Meet Our Team
Q&A with Dr. Robin Love
Dr. Robin Love, is co-lead of TWCC’s Nepal Program. In 2016, Dr. Love, and some colleagues, started Partners in Compassion – a hospice twinning project with Bhaktapur Cancer Hospital in Nepal.
This spring, he will be recognized with a lifetime achievement award by the Canadian Society of Palliative Care Physicians (CSPCP). He retired in December 2023 from his role as the Medical Lead for the Palliative and End of Life Care Program at Nanaimo Regional Hospital (Canada).
Photo: Chuck Russell/Two Worlds Cancer
Congratulations on your recent retirement and the lifetime achievement award from the Canadian Society of Palliative Care Physicians. What does that mean to you?
I feel terribly honoured by my colleagues that I would be recognized for this. I've been involved in this work since 1991. I've been involved in lots of different aspects in starting the palliative care program here in Nanaimo, an innovative program. We've been clinical leaders with a lot of the things we do.
I was the first president of the section of palliative medicine at Doctors of BC. So I've been involved in the political stuff trying to get [palliative care] recognized as a specialty. I was the Continuing Medical Education lead on the national board and a founding member of CSPCP. I just happened to be at the first meeting in Montreal when we started it.
This retirement thing has been really lovely. They solicited letters and photos from former students, former residents, nurses and colleagues. It’s incredibly rewarding hearing some of the things that people said about how they still remember how I talk to patients, the way I phrase certain things, and that's how they do it now. So I feel very proud and honored by that. It clearly had a big impact on a lot of people.
How did you choose medicine as a career and then palliative care as a specialty?
My father was a doctor and growing up I was kind of interested, but I actually thought that I didn't want to work as hard as he did and I didn't want as much responsibility. So I did a biology degree and I was working as a forest ecologist for a couple of years. I didn't have a forestry undergrad [degree], so it would've ended up taking me three years to do a masters in forestry. I thought, ‘Three years, huh? Medical school's only four years.’ And then coincidentally, somebody said, “Do you remember so-and-so from high school? He just graduated from medical school.” And I thought, ‘Well, if he can do it, I can do it.’
When you started your practice in Nanaimo, what drew you to palliative care?
In the first year of medical school, Alan Nixon, who was the palliative doc at Vancouver General Hospital, gave a talk about palliative care. He showed a film from the Royal Victoria Hospital in Montreal with Balfour Mount (considered the father of palliative care in North America) about their palliative care program. And I remember being really struck by this work.
I did my two-year family medicine residency in Montreal. I was very fortunate to spend a couple of weeks at the Royal Victoria Hospital. And so I worked on the [palliative care] ward and I had the amazing good fortune that Dr. Mount wasn't particularly busy that two weeks. So I basically had a lunchtime, one-on-one seminar with Balfour Mount talking about every subject in palliative care.
When I moved to Nanaimo, palliative care was something I thought I would do for my own patients, but maybe later in my career I would get involved because I was busy delivering babies, working in the emergency room, and running my family practice.
But I could see at the hospital no one had expertise about doing palliative care work. So I would come across these situations where people had these difficult symptom issues and I knew how to fix them. I can remember coming home at the end of one of those days and saying to my wife, Deirdre, “I have to start a palliative care program.” So I contacted Victoria Hospice and I did three extra weeks of training with Victoria. And with the hubris of youth, I sent out a letter to all the other doctors saying I was willing to do palliative care consultations with a grand total of about six weeks of training. Dr. Michael Downing ,and the Victoria Hospice team, who I phoned for advice when I didn't know what I was doing were incredibly supportive of me through my early days.
When was the first time you went to Nepal and what took you there?
So TWCC Director Dr. Stuart Brown, who was a GP in Parksville, called me one day and asked if he could come and learn some palliative care. After a couple of days, he said, “This is really good because I've signed up to do a palliative care locum in Saudi Arabia and I figured I better learn some palliative care before I go.”
At one point when he'd been there two or three years, he asked me if I could do a locum in Saudi Arabia. So I went and did eight weeks as a locum with Stuart in 2001. And that was a fantastic cultural experience. A few years later, I was actually looking for a medical trip to do with my son. Out of the blue, I got a phone call from Stuart saying, “We're going to Nepal. Would you like to come to Nepal to do some palliative care teaching?”
