Competency-Based Curriculum in Palliative Medicine

1. Competency-Based Curriculum in Palliative Medicine Tomasz R. Okon M.D. Director, Marshfield Clinic Palliative Medicine Fellowship

2. Objectives • Present the process of developing a competency-based curriculum in the Marshfield Clinic PM Fellowship in an ACGME template format • Illustrate the importance of careful selection, and linking of objectives, competencies and assessment methods as a necessary condition of an effective curriculum

3. Traditional Curriculum: definitions and components All the coursesof study (e.g. medical rotations) offered by an educational institution A document outlining such courses/rotations and specifying outcomes of the learning Curriculum Old vs. New Paradigms

4. Curriculum Old vs. New Paradigms Competency Based Curriculum (ACGME): development steps and components • Conduct needs assessment and write goals • Identify competencies addressed by this rotation or experience • Formulate matching objectives • Determine teaching methods • Determine assessment methods • Determine program improvement methods

5. Three Rules We Learned the Hard Way 1.Local Integration • We learned that a local integration (linking) of the six steps of the curriculum development was critically important • Parts from a Volvo won’t fit into a Saab • Or, more specifically, for any intended, specific educational output, one needs alland matching components selected to the end of achieving that output

6. Three Rules We Learned the Hard Way (cont) 2.Clinical Customization • We learned that if the intended, specific educational output can be discerned in the context of (comprises) a discrete clinical activity, it was prudent to develop the curriculum around it • Lump all you can lump; split only what you have to split

7. Three Rules We Learned the Hard Way (cont) 3.Diversified Learning Strategies • We learned that exclusively utilizing the behaviorist approach (all outputs assessed behaviorally) limits, instead of enriching • It is not what is poured into a fellow that counts but what is planted; paraphrased after L. Conway • Whenever feasible, use cognitivist, humanist and constructivistapproaches

8. Step 1: Needs Assessment One could conduct a comprehensive needs assessment • Described at great length in Kern et.al. Curriculum Development for Medical Education, 1998 • This excellent approach was thoroughly discussed last year at this conference (Module 1)

9. Step 1: Needs assessment (cont.) Or, as we have done it, one may decide that the face validity of a set of minimal competencies is compelling enough to use them as a firm starting point • At MC, we did not engage in the preliminary work interviews, discussions, tests, surveys, etc. • Instead, in 2003 we assumed that the competencies we developed locally on the basis of the British standards were sufficiently robust and comprehensive

10. Step 1: Needs assessment (cont.) • Presently, specialty-wide articulation of a set of competencies is available; it is an excellent starting point for individual programs’ curricular work • The HPM competencies define what all fellows need to become proficient at (unifier) • The unique character of a fellowship defines what kind of trainees you select (modifier) • All trainees are presumed to aim at boardcertification while acquisition of the HPM competencies is presumed sufficient for this goal (unifier)

11. The ACGME Template http://www.acgme.org/outcome/e-learn/module4_CurriculumTemplate.doc

12. Step 2A: Rotation Description INPATIENT PALLIATIVE MEDICINE ROTATION The Palliative Care Service rotation is the core of the Marshfield Clinic PM Fellowship program • Rather than the customary, two to four week learning experience, this rotation lasts throughout the entire year of the fellowship and comprises a total of seven to nine months of principal patient care in the 11-bed palliative care unit and consultative service in all other units of St Joseph’s Hospital • The Fellow: • provides consultative and principal palliative care, with appropriate oversight and teaching • to the end of becoming a proficient specialist Palliative Medicine physician

13. Step 2B: Goals for the Rotation The primary goal of this rotation is for the Fellow to learn the independent practice of Palliative Medicine, in both principal and consultative roles. • The most general, non-measurable, global statement about the final, desirable “real-world” skills (and knowledge) To that end, the trainee will be able to: • confidently address pain and symptom control, psychosocial distress, spiritual issues and practical needs of the patients; • provide the information needed for the patients to understand their condition and treatment options, discern their values and goals; • develop trusting and respectful physician-patient relationship; • efficiently collaborate with other IDT members to ensure comprehensive and effective care. • adapted from the HPM competencies

14. The Hard Work Begins

15. Step 3: Identify CompetenciesLocal Curricular Integration If the identified competencies are unsuitable for the best locally existing… • teaching methods, or • assessment methods and • curriculum improvement process …then the curriculum – aimed at producing the desired output – is likely to fail.

