Development of a Clinical Fellowship Program in Palliative Medicine

Transcription

1 Vol. 20 No. 5 November 2000 Journal of Pain and Symptom Management 345 Special Article Development of a Clinical Fellowship Program in Palliative Medicine Susan B. LeGrand, MD, Declan Walsh, MD, Kristine Nelson, MD, and Donna S. Zhukovsky, MD Palliative Medicine Program (S.B.L., D.W., K.N.), Cleveland Clinic Foundation, Cleveland, OH, USA; and Department of Symptom Control and Palliative Care (D.S.Z.), The University of Texas, MD Anderson Cancer Center, Houston, TX, USA Abstract There has been growing interest in the United States in postgraduate training in palliative medicine. In order for this to proceed in an organized fashion, educational standards need to be developed. We must define what our knowledge base is and what we require of a specialtytrained individual. This article reports the development of the first fellowship program in the United States, with the goal of encouraging further discussion and ultimately obtaining specialty recognition. J Pain Symptom Manage 2000;20: U.S. Cancer Pain Relief Committee, Key Words Palliative medicine, clinical fellowship, postgraduate training Introduction In 1987, the Palliative Medicine Program (PMP) was established at the Cleveland Clinic. The PMP began as a consultation service with a full-time physician, clinical nurse specialist, and part-time social worker. The program expanded to become the first comprehensive service of its kind in the United States providing clinical services, research, and educational activities. 1 It was designated a World Health Organization (WHO) Demonstration Project in The inpatient Harry R. Horvitz Center opened in Address reprint requests to: Susan B. LeGrand, MD, Director, Palliative Medicine Fellowship Program, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland OH The Palliative Medicine Program at the Cleveland Clinic Foundation is a World Health Organization Demonstration Project. Accepted for publication: December 13, The Palliative Medicine Program is part of the larger Department of Hematology and Oncology and the Taussig Cancer Center. It currently has four full-time attending staff and a full-time research consultant. It consists of an inpatient service the Harry R. Horvitz Center, consult service, outpatient clinics, home care, and the Hospice of the Cleveland Clinic. In 1998, the program saw 846 consults, had 708 inpatient admissions, and had 833 hospice admissions. The Hospice daily census averages patients. As a WHO demonstration project the PMP is host to visitors from other institutions in the United States and worldwide. In addition, the Roxane Scholars Program in Palliative Medicine (supported by Roxane Laboratories, Columbus, Ohio) allows interested individuals to visit for 1 2 weeks. These visitors contribute to the educational environment. The program also has two annual Visiting Professor lecturers and organizes two Palliative Medicine conferences each year. U.S. Cancer Pain Relief Committee, /00/$ see front matter Published by Elsevier, New York, New York PII S (00)

2 346 LeGrand et al. Vol. 20 No. 5 November 2000 The Cleveland Clinic Foundation is a national leader in postgraduate medical education. There are currently 56 approved residency/fellowship training programs and 67 non-accreditation Council on Graduate Medical Education (ACGME) approved programs, with approximately 740 residents and fellows in training. In 1997, the Foundation had 419 medical students from 55 medical schools complete 533 rotations. The Foundation has a commitment to postgraduate training and, until recently, had absorbed the full cost of the non-acgme programs. For the past year and the foreseeable future, each department has assumed 50% of the cost of salary and benefits for fellows in these programs. As the PMP grew, it was felt appropriate to begin a fellowship in Palliative Medicine. At the time, no formal training was available in the United States. The program submitted the initial application for a fellowship position to the Cleveland Clinic Foundation in June 1988, less than two years after the Palliative Medicine program began. The first fellow was accepted in July A second position was added in 1992, and a third in Of the ten fellows who have completed the program, four are in an academic practice of palliative medicine, three are in general medicine, one is involved in pharmaceutical research, and two are unknown. Their credentials have been readily accepted. There have been numerous articles published in recent years addressing the educational needs of medical students, residents, and practicing physicians in palliative medicine. However, in a recent Medline search ( ), nothing was found on fellowship training in this area in the United States. This is a report on the development of the clinical fellowship program in Palliative Medicine at the Cleveland Clinic Foundation in the past 10 years. Program