So Conor and I spent three weeks in Nepal. We did two weeks of palliative care work and then a trek. For me, I really loved the teaching in those settings. I’ve always believed all that is needed is a few beds, a few good nurses, and some simple drugs and you can do really good palliative care for most people. So that's what got me involved and kept me going.
When you came back from that first trip, what was that the inspiration for Partners in Compassion?
There were two components to that. One was when we visited, someone from Nepal said, “I'd like to start a palliative care program. Can you help us?”
I came home with a story from one of the hospitals we visited. There was a man there who had cancer of the pancreas. He was going to die within a few weeks, but he had terrible, intractable nausea and vomiting. We asked the Nepali doctors, nurses and a pharmacist if they had tried Haloperidol. We knew they had that drug and we knew it was cheap. But they said they hadn’t tried it because the family couldn’t afford it.
In many hospitals [in Nepal], families can stay for free, but the family has to pay for all of the supplies. We asked the pharmacist how much Haloperidol would cost and he said “three rupees”. That is only a few cents. I thought, ‘This poor fellow is going to vomit until he dies in a few weeks for the sake of 25 cents Canadian.’
When I came home from that trip, I told that story to quite a few people, but it was my wife Deirdre and Charlotte, a nurse at the Palliative Care Unit, who said, “I've got a Loonie (one-dollar coin) in my pocket. You mean that would've looked after that patient for the rest of his life? We have to do something. What can we do?”
The second part was coming up with an idea about our Nanaimo program partnering with a program there. We went back to Nepal and the staff at Bhaktapur Cancer Hospital (BCH) were very interested. That's when we formalized the relationship as Partners in Compassion in 2016.
We knew that there were some partnerships like this that weren't successful. One of the fathers of palliative care in India, Dr. Rajagopal, was actually quite critical and negative about this idea at first. He said, “There are too many partnerships like this where the Westerner comes and they give a one hour lecture, and then they go on a trek for two weeks.” He also was very clear, “Is this just top-down charity from you to them, or is this a partnership? What does that mean and what will be in this for you?”
So we took those ideas very seriously. We did a lot of research on hospice twinning projects and really couldn't find any practical advice. We interviewed more people like Dr. Rajagopal and people in Nepal. Then we got funding from the Canadian government to write ‘Canada's Guide to Hospice Twinning’.
I thought that one of the most important things would be physicians mentoring and teaching the medical stuff. But their first request was for nurses to teach their nurses and an administrator to help the head nurse sort out the administration part of running a palliative care ward. So that's why the first official visitors to the twinning project were Leslie Sundby, a nurse administrator [and today co-lead of TWCC’s Nepal program], and two of the senior nurses from our palliative care unit. Since then, physicians have been an important part of the group, but we've really tried to pay heed to the principles that we set up.
At the beginning, Partners in Compassion was separate from TWCC – It was the Nanaimo Palliative Care Unit, the Nanaimo Community Hospice (a volunteer organization) and Community Nursing.
Have the challenges changed since day one of Partners in Compassion or are the challenges similar?
Well, I think some of the challenges are different. At the beginning, drug availability was really an issue. They had a bit of morphine available sometimes. Most of the doctors were terrified to use morphine. So we did a lot of work teaching them how to use this drug safely. That's much more widely accepted now and Nepal makes their own morphine so the supply of the basic medication is much more reliable.
The ongoing struggles are: other specialists who don't understand palliative care and don't support it, some old fashioned ideas that you're shortening life by giving morphine, and ongoing, aggressive chemotherapy treatments when it should have been stopped sooner. Today, the work that Dr. Bikash Anand is doing at BCH is first class. He’s the first palliative medicine specialist in Nepal. He needs an associate or an assistant because it's just overwhelmingly busy.
Is there a recent experience that sticks with you in terms of what you see as the best possible care that a patient can receive and how that happens now?
What strikes me now is when we go to the Bhaktapur Palliative Care Unit, there are 12 complicated patients there and any one of whom would be a complicated patient back home. It’s seeing the consistent care that they're getting – the nursing care, the attention to detail, the good advanced symptom management. They're way beyond the basics of just giving morphine and Haloperidol. They're doing advanced pain management that anybody would be proud of to do.
A striking example is one of the things that the Sunflower Children’s Network is doing in the pediatric program [at BCH] – teaching the pediatricians and oncologists about conscious sedation. These little kids are getting repeated bone marrow aspirations which are very painful and traumatic. Previously they were done with only Tylenol – if they were lucky. Now the kids are being given modern, advanced, and safe conscious sedation. And it's just miraculous. The physicians and nursing staff are extremely grateful for that because before, without any sedation, it was pretty rough on the staff too.
