Working and teaching in a palliative care department

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Published: 27 Mar 2017
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Prof Sushma Bhatnagar - All India Institute Of Medical Science, New Delhi, India

Professor Bhatnagar meets with ecancer at IAPCON 2017 to describe the inception and growth of the palliative care department at the All India Institue of Medical Science from initially providing purely anaesthesia to becoming a large teaching department.

The department has dedicated palliative care wards where patients are treated and stabilised before being sent home; there is also a pain clinic held all day every day to which patients are referred as soon as they develop metastases.

Teaching seminars are held both within the department and also across the whole institution and the majority of graduates from the department go on to work in palliative medicine throughout the whole of India.

Professor Bhatnagar speaks about her own training through the Cardiff Diploma and how this has provided a range of useful materials to use in teaching her own students.

She concludes by discussing the plans for the next Palliative Care Conference.

As I said, our department is the Department of Onco-Anaesthesia, Pain and Palliative Care. Around eighteen years back we started with the Department of Anaesthesia; being anaesthetists we used to look after cancer pain patients. So for that time the palliative medicine in India was developing, it was growing at that time, two decades back. We thought that it is not only pain which patients need to be taken care of, we started doing other management and simultaneously we heard that palliative medicine is growing so we got involved in palliative medicine. Finally we thought that it’s not only pain, patients need other symptom management so we started doing the symptom management in cancer patients. Slowly it has developed and once we have realised that it should go into the other branches also we have started taking care, we have started talking to other branches. Finally the day came when we started a separate, dedicated department and started dedicated palliative medicine courses.

Now, initially residents used to come for post-MD qualified anaesthetics but what I have realised is when we were doing this they came there for three years so one year used to go… I can say that it used to be rotation but one year was there for pain and palliative care. Somehow, I don’t know what inspired them and what motivated them that 60-70% of our residents, those who have left our hospital or our centre after three years, they are doing exclusively pain and palliative medicine, they have left anaesthesia. So it’s a big achievement that anaesthetists are quite a lot in the country but those who are getting trained over here they just want to do pain and palliative care and they are doing an excellent job all over the country. So it is not in Delhi, they are all over the country and whenever there is any event they come and we have a lot of get-togethers. We meet quite often, at least once in a year, and they discuss their achievements, what they are doing. So they are doing a wonderful job.

Initially I was alone with a single faculty with three resident doctors then I remained there for five years alone with three resident doctors in the cancer centre. Then two faculty, a second faculty came – one of my residents became faculty. Now we are six faculty with 35 resident doctors. So these 35 resident doctors, they come here to join us in anaesthesia, the Department of Onco-Anaesthesia and Palliative Medicine, so they work for palliative medicine.

This is a routine department. When we started in palliative medicine there was a provision that we will take three students per six months. Initially because All India Institute students are the cream of the cream students, they are the brilliant students, and it’s a new branch for them. So the first batch, they joined and they left it because they got the best branch in their own institute and their own centres. So there was nobody in the first batch, even it was quite disappointing whether people will come or not. But in the second batch people have started joining now; we have four MD palliative medicine students and every year, every six months, we are getting two students. So we have senior resident doctors in palliative medicine; we provide indoor care for the patients because we have dedicated palliative care wards where we give palliative care and all symptom management we do, including intervention. It’s not only the intervention for pain management, we are doing [?? 4:21], we are doing pleural fluid effusion, pleural pigtail catheter for  pleural effusion. If patients need a tracheostomy we do bedside tracheostomy, percutaneous tracheostomy. Everything we are teaching to the resident doctors besides how to use opioids, the safe use of opioids, safe taking care of symptoms of the patient.

Once patients get stabilised we are sending them home and for home we are taking the help of our homecare team. We have 27 homecare teams which are in the single umbrella organisation that is the cancer pool [?], so Delhi and NCR. Not a single patient, if we want to send them home they are taken care of very well by cancer pool [?] teams. So they are looking after very well. This collaboration is going on since the beginning.

