Improve physician training in pain management and palliative care

As a radiation oncologist, I have treated countless patients in need of opioids and other pain management medications to help ease the agony and discomfort — which can sometimes be extreme —that unfortunately comes along with a cancer diagnosis.

What many people don't realize is that the need for palliative care and pain management spans across patients experiencing every stage and type of cancer, not just those who are terminally ill. In fact, many of my patients move on from treatment to lead healthy lives, saying goodbye to both the cancer treatment and the pain medications that go with it. But, with the growing opioid epidemic in the United States, these drugs, along with the physicians who prescribe them and the patients who need them, are now under a new and brighter spotlight.

While stricter regulations, such as the new FDA enhanced warning labels, and greater oversight of the pharmaceutical companies manufacturing these opioid medications are important aspects of combating opioid addiction, labeling and legislating alone are not enough. We must also focus on another piece of the puzzle: improved palliative care and pain management training for medical professionals. This need for training applies to brand new medical students, residents, and fellows as much as to senior physicians at the cusp of retirement.

But the truth is that most physicians do not receive an adequate amount of this kind of training if they receive any at all. This is especially – and ironically – true for those who specialize in the management of cancer patients. Most oncologists agree that palliative care is an integral part of their clinical work, yet the extent of formal education and hands-on practical instruction in palliative care during many oncology specialty-training programs is insufficient.

Palliative care is more than a science: it is also an art. Greater and deeper understanding of the factors involved in palliative care, from symptom assessment and management to therapeutic goal-setting, advance directives, and end-of-life care can transform the way physicians communicate with patients, caregivers, and loved ones. By educating oncologists-in-training in pain management, we can create a culture in which palliative care becomes part of a regular and expected care routine, rather than something extra that is outside of their comfort zone.

I will never forget the exquisite discomfort of an advanced prostate cancer patient who was suffering from severe pain because the tumor had spread to his back.  But what stands out most in my mind was the distress of my young trainee when the patient's wife and adult children asked her opinion on how we could manage his pain and achieve his desired goal of getting out of the hospital and back home to his family.

As my trainee started to explain that the "pain management team" would help with the various pain medication doses and that his "primary team" would review his prognosis, it became readily apparent that there is a fine line between not overstepping one's role and feeling comfortable with difficult questions about end-of-life care. We are very good about teaching our trainees the distinct roles of the various cancer specialists, but we could all do better at teaching common goals, and modeling how to have open and honest conversations with patients and their family.

And these conversations become undoubtedly more challenging when a cancer patient is in extreme pain and loved ones are in distress -- making clear communication skills on the part of the physician that much more important.

Recently, I've seen more medical students, residents, and even longtime practicing physicians express interest in improving their palliative care skills. I hope that trend will continue as we also see medical schools focus on more holistic approaches to patient care, which includes highlighting palliative care as a key part of a physician's training. But at the end of the day, training, education, and even the FDA's new warning labels are ultimately just a spark to trigger a thoughtful dialogue of risks and benefits between the prescriber and the patient.

Neha Vapiwala is a Vice Chair of Education, Radiation Oncology and the Advisory Dean at the Perelman School of Medicine at the University of Pennsylvania.  

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