When palliative medicine became a specialty – by Derek Doyle

The University of Glasgow awarded the honorary degree of Doctor of Science to Derek Doyle, one of the pioneers of modern palliative care, in July 2014.  Since then Dr Doyle has been a popular and regular contributor to our blog. Here he blogs about the origins of palliative medicine as a specialty.

Some readers may be young enough not to remember the days before palliative medicine became a specialty. Others may remember how hurt they were that it  became one. Yet others will tell you what a difference for the better specialty status has conferred. Whatever your memories and views, what exactly happened all those years ago ?

The ‘pre-specialty’  years

Like most “new” things it did not happen suddenly, taking everyone by surprise. Many events led up to it and many hours were spent discussing the pros and cons. What follow are the memories of one old man involved in the negotiations, memories probably coloured and biased.

Before 1987, the ‘pre-specialty’  years of palliative medicine were undeniably exciting, but very hard work. Thousands of patients had been cared for and many relatives had expressed pleasure with their care. Many General Practitioners had, so they told us, enjoyed having us (hospice doctors) at their side enabling them to give the best possible care;  but there were many who felt they would have cared just as well without us, as they reminded us they had done for years (though on average only 20 patients per GP died each year, 80% or more of them in hospital). The situation in hospitals was similar. When a ward Sister or relative suggested we be called in to advise, many physicians (especially oncologists and radiotherapists) either said they did not know much about us or hesitated about calling in someone who was not an accredited specialist as they were.

Not just recognition

The first reason, therefore, for obtaining specialty status was to gain not just recognition but standing.

The second was to develop education and training in palliative medicine, primarily for Senior Registrars (as they were then called) aspiring to be consultants in most of the principal medical specialties and for all medical students and junior doctors if possible. Much evidence had come to our notice of widely varying amounts of teaching (and quality of teaching) on the subject throughout the country, and of poor support of junior doctors confronted by the challenges of caring for the dying.

The third reason was to develop and hopefully publish research, knowing that funding was more likely to come to accredited specialists than non-specialists. Today it is still, quite wrongly, said by some that no research was done in pre-specialty days.

All the credit for getting the negotiating moving must go to Dr Gillian Ford, a friend of Dame Cicely Saunders, a volunteer at St Christopher’s Hospice and ex-Deputy Chief Medical Officer for England. A three-person deputation from the Association of Palliative Medicine met officials of the Royal College of Physicians of London and the Joint Committee for Higher Medical Training every few months for about two years, their questions and challenges always courteous but equally searching and challenging.

Would specialty status help?

We were asked if there was a sufficient ‘knowledge base’ to merit specialty status (as our questioners put it –  “after all we all looking after dying people every day!”) Were there many doctors wanting to be specialists? Were there any who had already left their specialty and come into Palliative Medicine?  Did we seriously believe doctors would leave their GP or hospital jobs to come into a lifetime of Palliative Medicine? Our affirmative reply was either a lie or a leap of faith!

Without giving names could we say we knew such people? How many recruits per annum would be needed? Had any of our number been trained in rigorous clinical research? What research that might get ethical approval did we have in mind and where did we think funding might come from?

Did we intend to start our own journal? (The journal Palliative Medicine had in fact been launched one year before these negotiations).

Did we have a  national body bringing  together all currently involved in Palliative Medicine? The Association of Palliative Medicine of Great Britain and Ireland was well-established.

Did we have any idea how much of our time would be taken up in committees, Board, and Faculty meetings? For that one and in the case of this blog writer the answer was – “No!”

It will be noticed that throughout these negotiations the word used was always Palliative Medicine when referring to doctors, Palliative Care when referring to nurses and professions allied to medicine. From our first meeting we had been told that any reference to “Hospice” was unacceptable as was “Terminal Care” or “Care of the Dying”. When asked for our preferred name we followed the lead of Canadian colleagues and said “Palliative”.

A few years later the specialty was honoured when the Oxford University Press invited us to produce The Oxford Textbook of Palliative Medicine, recently out in its 5th edition.

Today the specialty is thriving but that means another blog or two!

Derek Doyle