16. Step 3: Identify CompetenciesLocal Curricular Integration (cont.) Example Output: The trainee will demonstrate empathy • After we identify this competency as: using “empathic and facilitating verbal and non-verbal behaviors”; and, • Assured that we have methods to teachusing the phrases (not just teach the phrases and body postures) • Can we meaningfully set criteria for meeting the behavioral objective, i.e. numerically define adequate performance and then reliably discern, code, measure it? • Can we monitor and improve the curricular process as it pertains to ‘demonstration of empathy’? • See an excellent review: Stepien & Baernstein JGIM; 21:524-530 • How much better is 60% response rate to emotional clues, compared to 40%?

17. Step 3: Identify CompetenciesLocal Curricular Integration (cont.) If a program is able to muster the teaching, assessment and improvement methods suitable for producing the desired output – ‘demonstration of empathy’ – • then this specific competency may/should be included in the curriculum (as is) Otherwise, one may identify a broader competency that includes, and relies on frequent (even though variable) demonstration of empathy to: • when needed, directly measure, • other times indirectly infer, • that empathy is effectively used in the process of palliative communication

18. Local Curricular Integration: Our Experience • In 2002, we started off with 49 specific competencies • By 2005, we learned that we did not have reliable teaching, evaluation and improvement tools – for so many discrete, specific competencies • What was the problem? • We formulated several precise, specific competencies, e.g. • The resident will incorporate rehabilitation into the management plan appropriately and effectively • But we had neither reliable teaching methods nor means of assessment and improvement to carry the educational process through its all stages (components) • Hence we merged and modified so that we presently utilize 29 discrete, locally developed competencies • They match the proposed HPM set - a minimum consensus • It would be unwise to be modifying the set by omitting HPM items • It may be necessary for some programs to ‘lump’, while others ‘split’ some items, in order to achieve an integrated process that: • Explicitly links all curricular components for any intended educational output

19. Step 3, Identify Competencies: Clinical Customization Clinical Customization • Identify/define specific competencies that commonly comprise a discrete (even if comprehensive) clinical task • One may develop/define curricular components in so far as they represent independent, unique skills of the trainee; for instance (from HPM Comp): • 4.1 Initiates informed relationship-centered dialogues about care • 4.2 Demonstrates empathy • 4.5 Uses age, gender, and culturally-appropriate concepts and language when communicating with families and patients • 4.6 Demonstrates the above skills in […] paradigmatic situations • Conversely, one may consider the behaviors necessary for # 4.6 to collectively constitute: • a discrete, observable clinical task (real or simulated) that • serves as an opportunity to judge, both • the comprehensive clinical task 4.6, and • more specific skills 4.1, 4.2, 4.5 etc • The curricular components (teaching, assessing, improving) work best when correlated with, and deployed in the context of discrete clinical actions • Thereby, the curricular process follows principles of adult learning • Example: PM CEX (Han PKJ et al Acad Med 2005; 80: 669-76)

20. Step 3: Identify CompetenciesMC PMF Final Version Core Competency 4: The resident will be able to apply interpersonal and communication skills that result in effective relationship-building, information exchange, emotional support, shared decision-making and teaming with patients, their patients’ families, and professional associates • Specific Competency 17 (MC 4.1): Trainee communicates effectively with patients and families/care-givers, and documents informatively, in paradigmatic palliative contexts, such as: • Giving bad news, Discussing transitions in goals of care from a curative/restorative to palliative, Dealing with families …. Etc. • Specific Competency 18(MC 4.2): Understands and skillfully uses advanced patient-physician communication techniques in challenging palliative contexts, such as: • Discussing “inappropriate” or “futile” care, Negotiating conflict in clinical circumstances, …Etc.

