PALLIATIVE CARE EDUCATION Where are we going?

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PALLIATIVE CARE EDUCATIONWhere are we going?

• David E. Weissman, MD
• Palliative Care Leadership Center
• Medical College of Wisconsin
• Froedtert Hospital

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Thank you
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Palliative Care Education

• Physician
• Nurse
• Social Worker
• Pharmacist
• Patient / Public
• Multi-Inter Disciplinary

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Palliative Care MD Education

• What is required?
• What is taught?
• Do trainees feel prepared?
• New initiatives.
• What needs to be done.
• The oncology/palliative care interface

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Palliative Care is

• The care of patients with advanced, progressive
  disease in whom cure is no longer possible
  limited prognosis, focus of care is quality of
  life.
• Same philosophy as Hospice
• Palliative care extends the hospice philosophy
  earlier into the disease course.

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Hospice
Therapies to modify disease
Palliative Care
Presentation
6m
Death
Therapies to relieve suffering and/or improve
quality of life
Bereavement Care
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1. What is required

• LCME Clinical instruction... must includeEOL
  care.
• But what are the standards and expectations?
• None currently exist.

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What do deans say

• EOL education very important 84
• Insufficient curricular time 67
• Oppose required courses 59
• Oppose clerkships 70
• Support integrated education into
• existing coursework 100
• Barriers
• Time, Faculty Expertise and Faculty Interest
• Sullivan et al. Acad Med 2004 79760-767.

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Graduate Education

• Review of ACGME requirements in 46
  residency/fellowship programs (31/15) (2000)1
• Pain, Non-Pain Symptoms, Ethics, Comm. Skills,
  EOL Clinical Experience, Psychosocial Care,
  Personal Reflection, Death and Dying
• Weissman, DE and Block SA.Academic Medicine
  200277 299-304

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Review by Specialty

• Internal Medicine, Geriatrics, Neurology had
  greatest content
• Within Internal Medicine, only Hem/Onc and
  Geriatrics had any EOL content
• General Surgery and Radiation Oncology added Pall
  Care requirements in 2001.

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ACGME Summary

• Few requirements
• Emphasis on requirements w/in hem/onc and
  geriatrics none re other causes of death
• Emphasis on technical over cognitive/
  communication/personal awareness
• Virtually no requirement for clinical training
• Impact of new general competencies is unknown.

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What is being taught?

• It depends!
• a) how you ask the question
• b) whom you ask

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Curriculum PenetrationPalliative Care

• Mandatory Rotation 5 (4)
• Part of Req. Course 110 (88)
• Separate Elective 32 (25)
• Part of Elective 42 (34)
• Other 14 (11)
• AAMC 2001 www.aamc.org

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Medical College of Wisconsin

• Medical Ethics Palliative Care 15 weeks
• Case-based 14  hours
• Lecture 14  hours
• OSCE 2 hours
• AAMC Database

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Graduate Education

• Annual AMA GME Survey
• Is there a structured EOL curriculum?
• Family Practice 92
• Internal Medicine 92
• Emergency Medicine 78
• Pediatrics 74
• Surgery 65
• Barzansky B. et al Academic Medicine 1999
  74S102-S104

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• But, what does structured curriculum mean?

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EOL Education

• Pain assessment / treatment
• Non-pain symptoms / syndromes
• Communication skills
• Ethics / law
• Hospice / community resources
• Terminal care / pt-family experience
• Provider Self-Care
• Multiple consensus reports

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National EOL Residency Education Project

• Objective improve residency end of life
  training/evaluation
• 394 residency programs (1998-2004)
• 12 month project to integrate an EOL curriculum
• Funded by Robert Wood Johnson Foundation

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of Programs with Required End-of-Life Education
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of Programs Assessing Residents EOL
Competencies
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• The presence of a structured EOL curriculum was
  rare.
• Prior to participation, program directors did not
  think of EOL care as a coherent educational realm
  containing discrete instructional domains.

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Do trainees feel prepared?
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Medical Students

• Mailed survey-M4s at 6 US medical schools
• Minority of students felt prepared
• Symptom management 49
• Discussion of EOL 33
• Culture/spiritual 22
• Students at schools with greater EOL teaching
  reported greater self-confidence
• Fraser et al. J Pall Med 20014337-343

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Residents Preparation

• Schwartz, et al (2002) FP residents 37 little
  or no precepting/support for EOL care.
• Stevens, et al (2003) Residents pre ICU
  rotation 79 none or too little teaching in EOL
  skills.
• Sullivan (2004) Residents feel poorly prepared
  for EOL decision making.

