Palliative Care in Family Medicine Residency Training: Key Curricular Elements and Strategies

1. Palliative Care in Family Medicine Residency Training: Key Curricular Elements and Strategies

2. Overview Our Palliative Care Journey Start of Clinical Programs Curriculum Development Needs Assessment Performance Competencies Methods Assessment Palliative Care Education Research Project

3. Needs Assessment Survey of Family Medicine Residents and Faculty Self Assessment of Knowledge Palliative and End-of-Life Care Pre-Test Nationwide Comparisons Conference

7. Our Steps in the Journey Residency Education Grant Funded Program in Teaching EOL Care CAPC National Programs Palliative Care Leadership/Mentorship Program Establishing of Clinical Program Developed Formal Residency Curriculum

8. Our Clinical Programs Palliative Care Team- Based in Department of Family Medicine Patient and Family-centered - incorporating the ideals and philosophy of Family Medicine Continuity Focus

9. Palliative Care Program Hospital Wide Interdisciplinary Patient Centered Family Centered Culturally Competent Serving poor, minority and immigrant populations

10. Program Achievements New 1 Year Palliative Care Fellowship Program Reduction in Length of Stay, especially in MICU Significant Cost Reduction/Avoidance with Increased Patient Satisfaction NYC Leaders in Development of Medical Orders for Life Sustaining Treatment (MOLST) Form Extensive Educational Programs for Physicians and Staff

11. Future Goals Extend Palliative Care Program to Long Term Care Facility Develop/Implement Outpatient Palliative Care Programs in Family Medicine Center and other Network Sites Establish Inpatient Palliative Care Unit In-Patient Hospice Beds Continue the Dissemination of Program Results/Products

12. Why Teach? Why Learn? Why Practice? Palliative Care fast becoming industry standard Now a distinct subspecialty board OUR patients life cycle Family Medicine model and philosophy of care uniquely suited to meet this need Compassionate complete care for advanced chronic illness AND end of life

13. Family Medicine and Palliative Care Family Physicians must collaborate to ensure that Palliative Care remains within our scope We need to come together for the purposes of: Education Training Research Scholarly Activity Establishing Clinical Standards

14. LCME Standards Clinical instruction should cover all organ systems, and must include the important aspects of preventive, acute, chronic, continuing, rehabilitative, and end-of-life care.

15. ACGME Residents should understand basic legal terms and concepts related to the practice of medicine, especially their legal obligations regarding patient information and the provision of end-of-life care.

16. JCAHO Ethics, Rights and Responsibilities Patient/Family involvement in decision making Address wishes of patient relating to end of life care Provision of Care Interdisciplinary, collaborative manner Pain Assessment and Management!!!

17. Curriculum Development Needs Assessment Goals Objectives Methods Resources Evaluation/Measurement

18. Needs Assessment Where are the learners now in reference to the goals? Assess with: Pre tests Group Discussions Direct Observation Asking Questions

19. Goals/Objectives To train Resident Physicians with the Knowledge, skills and attitudes to provide comprehensive, compassionate care to the patient with advanced illness What do they need to know, do, feel?

20. Performance Competencies Patient Care Medical Knowledge Practice Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems Based Practice

21. Patient Care Communicate effectively with patients and their families Gathers essential information about patient wishes Work with multidisciplinary team to provide palliative care Utilize assessment tools to identify pain and symptoms that need to be addressed

22. Practice Based Learning and Improvement Demonstrates self awareness about issues related to palliative and end of life care Identifies barriers to appropriate palliative and end of life care within the practice, institution or community Analyzes data related to cost effectiveness and patient/family satisfaction with palliative care

23. Medical Knowledge Knowledge of pain assessment and treatment utilizing pharmacological and nonpharmacological methods Prognostication Evaluation and treatment of terminal symptoms Regulations related to advance directives

24. Interpersonal and Communication Skills Utilizes effective listening skills and communicates well verbally, nonverbally and in writing Delivering bad news Family conferences Establishing treatment goals Discussing DNR orders