Goals The goal of this fellowship is to educate physicians to cope with the complex issues that occur in those with life-threatening disease. They must be: 1) prepared to deal with multiple physical and psychological symptoms or complications; 2) skilled at communication and decision-making in advanced disease; 3) able to integrate complex clinical information; 4) knowledgeable of psychosocial issues; and 5) competent in terminal care. They must become skilled communicators not only with patients and families but also with other professionals. They must be sensitive to team dynamics, effective in team meetings, and able to design and implement a flexible treatment plan. They will hopefully become the educators and researchers of the future, as well as improving the symptom care quality of life and overall management of the patients they personally encounter. Application Process Eligibility Fellow applicants must have completed an ACGME-approved residency and be board eligible or certified in their field. The goal of the application and interview process is to identify emotionally mature individuals interested in clinical or educational careers in Palliative Medicine or Hospice. In this country, cancer patients have been the primary recipients of palliative care and initial thought was given to requiring prior oncology training. The decision was made to open the program to any interested physician who had completed an approved residency. Applicants have come from Internal Medicine, Family Practice, Anesthesiology, Hematology/Oncology, and Gynecology. Foreign medical graduates must have completed the U.S. Medical Licensing Examination (USMLE). As the field of palliative medicine has grown, the number of applicants for each position has increased. Currently we receive two to three applicants for each position. Interviews Interested individuals are sent an information packet (Table 1). Appropriate applicants are then offered an opportunity to visit the program for a day of interviews. The interview process is designed to: 1) determine their medical interests; 2) evaluate their personal capabilities; and 3) educate the applicant on the difficulties inherent in the field. Applicants meet with all attending staff and with some support staff including Social Work, Nursing, and Physician Assistants. It is important to understand what led an individual to pursue this field. Each applicant is rated on a 1 5 scale. They are specifically rated on: 1) education, 2) training, 3) relevant work experience, 4) inter-

3 Vol. 20 No. 5 November 2000 Palliative Medicine Fellowship Program 347 Table 1 Orientation I. The philosophy of palliative medicine A. History of palliative medicine/hospice B. History of CCF program C. Structure of CCF program/policies/procedures II. Ethics III. Principles of symptom control IV. Symptom assessment and recording V. Review of opioid pharmacology A. Preferred drugs B. Pharmacokinetics in the elderly; renal and hepatic failure C. Alternative routes of administration D. Pharmacoeconomics VI. Important drugs in palliative medicine VII. Communication Skills A. Communication with patients/families B. Communication with colleagues VIII. Decision-making A. Balancing risks and benefits B. Deciding what is reasonable C. Determining prognosis IX. Care of the dying X. Current research protocols CCF Cleveland Clinic Foundation est demonstrated, 5) communication skills, 6) interpersonal skills, 7) teamwork, 8) flexibility, 9) maturity, and 10) overall ability. Interviewers are also asked to recommend hiring Yes, No, or Undecided. Depending on the response, applicants may be offered positions after the first interview, declined offers, or offered a second series of interviews. With the interviews for 1999 positions, attendance at morning report and rounds (see below) has been added to the interview day to facilitate more indepth exposure to the program for the applicant and more prolonged contact with the staff. Fig. 1. Palliative medicine program organization. Program Structure The structure of the PMP is based on the multidisciplinary team integral to effective management of this complex population. Fellows are expected to become active members of the team and relate to other members in a professional manner. The fellowship positions are for one year with an opportunity to renew. Two years is encouraged for all but the most experienced practitioner. The program is organized into three separate services (Figure 1). Fellows rotate in four-week blocks and attendings by calendar month. This preserves continuity of care, as involved physicians do not change at the same time. Inpatient Service The most intense experience is the inpatient service on the 23-bed Horvitz Center. Fellows and attending staff round seven days a week to ensure continuity of care. The unit provides symptom control, management of complications of advanced disease, as well as end-of-life care. The inpatient team consists