21. Identify Competencies: To What Ends? Summative (“lumping”): • To account and demonstrate to the lay public, the profession and the certifying body (ACGME) • That the trainee is truly prepared for an independent practice of HPM • It is irrelevant – for the purpose of summative evaluation - what are the details of clinical communication (such as, for instance, demonstration of empathy), or how we teach and evaluate them • The public, the profession and the certifying body want to be assured that, whether trained in AL or WI, the trainee will have achieved proficiency to practice independently Formative (“splitting”): • To facilitate acquisition and mastery of specific competencies, judged by development of detailed knowledge, skills and attitudes that – at the end of the training - allow for independent practice • Here, it is fundamental to discern individual needs, teach and evaluate • A very detailed and specific descriptions of the desired outcomes (K/S/A) are critical in order to teach, evaluate and improve the process

22. Competencies: Summative-Formative Integration For summative purpose, the brief, general descriptions of the competencies #17 and #18 are sufficient, BECAUSE: All parties to the curricular process have full understanding • what the summative items (1-29) mean, and • how they flow from (are integrated with) the formative tasks of the curriculum For instance, unfolding of the 17th competency reveals that it contains several specific elements: • Knowledge • Skills, and • Attitudes • which collectively comprise the most specific level, • that of OBJECTIVES for the curriculum

23. Step 4: Formulate Objectives • What is the knowledge necessary for competent, effective communication with patients and families/care-givers, in paradigmatic palliative contexts (competency 17)? • We formalized it by specifying specific behaviors • SEE COMPLETE DOCUMENT FOR COMPREHENSIVE DESCRIPTION • For instance, the first item describes four behaviors • Recalls components of, • outlines specific content of, • states exemplary phrases, and • discusses specific tasks of all steps of communication sequence of SPIKES R • when asked to do so in the weekly FFS (Formative Feedback Sessions) with at least 75% accuracy

24. Step 4: Formulate Objectives What are the skills necessary for attaining this competency? • The trainee routinely uses a range of structures and styles of communication to initiate relationship-centered dialogues about care, by eliciting concerns across physical, psychological and social domains, establishing awareness about illness and prognosis, facilitating informed decision making and promoting autonomy in individuals. Specifically, the trainee: • Demonstrates all (100%) components of SPIKES R sequence • during simulated communication role-playing case; and/or: • Demonstrates all appropriate and necessary (per faculty observational judgment) components of SPIKES R sequence • during actual patient encounters What level of skill is deemed inadequate, but remediable? • The trainee sometimes fails to demonstrate this entire range of skills (100% of SPIKES R), • Such that clinical care would be compromised without close supervision (per faculty observational judgment) Again, Please refer to the evaluation form #17 and the comprehensive competencies table for full list of SPIKES-R items

25. Step 4: Formulate Objectives Lastly, what are the attitudes necessary for attaining 17th competency? • The trainee values and recognizes the need for a range of communication skills, and reflects on his/her practice to ensure that his/her skills are developed. • Specifically, whileregularly journaling in the reflective portfolio, and on that basis, at least once monthlydiscussing with faculty self-selected cases and/or problems, the trainee: • Reflects insightfully on: • relationship-centered dialogues about care, • empathic and facilitating behaviors, • recognition and response to own emotions, • communication of new knowledge to patients/families adjusting language and complexity of concepts based on the patient/family’s level of sophistication, understanding, and values, as well as on developmental stage of patient • Demonstrates self-awareness and ability to recognize differences between the clinician’s own and the patient and family’s values, attitudes, assumptions, hopes and fears related to illness, dying, and grief

