Palliative Care Undergraduate Curriculum at the University of British Columbia

1. Palliative Care Exam Results 2005 70 60 50 40 #of students (total 128) 30 20 10 0 60-70 70-80 80-90 90-100 scores (%) Dr. Pippa Hawley 1, Dr. Patricia Boston2, Leah May Walker 3, Dr. Romayne Gallagher 4 1.FRCPC Pain & Symptom Management/Palliative Care Specialist, Director of Undergraduate Education, 2.UBC Director of Palliative Care, 3.Education Coordinator, UBC Family Practice, 4.CCFP Clinical Professor, Division of Palliative Care, Project Consultant - Pallium Palliative Care Undergraduate Curriculum at theUniversity of British Columbia Background Structure Teaching Methods and Innovations Evaluation The intent of the curriculum is that students are introduced to the principles of palliative care, and as they proceed through the 4 years of training, develop a greater depth of knowledge and understanding. By graduation, they are comfortable in caring for patients with palliative care needs. Year 1 Overview of Palliative Care is introduced in the Family Practice Block with a 3-hour mandatory session. Students are introduced to pain management issues in a lecture in the Human Biology Block of the curriculum: Principles in the Treatment of Cancer. Students are introduced to advanced directives in the Ethics Block of Doctor, Patient & Society. Year 2 Overview of Palliative Care #2, a 3-hour session in Family Practice Block exploring the objectives of palliative care in more depth. Brain and Behaviour Block: 1 week PBL case with a focus on Postoperative Neuropathic Pain. Brain and Behaviour Block: 1 hour lecture on Pharmacology of Drugs Used in Acute Pain: Opioids Family Practice Continuum: Community Practice Sessions, 20 afternoons/yr per student, in pairs with family doctors, one doctor in each group with some palliative care in practice Elective: Students may choose the Interprofessional Course in Palliative Care, a 1-month intensive course in clinical and academic settings. Each year, 4 palliative care teams representing students from medicine, social work, nursing and pharmacy complete the course. Year 3 In 3rd year clinical clerkship the students have two academic half-day 90 minute teaching sessions devoted to Palliative Care. The first is in the medicine (CTU) block and is a case-based introduction to pain and symptom management. The second is in pediatrics which takes place at Canuck Place, Vancouver's children's hospice. Year 4 Phase 6: The Palliative Care course is a series of 4 small-group tutorials (9-hours in total) taught by practicing palliative care physicians, followed by an examination. Phase 6: The Doctor/Patient Relationships Course includes a session on “Dealing with Emotionally Challenging Patients”. Phase 6: The Cleo Lectures include the session ”End of Life Decision Making” and one entitled “Breaking Bad News”. Students can choose a Palliative Care elective in 3rd or 4th year. These electives have proven to be popular, with 10 electives scheduled for 2004-5 so far. The Palliative Care examination is held along with the Pharmacology and Therapeutics examination at the end of 4th year. It is a multiple-choice exam with a pass/fail outcome. Any student failing the exam is offered a one-on-one tutorial with the Phase 6 course director, followed by an opportunity to re-sit the exam. Evaluation of the Palliative Care Course in 4th year has been positive. Following the 2004 course 44 student evaluations were completed (a little less than half). When asked how effective the course had been in meeting its designated learning objectives, the responses were: Does not meet requirements 1 Requires improvement 0 Meets requirements 32 Exceeds requirements 11 The Overview to Palliative Care lectures in 1st and 2nd year are taught to the whole class by the Director of the UBC Division of Palliative Care. Dr. Patricia Boston assigns pre-reading from two texts that prepare students for an introductory lecture; asks students specific questions relating to the objectives as they are watching the film “Endnotes”; leads a discussion on those questions; and ends the session with a didactic on self-awareness and self-reflection. The 2nd year session follows a similar format, working through the undergraduate objectives in much more depth. The 3rd and 4th year sessions are taught by practicing palliative care physicians in a small group setting. The case-based interactive approach is utilized wherever possible, and the last session includes one hour specifically aimed at exploring the students’ personal attitudes and, beliefs around death and dying, and experiences with end of life care throughout their undergraduate years. The elective students are taught through clinical involvement with patients through consults on the wards, Palliative Care units and in Pain and Symptom Management/Palliative Care Clinics, depending on the setting of the elective. The academic component of the interprofessional palliative care course is lead by an interprofessional faculty (medicine, nursing, pharmacy and social work). It is presented using a case-based format and is supplemented by presentations and workshops given by a variety of physicians, nurses, social workers, pastors, physiotherapists, pharmacists, community members and even family members of palliative care patients. The greatest emphasis of the course is on self-reflection, and thus students are asked to keep