Should palliative care be a specialty?

Criterion 1: A subspecialty has an in-depth body of knowledge beyond the scope of the foundational specialty

In 2003, the Canadian Institutes of Health Research created a $12 million funding program dedicated to research in palliative and end-of-life care.3 There are now at least 10 major dedicated scientific journals, many new textbooks being published every year, and annual international research meetings on 5 continents on the subject of palliative care. It is simply not possible for busy generalists to maintain a comprehensive knowledge of the field. Arguing against palliative medicine as a subspecialty puts exactly that unachievable responsibility on the back of every generalist. Family physicians treat congestive heart failure, but that does not mean that cardiology is not a subspecialty. Most palliative care does not require the services of a palliative medicine subspecialist, but that does not mean that palliative medicine subspecialists are unnecessary.

Criterion 2: A subspecialty has identifiable competencies that build on foundational specialty training

Identifiable competencies have been clearly articulated through the CFPC and RCPSC conjoint accreditation process for palliative medicine training programs since 1999. The broad domains of competency are, of course, similar for primary and subspecialty palliative care providers. They have comparable levels of expected competency in some domains (eg, interprofessional collaboration skills). In other domains, such as symptom management, however, the level of expected competency is substantially different, justifying the existence of a cadre of physicians (subspecialists) dedicated to advancing these competencies.

Criterion 3: There must be evidence of a need for subspecialists

Canada can be justifiably proud of advances made during the past 30 years in care of patients with palliative needs. Good access to high-quality primary and subspecialty palliative care at home, in clinics, and in long-term care facilities and hospitals is far from universal. Recognition of the subspecialty of palliative medicine will not automatically guarantee appropriate supply and distribution of primary and subspecialty physician resources, but it is one important element of what must be a comprehensive strategy for building palliative care capacity at all levels.

Criterion 4: The change in scope of practice must not adversely affect any field of medicine

While it is impossible to prove prospectively that there would be no detrimental effects, there is no reason to believe that the existence of a recognized subspecialty in palliative medicine is likely to harm family medicine any more than the existence of a subspecialty in endocrinology. Some argue that increasing the availability of subspecialty resources would, in fact, encourage greater provision of primary palliative care as primary physicians would have the assurance of good backup if they need it.

Criterion 5: There must be adequate infrastructure to sustain the subspecialty, including a professional organization and recognition in other jurisdictions

Palliative medicine is a recognized subspecialty in the United States, Australia, New Zealand, the United Kingdom, Ireland, and 5 other countries in Europe.4 The Canadian Society of Palliative Care Physicians was established in 1994 and is the primary national voice for palliative medicine. The Society is involved in research and advocacy, and coordinates national efforts in undergraduate, postgraduate, and continuing education.

In summary, palliative medicine in Canada meets the RCPSC standard for a subspecialty, and it is legitimate to think of the discipline as a subspecialty. But it is a unique subspecialty that must be accessible to physicians from both CFPC and RCPSC training streams. While the concept of family medicine as a path to a subspecialty is new in Canada, international precedents exist. Australasia, the United Kingdom, and the United States all recognize palliative medicine subspecialists from both family medicine and other specialty backgrounds.

One question must guide every decision about training or credentialing of physicians: In the long run, is this likely to improve the care of patients? When cardiology was first recognized by the RCPSC in 1965, the tools of the newly minted specialty consisted of acetylsalicylic acid, nitroglycerine, hydrochlorothiazide, propranolol, and the electrocardiogram. It was the creation of the specialty that laid the foundation for subsequent advances.

The discussion about palliative medicine as a subspecialty must take a similar long-term view. Palliative medicine is a subspecialty that is, and must remain, intrinsic to family medicine. This is precisely why family physicians are ideally suited to creating a subspecialty of palliative medicine that will embrace the distinct contributions of physicians trained through the CFPC or the RCPSC. Our children will be glad we did.