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National EOL Residency Education Project

• Baseline self-assessment (1997-2004)
• Residents and Faculty N 9227
• Int Med Fam Prac Neurology Gen Surgery
• Self-Confidence24 EOL tasks
• Concerns ethics/law/malpractice
• Knowledge 36 item MCQ test

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Mean Self Confidence 26 EOL Clinical Tasks
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Mean Level of Concern Six Common EOL Clinical
Scenarios Regarding Ethics/Law
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Palliative Care Knowledge Exam Mean Score
5349 Residents and Faculty 114 Internal
Medicine Residencies
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• Residents and faculty do not know, what they do
  not know
• Large arrogance-ignorance gap
• No change in data between 1998 and 2004
• No difference between specialties
• Levels of transition are the greatest points of
  educational tension for new learning
• M3, Intern, 1st year Fellow, New Faculty

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New Initiatives
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• Comprehensive needs assessment
• Experiential opportunities
• Hospice rotations
• Hospital-Palliative Care rotations
• Integration of ethics with palliative medicine
• Communication skills training and assessment
  programs
• Palliative CEX-residency
• Residency EOL Curriculum
• Faculty development
• Materials development

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Palliative Education Assessment Tool (PEAT)

• 14 NY medical schools
• Intensive needs assessment process (PEAT)
• 6 domains Pall Care, Pain, NeuroPscyh, Other
  symptoms, ethics/law, Comm. Skills, Pt/Family
  non-clinical perspectives
• 10/14 completed strategic planning process
• 67/71 specific goals implemented
• Wood EB et al. Academic Medicine 2002 77285-291

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University of Maryland

• 3rd Year students during Internal Medicine
  Clerkship--ambulatory module
• 16 hours-required
• Didactic
• Testing
• Hospice visits
• Self-study material
• Writing exercise

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Palliative CEX

• Pilot Project, U Pittsburgh Int Medicine
• Direct observation of clinical encounters in EOL
  communication with formal evaluative process.
• 95 of participants reported that the exercise
  increased their self-confidence and competence in
  EOL discussions.

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Fast Facts and Concepts

• 143 one-page, referenced, summary of key teaching
  information
• Designed for teaching faculty/ residents/nurses/ot
  hers
• Suitable for rounds
• Mailbox stuffers
• E-mail network
• Downloadable to PDA
• Available at EPERC (www.eperc.mcw.edu)
• Origin Dr. Eric Warm, UC

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End of Life/Palliative Education Resource Center
(EPERC)

• Advancing End of Life Care Through an Online
  Community of Educational Scholars
• EPERC
• www.eperc.mcw.edu

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National EOL Residency Education Project

• Curriculum Reform Project
• Four specialties
• Buy-in from National Associations
• Significant penetration (50 of all IM programs)
• Directed at level of Program Director
• Included Chief Resident Program Director and at
  least one other faculty member

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• Intervention
• Needs assessment-baseline data (P Mullan)
• 2 1 day education program
• Modeling education delivery
• Pain, Communication Skills
• Instructional design methods
• Faculty development methods
• Action Planning for curriculum change
• Follow-up and Mentoring
• Ready-to-use educational materials

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Why instructional design?

• We learned in the first project year that
  residency program directors had little
  understanding of basic instructional design
• Writing objectives
• Matching objectives to learning formats
• Constructing lesson plans
• Matching evaluation to objectives

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Why Faculty Development?

• In the first project year we learned that the
  program directors, and other faculty who
  participated, had virtually no expertise in any
  of the EOL educational domains. The attendees
  asked for resource material for themselves and
  their faculty.

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Seven Outcome Benchmarks

• New educational programming in
• Pain assessment
• Pain management
• Non-pain symptoms
• Communication skills
• Clinical EOL experiences
• Faculty Development
• Integration into standard teaching formats (e.g.
  Morning Report, Grand Rounds)

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Outcomes1 year

• 30 drop-out
• 70 curriculum changes
• New Curriculum integration
• New faculty development program
• New QI education initiatives
• Faculty/Resident Career Impact
• Hundreds of published abstracts (JPM)
• Long-term impact unknown

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Summary of EOL TeachingWhat do we know?
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• Much of EOL clinical learning occurs in the
  setting of educational tension !!
• I dont know what to do (clinical)
• I have to learn it (testing)
• Ill get into trouble if I (legal, ethics)

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EOL Tension Points

• Pain management
• Clinical inadequacy
• Fears overdose, addiction, regulatory
• Treatment withdrawal
• Clinical inadequacy
• Fears legal, malpractice, ethical, religious,
  physician culture
• Family care
• Emotional reaction of self
• Conflicts culture

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• Training Level
• M3, Intern, 1st year fellow, New Faculty
• Professional Role
• Peer pressure
• Financial pressure

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Teaching Methods

• Didactic--ok for knowledge but, EOL care
  involves attitudes and skills
• Experiential learning--role play, calculations,
  treatment planning, hospice home visits,
  palliative care service rotations
• Mentoring / Role Models--Necessary to reinforce
  positive attitudes
• Self-Reflection--trainees must have opportunity
  to explore personal attitudes and self reflect
• Self-Studya valuable, but underutilized
  technique.

