in providing basic competencies (primary level capacity) as well as experts (secondary level capacity). I also have written about how we overcame this in Windsor. While we did not clone doctors, we instead decided to train local family medicine residents and then provide them with a route to added competency through a PGY3 program. This helped us to not only build secondary level capacity but also ensured that every family physician trained in Windsor had basic palliative care competencies. Those who showed an aptitude for palliative care, like our two residents, were invited to “come to the dark side” and consider the PGY3 program.

This “Jedi Mind Trick” has proven very effective for us here in Windsor. I would, however, resist the urge to make ultimatums, as Vader suggests to Palpatine: “He/She will join us or die.” We prefer a more voluntary approach.

Using this approach, Windsor-Essex has gone from two palliative physicians in 2012 to 12 in just under a decade. We now have palliative physicians in every acute care hospital, a robust community program, two residential hospices, a 20-bed PCU, a high-volume outpatient clinic at our regional cancer centre and are working toward consultative support for our long-term care homes.

Over the past decade, since the signing of the Declaration of Partnership in 2011, our PGY3 program has trained 19 family medicine residents with advanced competencies in palliative medicine. Of these, many have remained in southwestern Ontario. Every family doctor trained in Windsor’s residency program (10 per year) completes at least one palliative care rotation.

Imagine if every medical school and training centre in Canada had been taking this approach for the past decade?

Meanwhile, in the United States, Hospice Palliative Medicine (HPM) is the fifth largest medical subspecialty, behind only Cardiovascular; Pulmonary and Critical Care; Hematology and Oncology; and Gastroenterology. Truly an astounding achievement!

One of my earliest Healthy Debate articles was about medical school training and how we fail to provide basic palliative competencies to all graduating doctors, nor do we train enough palliative medicine specialists to meet the growing demand. Our PGY3, a joint venture between London, Windsor and Sarnia, proves that it is possible to train enough palliative medicine physicians to meet the existing and growing demand for palliative medicine in clinical care. We didn’t even have to resort to cloning (although this could speed up the process significantly).

As such, I once again push back on the unproven notion that blithely states: “We can’t train enough palliative physicians.” In fact, much like the Imperial Commander on the second Death Star, I recommend we “double our efforts.”

Why is it that there were 24 Anatomical Pathology positions in the first round of the 2022 CaRMs match yet Palliative Medicine does not even appear? This is not to punch down or downgrade the importance of Anatomical Pathology but to emphasize the lack of importance that has been placed on training enough Palliative Medicine specialists.

Furthermore, as of 2022, less than half of Canada’s medical schools, only eight of 17 , offer a Royal College training program in Palliative Medicine. Nearly all medical schools offered residency positions in Anatomical Pathology.

Now, some of you might be rolling your eyes about admiring Palpatine and I get it. While his return in Rise of Skywalker seemed rushed and shoehorned into the final installment of the Skywalker Saga, he did end up in the universe’s worst ICU, clearly due to a lack of good advance care planning and goals of care discussions. I remain, however, a fan of his inSidious ability to identify and recruit talent as well as to build an army to defend his empire.

Perhaps if we can apply these three approaches to palliative care in Canada, some day we too can have an army of health-care providers who have basic competencies in palliative care as well as enough specialists to treat patients and coach and mentor other members of the health-care team.