of bedside nurses, nurse clinician, physician s assistant (PA), social worker, fellow and attending staff. Complementary services such as music therapy and pastoral care are available by consultation. All inpatients have an assigned PA responsible for routine management under the supervision of the fellow who in turn is supervised by the attending. The fellow is responsible for interacting with the social worker in some of the family conferences that are done for each new patient on the program. Night and weekend call on the inpatient service is by a senior internal medicine resident with backup by telephone from the fellow and the attending staff physician. Consults The inpatient consult service is coordinated by the close interaction of the fellow, the nurse clinician, and the attending. Consults are predominantly from Hematology/Oncology (30%) or Radiation Oncology (30%). The fellow is responsible for developing a detailed problem list that outlines ongoing symptom concerns as well as past history, co-morbid complications, and medical problems. An initial consultation is dictated using a standardized format as well as a written note. After discussion with staff, either recommendations will be made or orders

4 348 LeGrand et al. Vol. 20 No. 5 November 2000 written depending on the preferences of the referring physician. Often patients will be transferred to the Horvitz Center. Other patients are followed on the consult service until discharge. Consult patients may also have family meetings similar to those on the Horvitz Center. These may be conducted by the nurse clinician, fellow, and/or the primary service with the nurse clinician present to assist. When appropriate, discharge plans include follow-up in the Palliative Medicine outpatient clinic. Clinic/Hospice The outpatient clinic and Hospice service is the third rotation. On this service fellows see all new outpatient consults in the clinic, as well as any urgent consults from other clinics such as Radiation Oncology. Problem lists and dictation of consults are done as on the inpatient consult service. Clinic. Outpatient clinic is in the afternoon five days a week. Nonemergent consults are usually seen here. The nurse clinician and the clinic fellow see new consults prior to staff presentation. In the past, fellows had little opportunity for continuity of care since they did not have patients of their own. Beginning July 1999, fellows began having their own clinic slots to allow follow-up for patients they have cared for on any of the three rotations. Hospice. Fellows participate in the weekly Hospice interdisciplinary team (IDT) meetings with the Hospice service attending. Attendance at these meetings includes 1) the hospice nurses, 2) the Palliative Medicine nurse clinician, 3) social work, 4) pastoral care, and 5) music and art therapy. All new hospice admissions, deaths, re-certifications and any hospital or Emergency Room admissions are discussed. The plan of care for each patient is reviewed and 50% of the patient census is discussed each week. Patients with symptom control issues or complications who are not physically capable of a clinic visit are identified for home visits. Home Visits. The program goal is weekly home visits for fellows on this service. They make the visit accompanied by the assigned hospice nurse and document their findings for the medical record. Since there is no direct attending supervision, these visits are not billed to insurance carriers. In the future they may also make rounds with an attending at the inpatient hospice facility located off-campus. Educational Activities Morning Report The educational week begins with the weekly Monday morning interdisciplinary team meeting reviewing the clinical activities of the entire previous week. The one-hour meeting is chaired by the Horvitz Center Attending staff and attended by all staff, fellows, PAs, research fellows, social workers, hospice referral nurses, nursing managers (or assistants) and Palliative Medicine nurse clinicians. The discussion includes 1) the outcome (i.e., transfer, discharge, etc.) of any consults and their followup plans; 2) the status of any patients currently in skilled facilities or inpatient hospice; 3) the occurrence or anticipation of any family problems with recent deaths; 4) any patients at high risk for medication or social problems on call; and 5) the status of current research protocols. During the rest of the week the daily thirtyminute morning report discusses 1) all inpatients, 2) current consults, 3) any new outpatient or inpatient consults, 4) on call contacts and 5) any deaths from the previous day. Fellows present each patient and discharge plans are discussed. Teaching Conferences Staff Teaching. One attending each month is designated as the teaching staff for palliative medicine and is responsible for a thirty-minute educational presentation each week. While these are specifically for the fellows, attendance by PAs, social work, and nursing is encouraged. More formal presentations are given often with invited speakers from within the Cleveland Clinic at the weekly Palliative Medicine Grand Rounds. All program participants, including all hospice staff, attend. Fellows also are encouraged to attend Hematology/Oncology Grand Rounds each week. Grand Rounds in other specialties, particularly Internal Medicine, are also available for interested fellows. Fellow Teaching. The clinic and consult fellows prepare a presentation of their choice each week for the team, based on subjects relevant to