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Ideal Curriculum

• Longitudinal M1 Faculty
• Graduated increasingly complex knowledge/skills
• Experiential mentored clinical experiences
• Reflective attitudinal discussions should
  account
• for significant teaching time
• Interdisciplinary team approach central to care

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If I was the emperor king

• All medical schools must have departments/programs
  of Palliative Care.
• All teaching hospitals must have a Palliative
  Care Consultation Service.
• All medical students and residents must complete
  a one month clinical palliative care rotation.
• All oncology trainees (Med, XRT, Surg) must
  complete a minimum of two months in palliative
  care clinical rotations.
• Training in Palliative Care must include
  interdisciplinary focus/experience in diverse
  care settings.

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• All med students and residents and oncology
  fellows, must complete training in communication
  skills that includes competency-based evaluation
  of specific skills
• Pain Assessment
• Giving Bad News
• Leading a Family Goal-Setting Conference
• Discussing use of artificial hydration-nutrition
• Discussing Hospice Referral

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What now?
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Bad News

• Poor application of existing knowledge persists
• Pain management
• Communication skills
• Ethical/legal principles
• Medical resource utilization

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Good News

• Consensus on what to teach
• Proven educational methods
• Excellent educational resource material
• Growing cadre of academic clinician/educators
  with EOL care as their primary focus
• But .

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Bad News

• Improvements within individual schools/
  residencies still largely relies on the presence
  or absence of an effective EOL Champion. Someone
  who combines
• Commitment and Vision
• Leadership skills
• Education skills
• Clinical Skills

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Will new champions emerge?

• Grant money for big projects is diminishing.
• New hot educational priorities continue to
  develop.
• Top-down support at the level of medical schools
  remains marginal at best.

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Good News

• The biggest motivator for improving EOL care is
  not coming from medical schoolsit is coming from
  their affiliated hospitals. Improved EOL care
  leads to
• Cost Savings
• Improved patient satisfaction
• Increasing thru-put

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Froedtert Hospital/MCW

• Palliative Care Audit 2003
• PC Referral vs. Usual care
• 12,500 savings/case for 5 most common DRGs
  leading to inpatient death.
• Total estimated cost savings
• 2.5 million/year
• CFO these are real dollars that we can apply to
  other expenses

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The UHC Palliative Care Benchmarking Project
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Palliative Care Bundle Improves Outcomes
Impact of Number of Key interventions
Patients receiving gt 8 of the key measures had a
gt3.6 day shorter LOS and gt 11,000 lower cost
per case than those patients receiving lt 8
measures
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Bundle By Diagnosis Group

• More than half (52.9) of the cancer patients
  received gt 8 of the key measures
• Less than 35 of the HF and respiratory patients
  received gt 8 of the key measures

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Palliative Care Consultation and Key
Interventions
Patients receiving a PC consultation more often
received gt 8 of the key measures from the PC
bundle than patients without a PC referral
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OncologyPalliative Care Interface

• Increasing recognition that Palliative Care
  Excellent Oncology Care
• US News Best Hospitals Criteria
• New models of continuous care that incorporate
  palliative care seamlessly with oncologic care.

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Hospice
Therapies to modify disease
Palliative Care
Presentation
6m
Death
Therapies to relieve suffering and/or improve
quality of life
Bereavement Care
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• But, there exists a tension about provider
  expertise and when palliative care approaches
  should be applied
• Role definition Oncologist vs. Palliative Care
  Specialist.
• Realities of treatment differences in training
  are reflected in different views of treatment
  effectiveness.

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• The fact that conflicts occur is natural (two
  species occupying a close ecological niche).
• The challenge for the future will be to ensure
  that the focus of care is on the patient-family
  if so, then integrating palliative care into
  routine oncologic care will be inevitable.

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Palliative Care Leadership Centers

• Assist hospitals/hospices starting PC programs
• Provide 2-3 day site visit with established
  program
• Provide 1 year of mentorship
• Contact Center to Advance Palliative Care
  www.capc.org

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Palliative Care Leadership Centers

• Medical College of Wisconsin
• Milwaukee, WI
• Fairview Health Services
• Minneapolis, MN
• Massey Cancer Center of the VCU Medical Center
• Richmond, VA
• Mount Carmel Health System Palliative Care
  Service
• Columbus, OH
• Palliative Care Center of the Bluegrass
• Lexington, KY
• University of California
• San Francisco, CA