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Training and telemedicine: the key to the palliative medicine specialist shortage?
  1. Giulio Ravoni1,
  2. Maria Fusilli1,
  3. Giulia Parretti1,
  4. Emilia Colpani1,
  5. Giampiero Porzio1,
  6. Giuseppe Spinelli1,
  7. Daniele Marinelli2 and
  8. Raffaele Giusti3
  1. 1 Home Care Service, Associazione Tumori Toscana, Florence, Italy
  2. 2 Department of Experimental Medicine, Sapienza - Università di Roma, Rome, Italy
  3. 3 Medical Oncology Unit, Azienda Ospedaliero Universitaria Sant'Andrea, Rome, Italy
  1. Correspondence to Dr Daniele Marinelli, Department of Experimental Medicine, Sapienza - Università di Roma, Rome, 324, 00161, Italy; danielemarinelli1{at}

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American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines advise that individuals diagnosed with advanced cancer should undergo early palliative care within 8 weeks of diagnosis. This recommendation stems from compelling evidence showing that simultaneous palliative care significantly improves patient symptoms, mood and overall quality of life.1 Additionally, it reduces caregiver distress and enhances the quality of end-of-life care. Unfortunately, these guidelines do not address the harsh reality that the need for palliative care far exceeds the available specialists and resources.2

Several studies have shown that the workforce of palliative care specialists is insufficient to meet the growing demands of health systems.

Projections for the future underline that this shortage of specialists will persist and worsen in the coming years.3 Recently, we analysed the Italian data, confirming this deficiency, which opens up worrying scenarios for the future.4 Different explanations can be hypothesised: burnout, lack of an academic career pathway and challenges in pursuing private practice.5

In the last two years, the Oncological Home Care Team of the Tuscany Tumor Association (ATT) has faced an acute shortage of physicians, which has endangered the continuation of the service.

The purpose of this letter is to describe the experience gained and the strategies we tried.

The ATT provides oncological home care for patients residing in the metropolitan area of Florence.

The team is made up of palliative care specialists, nurses, psychologists, nutritionists and social and health workers, and it is active 24/7, by providing a night and vacation on-call service.

Written and shared protocols for symptom assessment and treatment are available to all operators in a dedicated application. All patients are subjected to triage and classified in red, yellow or green, based on the delirium-palliative prognostic (D-PaP) score, severity of symptoms and complexity of therapy. An electronic medical record, accessible on smartphones or tablets, allows for rapid sharing of clinical data by all operators.

ATT seeks the best integration with the oncology units operating in the metropolitan area of Florence through specific programmes aimed at early activation of home palliative care. Continuous education and research are pivotal to the ATT policy. ATT does not receive funds from the National Health System, and its activities are completely free of charge for patients. Data of ATT activity are shown in table 1. Over the last 2 years, the number of physicians in ATT has decreased from seven to two (‘permanent physicians’). Moreover, one of the two doctors became pregnant. In this period, we have had physicians who, for short periods, decided to work in ATT, in most cases waiting for job positions that better matched their expectations (‘short term physicians’). These were doctors with no or limited experience in palliative care.

Table 1

Data of Tuscany Tumor Association activity

Faced with the sudden shortage of doctors, we looked for solutions, shared as much as possible by the entire team. First, we attempted to identify the strengths of our team: experience and leadership of the two permanent physicians, experience and ability to work independently of nurses and willingness of short-term physicians to learn the basics of palliative care. Based on these strengths, we have activated training and clinic programmes in order to warrant symptoms treatment, continuity of care and non-abandonment at end of life.

We aimed at expanding the skills and autonomy of nurses with lessons on specific topics, webinars, journal clubs and one-to-one training sessions (ie, ‘Nurses upgrade’). Active participation of nurses in multicentric clinical trials was encouraged, as was attendance at congresses and courses.

Then, we aimed at making short-term physicians autonomous in managing patients at home as quickly as possible (ie, ‘Smart treat’). The training included a first phase with individual lessons on the assessment and treatment of the most common symptoms, the management of emergencies and the end of life. Subsequently, the training continued in the field, with a 2-week period alongside a ‘permanent physician’. Finally, they began to work independently following, at the beginning, green or yellow patients, always with tutorship. For the training of short-term physicians, we aimed to simplify symptom treatment protocols by identifying a set of ‘essential’ drugs (morphine, fentanyl, duloxetine, haloperidol, metoclopramide, dexamethasone) that can effectively manage most symptoms. ‘Think simple’ was the mantra in the training of short-term physicians.

At last, we implemented telemedicine: we chose a ‘hybrid’ form, alternating remote contacts with home visits in a ratio of 2:1. Only yellow and green patients were considered eligible for telemedicine.

After a year, we can draw some conclusions. First, involving the whole team in strategic choices has strengthened team spirit and a sense of belonging. Analysing the data, the length of hospitalisation and the percentage of patients in active treatment increased, whereas the percentage of deaths at home remained stable at excellent levels. The number of emergency calls at night and on weekends has not increased.

The shortage of doctors specialised in palliative care is a current problem that is destined to find no solution in the short term. In the works published on the subject, changes in government policy are required. However, those changes would produce long-term results.

Therefore, we face a different issue: what shall we do immediately?

The demand for palliative care increases and the workforce of palliative care specialists decreases.

The programmes we have activated have been shown to be effective, quickly applicable and sustainable.

We believe that, in the future, it will not be possible to do so without enhancing the professionalism of nurses, expanding their skills and autonomy.

Regarding short-term physicians, the outcomes were influenced by the doctors' own motivations, particularly for oncologists who wanted to gain temporary experience in palliative care. In these cases, the results were excellent.

Finally, telemedicine has made it possible to better manage resources, guaranteeing good patient management and providing a hybrid form of care, despite the absence of in person contact.

While waiting for government bodies to address the issue of shortage of specialists, expanding fellowship positions, and improving the working conditions of physicians, individual providers must take action to find solutions shared with the entire team. Each provider must look for its own solution, considering the territory, characteristics of the patients, experience of the team and availability of resources: one size does not fit all.

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  • Twitter @dmarinelli93, @oncoblogger

  • Contributors RG: writing - original draft. GPorzio, DM and RG: writing - review and editing. GR, MF, GParretti, EC, GPorzio, GS: resources.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.