Collaboration is something that's really important and the basis of our approach at TWCC. What do you bring back?
Every single time, it makes me incredibly grateful for the country we live in, the hospitals we have, the care we have, the palliative care unit that we have, and the way we're able to look after patients very effectively.
It also reinforces that it's the same principles – no matter what culture or who the people are – It's kindness, treating them with respect, looking them in the eye, giving bad news compassionately.
How much has technology helped provide real-time support and mentoring for the medical and nursing leadership in Nepal?
Three or four years into the twinning program, we tried to set up some Skype video calls to sit in on their rounds and have discussions. And the technology just wasn't there. The internet in Nepal was very unreliable. It was just a complete failure.
So it's been interesting to see technology, like WhatsApp and Zoom, develop and to see how effective it has been. It just makes me a little bit sad that we weren't able to do that in 2007 or 2008 because it would've been helpful. Now we have Zoom ECHOs with a hundred participants all online at the same time, and the tech is nearly flawless.
And I think the mentoring is really important because they deal with some very difficult cases that are socially, psychologically, and medically challenging and stressful. It's really important to have an experienced colleague that you can phone and just talk things over. Every couple of weeks, Dr. Bikash and I will have a conversation.
I think now we're reaching a point in Nepal where there's starting to be a critical mass of younger palliative physicians. I'm really optimistic that the new cohort of young docs who are just coming on as full-time, or even part-time, dedicated palliative docs will create their own community.
We want to work to the point where they’re doing the training in Nepal, we see BCH as a significant player in that (currently we sponsor physicians and nurses to go to Hyderabad, India).
What do you see as the benefit of supporting these types of initiatives?
Well, I think we have good examples in Nepal where we've helped initiate and maintain a couple of programs.
At some point, you reach a critical mass where the country has enough of its own experts, and you don't need outside experts to come to Nepal. India is well into this phase, where there are enough local experts in India to do the work and do the education. With one caveat, when we go it's for free. If a doctor in Nepal takes a week off to go teach palliative care they're not being paid for that. So it is an advantage in that we're going as volunteers. We can't expect them to be full-time volunteers.
In Nepal they've done some innovative things. If you get diagnosed with cancer or some other serious illnesses, the government now gives you a credit. It's about $800, which is quite a bit of money there. So the oncologists and other physicians can draw out of that account for medical treatments. And I think really what we need to be saying is that of that $800, 10% is designated for palliative care. Most of those people are going to die from their cancer, so some funds could be used for their palliative care as they're near the end of life.
The World Health Organization is showing interest again in palliative medicine that will help push the government to try and come up with some kind of plans. Having the Nepali trained docs will certainly make a difference.
Providing palliative care can be very demanding at times, how do you cope with the emotional component of this work?
I have this conversation with all the residents that I teach.
The first thing is that I am very clear about what my goals are. My goal is not to make people live longer or cure their cancer. My goal is to make their death less bad than it would be without us. We can succeed at that 98 percent of the time. That doesn't mean all the deaths are easy and good, but better than they would have been without our team.
We make the hard decisions as a group. Every morning, we have a team meeting and we talk about each case briefly. So the hard decisions are always supported by the nurses and my other colleagues. And then the second thing is debriefing before you go home. I have colleagues who I can wander down the hall and chat with for a few minutes if I have a tough case to discuss. Then at home, having a very supportive wife that I also can debrief with in general terms.
Then the final thing is having good activities and hobbies you do that are totally different from what we do at work. I have a really nice woodworking workshop. I don't think about medical work out there. It takes enough concentration that you have to be in the moment, not daydreaming or thinking about work.
So a healthy hobby, that's different from work – fly fishing, birding, hiking, gardening. I'm kind of a polymath. I'm interested in almost everything.
Anything else you want to share?
I can't think of a more rewarding career. When I think about what would I do differently, I probably could have started another program in Nepal. I should have published some research – we did some innovative things here in Nanaimo that other units weren't doing.
I loved my family practice, which I did for 32 years. The palliative care I loved. I loved the combination. I loved delivering the babies for 10 years. The international travel has been an incredible privilege.
And the colleagues I've worked with, you just couldn't find a nicer, finer group of people than the people who do this work.