Educating Future Physicians In Palliative And End Of Life Care Project: Successes & Challenges

1. Educating Future Physicians In Palliative And End Of Life Care Project:Successes & Challenges Larry Librach MD,CCFP,FCFP Physician Leader EFPPEC W. Gifford Jones Professor Pain Control & Palliative Care University of Toronto

2. “In some respects, this century’s scientific and medical advances have made living easier and dying harder” “Approaching Death”-The Institute of Medicine

3. Background • In 2003, Health Canada provided funding for a national education project for future physicians called EFPPEC • The project is heading into last 1 ½ years of its mandate • We gave a preliminary report 2 years ago

4. Project Overall Goal • By the year 2008, all undergraduate medical students and the residents at Canada’s 17 Medical Schools will be receiving effective training in palliative and end-of-life care and will graduate with competencies in these areas.

5. Issues Leading to the Development of EFPPEC

7. The Education Work Group of the Canadian Strategy on Palliative & End of Life Care • Interprofessional group • Identified core competencies for all health care professionals • Identified needs for education by surveys

8. End of Life Care Needs of Canadians • “Quality End-of-life Care: The Right of Every Canadian” Canadian Senate Report 2000 & 2005 • Social responsibility of medical schools

9. Documented Deficiencies In Training Future Physicians • Oneschuk D, et al. The status of undergraduate palliative care education in Canada. J Pall Care. 2004;20:32-37 • Noted lack of curriculum in all postgraduate residency programs

10. Palliative Medicine • Recognition of palliative medicine as a specialty • Residency program • CSPCP • Academic expertise in education

11. Not just Palliative Care specialists & teams Palliative care not just “at end”. All Family Physicians Should Be Involved In Providing Palliative Care

12. The Informal & Hidden Curriculum • Influence of faculty as role models • Good & bad • Faculty behaviour & attitude influences residents • Implicit & explicit messages

13. The Growth of Palliative Care • More prominent organizations • CHPCS, QEOLCC • Norms of Practice • Regionalized care • Need to meet demands for PM physicians & care standards

14. EFPPEC Structure

15. EFPPEC Partners • AFMC is principal partner. • CHPCA is co-partner. • Health Canada funding • Office is located at CHPCA in Ottawa.

16. EFPPEC Project Team • Project Manager: • Louise Hanvey • Physician Leader: • Larry Librach • Administrative Assistant: • Jennifer Kavanagh

17. EFPPEC Management Committee • Alan Neville (Chair)-McMaster University • Rob Wedel-U of Calgary • Hubert Marcoux- U of Laval • Paul Daeninck-U of Manitoba • Doreen Oneschuk-U of Alberta • Maryse Bouvette-MN • Sue Maskill-ACMC • Sharon Baxter-CHPCA • Gerard Yetman- Health Canada

18. Challenge: Integrate, Not Usurp • A curriculum that is already full. • Map out opportunities for integration Block SD et al. Journal of General Internal Medicine. 1998: 13(11):768-73,

19. Tasks & Status

20. Enlist Support of Deans of All 17 Medical Schools • Need for “top down” authorization • Easier than expected • AFMC accredits these schools & is sponsoring partner • All in favour and enthusiastic

21. Task 1Local Team Development

22. Background • Every medical school has a somewhat different culture & blend of learning methods • Each school has curriculum that may have EOLC components that need to be identified • “Bottom up” approach

23. Tasks for Local Teams • Form an interprofessional team of educators • Identify team leader(s) • Implement a curriculum inventory tool & submit • Begin to integrate into curriculum committees & process for UG & PG • Attend first EFPPEC symposium

24. Results • All 17 have identified local teams & leaders • Most are very active • 3 are still struggling although getting more active • All teams are IP

25. Results • Initial curriculum inventories done in the majority • 11 of 17 • Good attendance at 1st symposium • Have established regular e-mail newsletters

26. Task 2Develop Consensus on UG Medicine Basic Competencies

27. Background • CSEOLC had developed core competencies • Used these to identify specific enabling competencies • Subjected these to national consensus building • PC, medical educators

28. Results of Consensus Building • From a participant list of 327 medical educators, there were a total of 210 respondents, a response rate of 64.2% • Most items achieved consensus of around 90% • Changes suggested & incorporated

29. UG Medicine Competencies • SEE HANDOUTS

30. Task 3Develop UG Curriculum Guidelines Based on Competencies

31. Background • There had been a previous attempt at defining curriculum objectives in palliative / EOLC • Too long • Not the “right” time • Local & provincial efforts had started by consensus that a national document would carry more weight

32. Tasks • Work with the UG Education Committee of the CSPCP, the Ontario group & the Québec Groups from the medical schools to see if efforts could be combined • Incorporate competencies, enabling competencies & limited specific objectives • Get national consensus on the curriculum guideline

33. Results • Almost two year project to meld the efforts of groups • Draft produced & subjected to national survey • Fewer responses in total but good input from educators • Changes have been made & penultimate draft being reviewed before translating & publishing

34. Further Tasks • Ensure the Medical Council of Canada exams incorporate EOLC questions & OSCEs

35. Task 4Continuing Professional Development

36. Background • Recognition that many PC educators not well integrated into system in their schools partly because of lack of training to be educators • Feedback from PC people indicating their need for education on teaching, evaluation, program development etc. • Expressed need for education forum in EOLC

37. Tasks • Establish an annual EFPPEC Symposium dedicated to teaching & learning in PEOLC • Partnered with an organization • IPE in nature

38. Results • 2 EFPPEC Symposia have been held in conjunction with the 5 partner Canadian Association of Medical Education • First devoted to opinion leader development • Second with workshops & progress reports

39. Results • Videoconferences • 4 so far • Across Canada • Inexpensive • Allow sharing of experiences

40. Challenges • How can this be sustained? • Expensive if current model maintained • Where & when to have the meeting • Most PC educators not at CAME meeting

41. Solutions • Move the meeting as a preconference to the annual CHPCA conference • 2007 in Toronto • CSPCP as partner • Incorporate an education stream throughout CHPCA conference

42. Task 5Postgraduate Competencies in PEOLC

43. Background • Get an initial buy-in (“top-down”) • 2 accrediting organizations for PGME • CFPC & RCPSC • Need to identify & incorporate any competencies, enabling competencies & objectives for each specialty • Rely on accreditation to ensure basic training

44. Background • Some literature examples but little Canadian activity • Need to avoid overwhelming objectives • Need to target specialties who need enhanced knowledge • e.g. oncology

45. Tasks • Work with CFPC • Already had made some changes • Develop specific objectives in format of 4 principles as well • Consensus building • Work with RCPSC • Establish specific objectives & do consensus building

46. Results-Family Medicine

47. Palliative Care & FM Training • From the most recent edition of the CFPC’s Standards for Accreditation of Residency Training Programs (The “Red Book”), the following section has been included: • “Palliative and End of Life Care • Residents must learn the skills, knowledge, and attitudes related to the management of physical, psychological, social and spiritual needs of dying patients and their families. Residents must be familiar with medical and societal attitudes towards death and dying.”

48. Common Competencies for Family Medicine Residents • SEE HANDOUT

49. Results-CFPC • Have achieved consensus • National working group of family medicine programs & educators working on curriculum guidelines

50. Results-RCPSC • Initial meetings with RCPSC to discuss mechanisms • Draft enabling competencies & objectives for: • Core medicine • Critical care • Groups working on pediatrics, oncology, core surgery