25. Professionalism Responds to the psychosocial needs of the patient and his/her family Demonstrates sensitivity and responsiveness to patients� culture, age, gender and disabilities Demonstrates a commitment to ethical principles and practices

26. Systems Based Practice Partners with social work/case management to transition patients to appropriate care locales Works within parameters of state specific regulations regarding hospice, etc Understands cost effective benefits to Palliative Care and how quality of care is enhanced

27. Family Medicine Education Curriculum Introduction to Palliative and EOL care Communication Skill Building Pain Assessment Pain Management Management of Symptoms Delivering Bad News Spirituality and Palliative Care Conducting a Family Conference

28. Domains/Topics

30. Methods Didactic Conferences/Grand Rounds Communication Skill Building Workshops Role Play Exercises Modeling Faculty Development Video vignettes Small groups Independent learning activities Case Based Presentations

31. Teaching Pain Management What does the physician need to know, do, and feel? Knowledge: Pharmacological modalities Skills: Pain Assessment Opioid calculations Attitudes: Believing the patient in pain Caring for the addict in pain

32. Pain Management Methods Modalities, Regulations Didactic Lectures Pain Assessment, Opioid dosing Skill building Workshops Small Groups Standardized patients Case Examples/Practice problems

33. Teaching Pain Management Communicating with patients about pain assessment Role play Video vignettes

34. How to Obtain a DNR/DNI Order Knowledge: Legal issues Definitions Skills: Communicating information Prognostication Attitudes: Self Awareness

35. Teaching Methods Regulations, Definitions Didactic Communication Skills Role Play Small Groups Video vignettes Attitudes � Creative Writing, Narrative

36. Clinical Teaching Family Medicine Center Inpatient Rounds/Bedside Teaching Palliative Care Service Home Visits Nursing Home Hospice Other disciplines

37. Evaluation/Measurement Post Tests Satisfaction Surveys Clinical Outcomes Direct Observation Chart Reviews 360 degree evaluation tool

38. Resources Center for Advancement of Palliative Care www.capc.org EPERC (End of Life Palliative Education Resource Center) www.eperc.mcw.edu American Academy of Hospice and Palliative Medicine www.aahpm.org

39. More Resources Unipac Series Hospice/Palliative Care Training for Physicians www.liebertpub.com/uni American Academy of Family Physicians

40. Palliative Care Research Project

41. Family Medicine and Palliative Care A natural fit What if we give it up? How can we keep it? Our trainees

42. The Project Surveyed all Family Medicine Program Directors � lists obtained through AOA and AAFP 3 separate mailings with 2 Program Director listserv reminders over course of 2 months 602 Total Surveys sent out Allopathic and Osteopathic Programs 261 Total completed to date 51 DOs; 210 MDs

43. Our Assumptions Directors would feel the topic was important Current curricular activities would be variable Expected few clinical services and even fewer fellowships (especially operated by Family Medicine) Unsure about didactics being offered

44. Looking at the Data

47. Do you feel Palliative and End of Life Care Training is Important for Family Medicine Residents? 100% YES

50. ROTATIONS Geriatrics Critical Care Family Medicine Inpatient Internal Medicine

58. WHO TEACHES THIS TOPIC? Family Medicine Faculty Behavioral Science Faculty Geriatrics Faculty Internal Medicine faculty Other

61. Program Director Comments �I think many of us are still trying to get a better grasp on exactly where Palliative Care is different than the role of a Family Physician and stuff traditionally accomplished.�

62. Program Director Comments ��Could always do more� �It would be nice to have a more structured curriculum� �Would like you to disseminate any curriculum you have� �This is a gap in our training program that needs to be addressed.� �Important topic with few known effective resources�

63. Program Director Comments �Always room for improvement in any curricular area � just not enough time or resources� �No time for this � too many competing disciplines� �Too little time!!!!!� �Until the RRC grants more time for this, it is simply not a priority�

64. Program Director Comments �Too much time wasted on requirements that very few FPs do such as OB,SURG � we need to eliminate those and add things like this� �Great topic � we feel it is a core skill here� �This is an absolute must � great survey!� �Rarely addressed by other specialties other than Family Medicine�

65. Discussion