To update our knowledge we have a routine teaching schedule; Monday and Friday are seminars, 8 – 9, plus we are also teaching our oncologists. For that on Thursday it’s a whole centre seminar, so we are presenting… twice in six months we are presenting our palliative care topics there for discussion. So our oncologists are also getting sensitised and we say that palliative care should start from the beginning but, truly speaking, it does not happen. As soon as patients come they will not like to meet palliative care physicians also. To solve this problem, and we don’t want patients at their end of life also, to solve this problem we have started one arrangement that as soon as patients get metastasised, even if a single metastasis is there and they are not having any symptoms, they get registered in our pain clinic. The pain clinic we start from Monday, it is the whole day Monday to Saturday, it is non-stop. So Monday morning, nine o’clock we start, five o’clock it’s over, similarly the whole week it is the whole day so any patient if he is having pain or any symptoms the whole oncology group knows that this is a room where patients will go. If a patient is having metastasis this is the room where they get registered, so these patients start seeing us and they get confidence that this is also a doctor who is going to treat me in future. So they get acclimatised and they start talking to us, they build up confidence so that it should not happen that when they are dying or when they are in the advanced stage really. At that time they come, that time it really becomes difficult to build up confidence.

What are some of the courses you are offering?

The Cardiff Diploma and MSc Cardiff means a lot for me. It means a lot for me, it means a lot for my own institute in two ways. I used to go everywhere and I used to deliver lectures in palliative medicine in various topics in palliation in each and every national and international conference. But whatever knowledge I was having in palliative medicine was through books, journals, conferences, short courses, short fellowships as there was no degree I was having that I can say that I did some post-graduation degree or some graduation degree in palliative medicine. So it gives me confidence in two ways: that I did an MSc from Cardiff University so now I am officially designated, I have a Masters’ degree in palliative medicine. The second thing: this degree has taught me significant things which I should say that the one particular thing which I have really liked that is research. So research and audit in the assignment which we did, it was extremely useful. One more very important thing which I must narrate, that that assignment, the way the teachers of Cardiff used to take care of our assignment, I can follow the same pattern for my students – what are the things which we should highlight; what are the things which we should not highlight? So this makes a lot of difference. So the Cardiff degree means a lot for me and it is right in my office, it is on the main wall. It is there in my office, it means a lot for me.

How do you use that knowledge? I know you talked about you use it for your own team assignments but do you also use that in your teaching and the courses that you deliver?

What tools did you use in preparing for exams?

The reading and material was quite useful and, you know, when you are giving some exams you read a lot and when you read a lot it means you read recent also so otherwise we tend to miss something. So my knowledge was updated and I read everything, almost everything, for the exam. The material which you have provided us online, it was extremely useful material and whenever there is some class or something I can ask them immediately to read this and it will be very useful material. So it was a useful thing.

What are you looking forward to as a conference organiser next year?

I’m very happy that the organisers have given me this responsibility, they have confidence in me. So we are going to hold this conference in Delhi, the All India Institute of Medical Sciences, and the theme of the conference which we have kept is Create, Collaborate and Communicate. I’m really looking forward that it is going to be a very, very useful conference; in this conference we are planning that we will release many guidelines, standard operating procedures for the safe use of opioids. We are planning very dedicated, focussed workshops so that people will have a take home message that this is the way we have conducted and this is the way we should use opioids and these are the dos and these are the don’ts for using. So we are planning a lot of focussed sessions and besides that I am also planning a pre-conference workshop on four topics, that is a chronic pain management workshop, [?? 11:43], then an end of life care workshop and how to use and procure opioids for pain management, safe use and procure. So I’m thinking that this conference is going to be a huge success and hopefully we will do well in this conference.

One more thing which I want to say, that for this conference I am not alone. I have a big team, a big taskforce, I can say that and they all are very sincere and dedicated and I am very, very confident that I will not be alone and there will be too many people to work for me. It's a big team who will work for this conference.