26. Didactic lectures(Local) Clinical teaching Case based teaching Role modeling Journal Club Mentoring M & M Simulation (see case scenario following evaluation form 17) Self directed learning modules(ONCOTALK, Textbooks and JAMA series) Individual or group projects Research projects Chart audit Step 5: Determine Teaching MethodsACGME resource site lists a rich inventory of teaching methods Underlinedare methods that we use for the 17th competency

27. Step 5: Determine Teaching MethodsSupplemental Method(s) For our purposes, the ACGME inventory remains inadequate; we needed additional, learning approaches and hence evaluation methods: • importantly, a constructivist orientation (in addition to the behaviorist orientation that ACGME emphasizes ) yields inclusion of • Reflective Journaling (RJ) as a teaching and evaluation method Reflective Journal is based on a complete patient log that fellow maintains – the log provides the minimum clinical data and CMR reference C:\Documents and Settings\okont\Desktop\palliative fellowship\Evaluation forms\Portfolio guidelines MC PMF.doc Fellow enters cases selected for the RJ, in a three column table: • 1st column ties RJ with the case log (identifier) • 2nd column focuses on self-reflection on challenging aspects of the case, personal feelings, or noteworthy outcomes noted at the time of clinical case or very shortly afterwards • 3rd column details post-discussion (faculty, and peers) resolutions or specific learning points and reflections

28. Step 5: Determine Teaching Methods Please refer to Marshfield Clinic Palliative Medicine Fellowship cross-reference table: • FOCUS ON COMPETENCIES BY TEACHING METHODS (in the handout) C:\Documents and Settings\okont\Desktop\palliative fellowship\Accreditation\# 2 Cross-Table competencies vs Teach Methods 2007 March.doc • The table organizes competencies and teaching methods: • It allows for immediate retrieval of: • articles (PDF hyperlinked on MC server) • evidence-based materials and links • guidelines

29. Step 6: Determine Evaluation Methods Evaluation content is largely determined in step 4 • When we identified specific objectives • Recall, that objectives (step 4) specified set of behaviors, conditions and criteria, hence effectively forcing specific evaluation criteria Specific methods of evaluation can be broadened, however • For instance, the same “checklist” (specifying content) can be used for various formats of evaluation (see next slide) • Furthermore, if non-behaviorist approach (theory) is utilized (as is the case in our program), corresponding (non-behaviorist) methods may be used – in the case of 17th competency, the format of Reflective Journaling • As a form of self-examination leading to construction of new meaning/concepts and their application to practice, RJ is a teaching method • Fellow must share RJ entries to formulate and discuss reflections (analyze and synthesize feelings, clinical challenges and learning opportunities) c/w constructivist learning theory • When the entries are discussed with faculty and peers, the discussion (selection of topics, insights, clarity and maturity of thoughts) becomes basis for evaluation

30. Step 6: Determine Evaluation MethodsAdapted from Holmboe et.al. Am J Med Aug 2006 p708-14

31. Step 6: Determine Evaluation Methods For the specific format of 17th competency evaluation please refer to: • (observation checklist #17) - form reproduced in the handout (direct observation) • global rating scale (360) – in the handout (foundational) • reflective journaling To review the evaluation process that we utilize, please refer to the handoutpalliative fellowship\Accreditation\#3 Cross-Table Comp vs Eval Method MARCH -07.doc • A section corresponding to single competency of the MC PMF comprehensive table of competencies is reproduced, along with: • the associated evaluation form (evaluation form #17) • and a schematic overview of the evaluative process

32. Putting it together Paste the data into: • http://www.acgme.org/outcome/e-learn/module4_CurriculumTemplate.doc Make sure that – following the integrative principle of curricular development - implementation occurs as planned Apply systematic curricular program evaluation for self-assessment and corrections Identify and state mandatory and secondary educational resources (textbooks, CBP, Web-based resources, seminars, development modules etc)