a journal reflecting their experiences and answering specific questions relating to working with palliative care patients. Students are also assessed in their interprofessional team work with assignments requiring teams to build cases together; and reflect and assess palliative team practice in popular films. Clinical practice experiences comprises half of the course content and occur in both institutional and community settings with multi-disciplinary teams of palliative care health professionals teaching the interprofessional student teams. The Phase 6 Palliative Care course is rich in content and in the number of palliative care providers tutoring the course. Students are taught in small groups of no more than 10 in order to facilitate meaningful discussion and reflection. In 2004-5, 9 hours in 5 sessions in a variety of formats (lecture, cases, film, readings and discussion) through two weeks were allotted to: Decision Making at the End of Life; Cases in Pain Management; Symptom Management; On Being a Doctor; Regulatory Issues; and Pain Relief – A Universal Human Right? This final session was introduced this year along with the international WHO initiative to improve access to pain management worldwide; the content of the session includes IASP material. Prior to 1997, palliative care curriculum content in the medical school was ad hoc and fell under other programs and departments. It comprised of a lecture and opportunities for an elective rotation at a Vancouver site. We have progressed significantly since then. In 1997, Palliative Care became a program. Because of efforts by the first director of the Division of Palliative Care, Dr. Romayne Gallagher, Palliative Care content was formally introduced into 4th year Phase 6 through the Department of Family Practice in 2000. Under the direction of Dr. Pippa Hawley, that course has continued to develop and expand; and Dr. Patricia Boston, the current Director of the Division of Palliative Care, has further formalized and expanded the 1st and 2nd year “Overview” sessions, ensuring curriculum is current, informed by our philosophy and meets our objectives. Philosophy The Division of Palliative Care, Department of Family Practice, Faculty of Medicine in the University of British Columbia, aims to ensure excellence in care of the dying through research, advocacy and education in undergraduate, graduate, postgraduate and public education. Our philosophy on palliative care education includes the premise that education and research for palliative care is not only education in the science and techniques of physiological pain and symptom control (including psychological, spiritual and existential suffering) but also in the ability to nurture, sustain and build team relationships and in the use of “self” as a primary source to compassionate care and as a therapeutic instrument. Competent and effective palliative care therefore requires a specialized body of knowledge and practices for the delivery of comprehensive, multi-disciplinary, “whole-person” care at the end of life. Our aim is to develop and implement educational and research initiatives that will enhance palliative care in varying clinical settings including hospices, emergency and intensive care, acute and tertiary care settings and in the community. Strengths and Challenges for the Future The Division of Palliative Care continues to improve the quality of teaching students receive, particularly the consistency with which the Phase 6 Back to Basics in Palliative Care course tutors cover the curriculum in the small group tutorials. The availability of electives has been increased: there are 4 elective sites in the Vancouver area, and at least 4 outside Vancouver. We would like to continue to increase the number of electives available to undergraduate students. We would like to expand palliative care content to include all advanced illnesses, e.g. diabetes, end-stage renal disease, ALS, cardio-vascular diseases, non-malignant illnesses, etc. We are also working to expand the definition of palliative care to include appropriate care in settings such as critical care units, intensive care, and emergency care. We plan to develop an undergraduate curriculum in Acute and Chronic Pain Management, which is a neglected area of medicine in the current curriculum. We are striving to increase the depth and quality of content in palliative care lectures, as well as increase the hours of mandatory instruction in the undergraduate program. In the 2005-06 year, plans are underway to develop palliative care content in Doctor, Patient & Society sessions. We continue to advocate for an interprofessional model of instruction of palliative care across the curriculum and among all the health disciplines. Undergraduate Objectives • The doctor should: • Know the meaning of terminal illness and of palliative medicine • 2. Understand the general principles of palliative medicine: • a) symptom management • b) psychological and social dimensions • c) spiritual and existential dimensions • d) ethical issues • e) grief, loss and bereavement • 3. Understand the concept of Whole Person Care • 4. Understand principles of communication in palliative care • 5. Understand the principles of teamwork in palliative medicine • 6. Recognize the importance of personal self-reflection and self-care • 7. Recognize the organizational and societal barriers to pain management.