Stories From the Field:

VIETNAM

Integration of required training in palliative care into medical specialty training programs at the University of Medicine & Pharmacy, Ho Chi Minh City

Eric L. Krakauer, MD, PhD

Since 2005, I have been assisting the Vietnam Ministry of Health and its major public hospitals to initiate and scale up palliative care services. Last year, I began collaborating with the medical school of the Ho Chi Minh City University of Medicine & Pharmacy and one of its large teaching hospitals, the Ho Chi Minh City Cancer Center, to build required training in palliative medicine into undergraduate and post-graduate medical training. In Vietnam, all official training and certification in medical specialties is provided by one of the country’s major medical schools. In 2015, the University of Medicine & Pharmacy, Ho Chi Minh City, southern Vietnam’s foremost medical school, issued a requirement that all specialist trainees in oncology, hematology, geriatrics, pediatrics, and family medicine receive 33 hours of classroom training in palliative medicine, and the President of the University asked me to lead the curriculum development and teaching. The course also would be open to specialty trainees in internal medicine and other fields as an elective.

In response to this request, I adapted the basic and advanced curricula in palliative medicine that I edited in 2010 to create a curriculum in palliative medicine for medical specialty trainees. In
November 2015, with generous support from an MGH Global Health Travel Award, I travelled to Ho Chi Minh to teach the first ever required training in palliative medicine for medical specialists in Vietnam. Because there were over 90 trainees, we taught the six-day course twice, once for all first-year trainees in oncology, hematology, geriatrics, family medicine, and for a few in internal medicine, and once for all first-year trainees in pediatrics. The curriculum outline is attached. The curriculum consists of lectures with question-and-answer, case discussions, and role play. Seventeen hours of practical, bedside training will be conducted in early 2016 by the staff of the Departments of Palliative Care at the Ho Chi Minh City Cancer Hospital and the Ho Chi Minh City University Medical Center whose senior medical staff members participated in the teaching of the course. All of my lectures and comments were translated sequentially into Vietnamese by bilingual physicians. I provided mentoring for all Vietnamese faculty members, and they will be expected to assume an increasing share of the teaching responsibilities over the next few years and ultimately to teach the entire course themselves. A passing grade on the final exam is a requirement for the trainees to graduate from their specialty training programs.

Informal feedback about the courses was overwhelmingly positive. Trainees were surprised and appreciative to be able to learn about and discuss topics missing from medical school curricula including pain and symptom assessment and relief, assessment and treatment of anxiety, depression and delirium, and self-care. The oncologists and hematologists in particular had experienced many patient deaths, and the death of a patient was especially traumatic for the pediatricians. Yet prior to the course, the trainees virtually never had had a chance to process their emotions related to the deaths. Extra class time was added with our faculty psychologist to give trainees a chance to speak about and share their experiences. Many trainees expressed frustration about their inability to prescribe morphine – Vietnamese regulations permit any doctor to prescribe morphine but only with permission of their department or hospital chairpersons. This permission frequently is not given. Thus, the trainees felt the frustration of learning about an essential medicine that they could not use. While I feel it is necessary to teach opioid analgesia in this setting, I also made time for trainees to express their frustrations and to think together about ways to effectively advocate for opioid prescribing practices in their home institutions that assure access by patients in need to opioid analgesia.

In light of the excellent responses received by the University leadership, plans have been made to expand the course in 2016 and to make it a requirement for all trainees in internal medicine and infectious disease as well. Instead of two iterations of the course, there will be three: one solely for the 50+ first-year trainees in internal medicine, one for the first-year trainees in oncology, hematology, geriatrics, family medicine, and infectious disease, and one solely for the 40+ first-year trainees in pediatrics. A new curriculum in pediatric palliative medicine will be adapted from the existing one.

While in Vietnam, I also met with the President of the University, Prof. Tran Diep Tuan, to continue planning for Vietnam’s first Specialist Training Program in Palliative Medicine and first academic Department of Palliative Medicine, both of which will open in 2018. I also travelled to Hanoi where I met with Prof. Luong Ngoc Khue, Director General of the Medical Services Administration of the Ministry of Health, to discuss integration of palliative care into Vietnam’s healthcare system and strategies for creating community- and home-based palliative care in particular. In Hanoi, I also met with Prof. Pham Thang, Director of the National Geriatrics Hospital of Vietnam, to plan training for the staff of the first department of palliative care in a general hospital in Vietnam to be opened at the National Geriatrics Hospital in May 2016. Finally, I met with leaders of Vietnam’s national hospital, the 2000+ bed Bach Mai National Hospital, to discuss development of palliative care training and services.