As doctors in Portugal, during the majority of our education, both pre- and postgraduate, we dedicate ourselves to memorizing lists or trying to understand different disease mechanisms. The main goal is the cure and we act with the certainty that there is a solution to each disease, or at least to the most of them, and we try to apply all that we've learned to the patient in front of us. However, all of this changes with clinical practice. We experience a disconnect between knowledge and practice, and what was taught to us is not enough, is not acceptable, and it doesn't provide enough quality of life. They “forgot” to teach us that the main goal is not only the disease but also its symptoms and, most importantly, the person who we have in front of us, whether their disease is curable or not.
To address this, there is a need to deepen knowledge, to practice, and to apply what we haven't learnt; such is the case in Palliative Care (Hui and Bruera, Reference Hui and Bruera2016; Kaasa et al., Reference Kaasa, Loge and Aapro2018). This care aims to improve the quality of life, provide symptomatic relief, and aims to care for the patient and their family members, many times involving complex interventions. If it makes sense to my training (Oncology) to know about this kind of care, it also makes sense for many other medical areas, since the only certainty that we all have is that one day we are all going to die. However, and despite some limitations, because there is no mandatory palliative care training in Oncology in Portugal and because I think that the change begins with each and every one of us, the choice to do a practical internship in this area seemed logical to me. For this reason, I chose a Palliative Care Unit in a private institution, as it is certified by the European Society of Medical Oncology. It's not possible to end such period and to not consider with all my certainty that this period of time contributed significantly to both personal and professional growth. During this time, I was able to identify patients with palliative needs at an early stage in disease trajectory, such as oncological patients or other complex diseases, for example, neurological disease or organ failure. Diseases are so prevalent in our day-to-day activity, with patients who are often submitted to futile measures and disproportionate approaches when really we should be focusing on comfort and the quality of life of the patient.
Another area of practice that improved significantly was symptomatic control. Even though I had previous knowledge, one should have in mind a lot of other factors, such as the need for regular or as-required medication, the knowledge of different drug actions, and their indications so on. One should favor oral administration as the route of choice, and in case of unavailability, the subcutaneous route, careful dose titration, trying to anticipate patient's needs, and prescribing in accordance with these. Opioid use should be demystified, and titration to prevent drug adverse effects is paramount. Forgetting these entities may lead to treatment abandonment and poor symptom control.
I reflect that this experience was particularly beneficial for improving communication skills with patients and their families. We lack communication skills training in medical school, and many times we avoid the uncomfortable position of giving bad news or to approach complex and conflicting topics with families. Some valuable tools are the realization of situation points and patient-centered family conferences, tools that I still apply in my everyday clinical activity. I highlight the importance and the indubitable gain of working as a team in a multidisciplinary way, with a common goal — the person in front of us.
I had the opportunity of being present in moments of happiness provided to patients, which may not add days of life to their lives, but certainly add life to the days they still have. It was a joy to learn in this internship and it fundamentally changed my practice, having the privilege of participating and learning as an active element of the team, in learning about the type of care that should be a basic human right to all.
For all the abovementioned reasons, I believe that training at a certified Palliative Care Unit is an added value to all Oncology interns and potentially to many other medical specialties; we can gain as doctors only if we treat the patient and not the disease.
