Personal experience
I started working in palliative care in Romania in 1995 as a young oncologist. Although I was well trained in assessing a given patient’s cancer stage and prognosis and offering anti-cancer treatment, I did not learn how to deal with symptoms or psycho-emotional, social and spiritual suffering. Education in palliative care and access to palliative care literature at that time was not as readily available as it is today so the only solution was to get training from abroad. This provided a strong motivation for us at Hospice Casa Sperantei, a young but dynamic NGO pioneering palliative care in Romania, to start training programs in the country to spread knowledge and to create allies in developing the palliative care field.
It was a challenge to engage the medical world: palliative care had no officially recognized status so there was great reluctance by physicians to commit their time for training in a field that did not provide the potential for career development. This was a common problem in the surrounding ex-communist countries such as Hungary, Serbia, Croatia; the exception was Poland where training programs were blossoming and attracting physicians not only from that country but from all Eastern European countries.
Looking for an explanation for this difference, the first that came to my mind was that palliative care services in Poland had started developing at an earlier time. However, other factors were also present – there was strong leadership in the country, palliative care was recognized as a subspeciality, and Poznan University was an academic centre which included palliative care as part of the curriculum. For me the lesson learned was that while providing clinical services helps individual patients, we need to go further in our work; specifically, it is essential to advocate to have palliative care recognized as a medical discipline.
So we started to organize consensus meetings with authorities and found supporters in the medical academic world. As a result, palliative care was recognized as a subspecialty in Romania in 2000. This was a turning point in our education programs. If it had previously been difficult to recruit ten doctors for an in-depth training in palliative care, once palliative care was officially recognized as a subspeciality the number of participants increased and new education centres had to open. At present our 18 month subspecialty training starts every second year in six centres throughout Romania with 120 participants enrolled and a waiting list.
European perspective
The European Atlas of Palliative Care1 monitors the development of palliative care at European level in terms of services, human resources allocated to palliative care, and access to medication. Professor Carlos Centeno from Atlantes University of Navara is leading this work and his research has highlighted that in 2005 palliative medicine had specialty status in just two European countries – Ireland and the UK – and subspecialty status in other five countries: Poland, Romania, Slovakia, Germany and France. In the following ten years, however, there were considerable changes.2 In 2014, 18 of 53 European countries had official programs on specialization or sub specialization in palliative care: Czech Republic, Denmark, Finland, France, Georgia, Germany, Hungary, Ireland, Israel, Italy, Latvia, Malta, Norway, Poland, Portugal, Romania, Slovakia, and the UK.3 In 2019, when the last edition of the Atlas was published, six more countries had palliative medicine as a specialty, 13 as a subspeciality and another ten as a specific field of competence. This shows a clear trend towards palliative care having official status and recognition.
Pros and cons for specialty / subspecialty status for palliative care
Having an official recognized national education program for postgraduate training in palliative care has several benefits:
A potential negative consequence can be that it slows down the pace at which new services are opened because education programs do not meet the increased requirement for trained staff, and this becomes a hindrance in service development.
Alongside specialty or subspecialty status for postgraduate training, there needs to be undergraduate education in palliative care; this will create an awareness and basic skills in palliative care for all doctors and nurses and improve palliative care throughout the healthcare system.
1 https://dadun.unav.edu/bitstream/10171/56787/6/Atlas%20Europa%202019_DEF.pdf
2 Centeno C, Bolognesi D, Biasco G. Comparative Analysis of Specialization in Palliative Medicine Processes Within the World Health Organization European Region. Journal of Symptom and Pain Management 2015 May; 49(5):861-870. https://doi.org/10.1016/j.jpainsymman.2014.10.019.
3 Centeno C, Noguera A, Lynch T, Clark D. Official certification of doctors working in palliative medicine in Europe: data from an EAPC study in 52 European countries. Palliative Medicine. 2007 Dec;21(8):683-7. https://doi.org/10.1177/0269216307083600.
