The Case for Focused Palliative Care Education in Oncology Training

James has advanced lung cancer. He does not yet know his visit today will be focused on disease progression. He is 32 and has two young children. As we enter his room, his wife notices our demeanor. Caregivers always do. She is focused, leaning in, lamenting what she knows will be bad news. “Unfortunately, the imaging from this morning shows new lesions in your lungs and bones. Your disease is progressing.”

In oncology, we often do not consider the importance of person-centered care in our daily clinical practice and how it relates to our training. Every day, in every oncology clinic, we make innumerable decisions on how to deliver bad news. Like most oncologists, we struggle with the words we choose. Do we begin by validating emotions, or asking how the patient and caregiver are coping? Is it necessary to ask permission: “Would you like to discuss what this means?”¹ Is this the appropriate visit to discuss prognosis? Do we focus on the progression of the tumor or investigate for new symptoms? How long do we stay silent when our patients cry? Some of these difficulties are a consequence of our limited education in palliative care during oncology fellowship.^2,3 In the above scenario, the subsequent words we choose will have a great impact on both the patient and his caregivers and how they process information and make decisions. Does the training of oncologists reflect the gravity of these clinical situations?

Oncologists give bad news to patients an average of 35 times a month,⁴ yet few have training or mentorship in communication skills.² Oncology fellows report more coaching on how to perform bone marrow biopsies, a technical skill, than on how to conduct a family meeting.² Oncologists are trained to be medicine oriented, not person oriented. This creates undue tension when our therapies are inadequate and cancer progresses. Research suggests that how we frame difficult conversations predicts patient preferences.⁵ For example, patients are more risk averse when considering gains (choosing adjuvant therapy in breast cancer) and risk seeking when considering losses (enrolling into phase I clinical trials at the end of life).⁶ Training in the science of communication can help oncologists effectively address patient emotions, elicit preferences, and then “choose wisely.” At the time of this writing, the majority of oncology fellows have isolated experiences in communication training, usually in the form of workshops or patient simulations.⁷ The time dedicated to such training is not commensurate with what is required to excel in clinical practice.

For oncologists in training, word choice may feel trivial compared with the plethora of other things that need to be learned. Yet, our words influence medical decision making and have implications for patient care. Studies suggest that offering palliative care versus supportive care has an impact on patient responsiveness to a needed specialty service.^6,8 Similarly, oncologists who ask about patient distress and present it as a normal expectation of cancer care are more likely to elicit patient suffering.⁹ The need for palliative care for patients goes beyond the need for skilled communication. The prevention, assessment, and management of both psychosocial and long-term physical symptoms from cancer and its treatment are important pieces of the need to train fellows in both palliative care and medical oncology. This is especially so because an increasing number of patients are living with cancer as a chronic disease. Chronic symptoms require increased attention.

As educators, our words influence not only patients, but the future generation of trainees who care for them. In all of our training experiences, sometimes separated by decades, the words from our mentors were largely focused on treatment and drug development. Rarely has an oncologist recommended a career focused on symptom management or palliation. We now gravitate to the few who have done that.

Ironically, an increasing number of physicians are involved in a narrower scope of practice upon graduation from their medical oncology fellowships. Perhaps, this is in response to the greater cognitive load of being an oncologist, as seen with the rapid US Food and Drug Administration approval of novel therapies. Yet the promise of new treatments is tempered by evidence that most patients will not benefit, and that adverse effects are more common in real life; for instance, pneumonitis developed in 19% of real patients versus 3% in the trials.¹⁰ This prognostic ambiguity creates new challenges in clinical practice. More importantly, these pressures dictate a need for the field to respond by reconsidering how we train the next generation of oncologists.

Behavioral economics reminds us that patients (and physicians) can be nudged in their decision-making. Consequently, our training has an impact not only on the words we choose in patient care, but also in advising other oncologists on career choices. Because nearly all decisions are framed in some way, the onus lies with us as educators and influencers to prepare the next wave of oncologists to value training in palliative oncology. Because the field of palliative medicine is focused on communication, prognostication, and individualizing the needs of each patient, it is time to consider opening the doors to dual training.

As physicians and professionals, we are a product of what we are exposed to. Fellowships will never be able to teach everything an oncologist needs to know in just three years. Third-line treatment in melanoma is subject to change. Learning how to communicate well with patients will remain a necessary skill. So will the need for impeccable assessment and management of symptoms. We must further invest in training oncologists who are competent in multiple palliative care domains. It is our daily duty to provide diagnostic and prognostic information that is tailored to patient needs and provides hope and reassurance without misleading patients. For some, this might mean more clinical exposure with palliative care teams. For others, it might call for mentorship or an advanced degree to allow a research focus. What is missing, and what is needed, are fellowships that allow tailored experiences that blend the focus on both treating the disease and the supporting the people living with it. The key is integration. How do we grow the concept of palliative care expertise within oncology? The palliative care needs of patients with cancer are unique. What do we communicate, perhaps unintentionally, when we send off our medical oncology fellows to another department to acquire skills in palliative care domains? We must train the next generation of oncologists to own palliative care as something they ought to do.

Our words matter. To repeat what we presented at the 2019 ASCO Supportive Care in Oncology Symposium, there are no—zero—programs that lead to dual certification in oncology and palliative medicine.¹¹ We are subject to the same bias as our patients. With oncology training focused on treatment, clinical trials, and drug development, it is not surprising that palliative care is still not integrated into cancer care. It is time to train our oncologists in a way that respects the weight of the conversations that occur every day.

AUTHOR CONTRIBUTIONS

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The Case for Focused Palliative Care Education in Oncology Training

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

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Thomas J. Smith

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No other potential conflicts of interest were reported.