I started working in palliative care in Romania in 1995 as a young oncologist. Although I was well trained in assessing a given patient’s cancer stage and prognosis and offering anti-cancer treatment, I did not learn how to deal with symptoms or psycho-emotional, social and spiritual suffering. Education in palliative care and access to palliative care literature at that time was not as readily available as it is today so the only solution was to get training from abroad. This provided a strong motivation for us at Hospice Casa Sperantei, a young but dynamic NGO pioneering palliative care in Romania, to start training programs in the country to spread knowledge and to create allies in developing the palliative care field.
It was a challenge to engage the medical world: palliative care had no officially recognized status so there was great reluctance by physicians to commit their time for training in a field that did not provide the potential for career development. This was a common problem in the surrounding ex-communist countries such as Hungary, Serbia, Croatia; the exception was Poland where training programs were blossoming and attracting physicians not only from that country but from all Eastern European countries.
Looking for an explanation for this difference, the first that came to my mind was that palliative care services in Poland had started developing at an earlier time. However, other factors were also present – there was strong leadership in the country, palliative care was recognized as a subspeciality, and Poznan University was an academic centre which included palliative care as part of the curriculum. For me the lesson learned was that while providing clinical services helps individual patients, we need to go further in our work; specifically, it is essential to advocate to have palliative care recognized as a medical discipline.
So we started to organize consensus meetings with authorities and found supporters in the medical academic world. As a result, palliative care was recognized as a subspecialty in Romania in 2000. This was a turning point in our education programs. If it had previously been difficult to recruit ten doctors for an in-depth training in palliative care, once palliative care was officially recognized as a subspeciality the number of participants increased and new education centres had to open. At present our 18 month subspecialty training starts every second year in six centres throughout Romania with 120 participants enrolled and a waiting list.
European perspective
The European Atlas of Palliative Care1 monitors the development of palliative care at European level in terms of services, human resources allocated to palliative care, and access to medication. Professor Carlos Centeno from Atlantes University of Navara is leading this work and his research has highlighted that in 2005 palliative medicine had specialty status in just two European countries – Ireland and the UK – and subspecialty status in other five countries: Poland, Romania, Slovakia, Germany and France. In the following ten years, however, there were considerable changes.2 In 2014, 18 of 53 European countries had official programs on specialization or sub specialization in palliative care: Czech Republic, Denmark, Finland, France, Georgia, Germany, Hungary, Ireland, Israel, Italy, Latvia, Malta, Norway, Poland, Portugal, Romania, Slovakia, and the UK.3 In 2019, when the last edition of the Atlas was published, six more countries had palliative medicine as a specialty, 13 as a subspeciality and another ten as a specific field of competence. This shows a clear trend towards palliative care having official status and recognition.
Pros and cons for specialty / subspecialty status for palliative care
Having an official recognized national education program for postgraduate training in palliative care has several benefits:
- It ensures a consistent way of training a country’s future palliative care specialists and clearly defines the competencies required to practise
- It might be linked with special rights concerning prescribing of specific drugs
- It allows assessment measures to be put in place – for future specialists, for training centers, for clinical bases for practical placements
- It pushes clinical placement bases to strive towards providing excellent clinical care in order to be role models
- It increases the standard of care for patients.
A potential negative consequence can be that it slows down the pace at which new services are opened because education programs do not meet the increased requirement for trained staff, and this becomes a hindrance in service development.
Alongside specialty or subspecialty status for postgraduate training, there needs to be undergraduate education in palliative care; this will create an awareness and basic skills in palliative care for all doctors and nurses and improve palliative care throughout the healthcare system.
1 https://dadun.unav.edu/bitstream/10171/56787/6/Atlas%20Europa%202019_DEF.pdf
2 Centeno C, Bolognesi D, Biasco G. Comparative Analysis of Specialization in Palliative Medicine Processes Within the World Health Organization European Region. Journal of Symptom and Pain Management 2015 May; 49(5):861-870. https://doi.org/10.1016/j.jpainsymman.2014.10.019.
3 Centeno C, Noguera A, Lynch T, Clark D. Official certification of doctors working in palliative medicine in Europe: data from an EAPC study in 52 European countries. Palliative Medicine. 2007 Dec;21(8):683-7. https://doi.org/10.1177/0269216307083600.
Daniela Mosoiu is Associate Professor at Transilvania University and Director for Education and National Development at Hospice Casa Sperantei, Brasov, Romania.