5 Vol. 20 No. 5 November 2000 Palliative Medicine Fellowship Program 349 palliative medicine. The presentation typically is stimulated by a case or a journal article. These are half-hour formal presentations, which also help to develop presentation skills. We envision our fellows becoming the educators in this field in their given communities and want them to be comfortable in this setting. Specific instruction and critique is given on presentation style and slide/overhead preparation. Psychosocial Rounds. These are held weekly and chaired by the Horvitz Center social worker. They may include discussion of a particularly difficult family/social situation or specific relevant topics. If the patient/family discussed is active in hospice then their nurse and social worker are encouraged to attend. Case Conference. Each week the Horvitz Center fellow presents a case chosen from the inpatient service for discussion. This meeting is chaired by the Fellowship Program Director and has two main goals: 1) To encourage the fellow to synthesize a case into several priority problems and to develop an independent plan for each. 2) To encourage the development of consistent patterns of care for specific problems. Research Conference. Weekly research conferences are held at noon Friday and chaired by the Research Director. At these meetings individuals interested in writing protocols will present ideas and discuss protocol structure, endpoints, design, etc. At other times, specific topics related to research methodology are presented. Quarterly, all articles in various stages of preparation and protocols in progress are reviewed to ensure they are progressing appropriately. Other Conferences. In addition to the regular weekly educational activities, each year there are Visiting Professor lectures. There are innumerable additional conferences on various subjects offered by the Cleveland Clinic that are also available to our fellows. The PMP offers two conferences each year a nursing conference in the Fall and a physician-oriented conference in Spring. Fellows are encouraged to present and attend. Electives. Fellows are encouraged to use elective time to explore specific additional relevant areas of interest. The goal is at least one, preferably two, elective months during the year. Suggested elective months include Anesthesia Pain Management and Liaison Psychiatry. Syllabus Orientation Because fellows come from varied backgrounds, it is important that they begin their training with a clear idea of what Palliative Medicine is and what it is not. Orientation prior to assuming patient care responsibilities would be ideal but is not possible. The initial orientation (Table 1) is usually accomplished with daily intense sessions during July. A clear definition of Palliative Medicine, as it is used in the Cleveland Clinic Foundation, is important. The PMP definition refers to palliation as care appropriate throughout the life of an individual with life-threatening illness, not just at end-of-life. Fellows need to understand the essential multidisciplinary focus of palliative medicine and this is stressed throughout. The importance of patient and family perception of symptoms is introduced. Relevant ethical principles are discussed as well as the fellow s personal feelings about Do-Not-Resuscitate orders, withholding treatment, and death and dying. While it is assumed that all fellows are skilled at history taking and physical exam, the specifics of taking and recording a symptom history are reviewed. The standardized paperwork and dictation format helps facilitate this. These are to help structure thinking about and communication of complex issues. The fundamentals of good communication are stressed including how to discuss difficult subjects such as advanced directives and prognosis. The orientation to the program focuses on rapidly introducing the concepts that will be addressed in further detail throughout the year. The remainder of the orientation is spent reviewing principles of symptom control, including a detailed review of opioid pharmacology. Symptom and Complication Management A detailed knowledge of the management of symptoms and the complications of advanced disease is the focus of much of the didactic teaching. Within each symptom complex, fellows should be able to understand the pathophysiology, determine an appropriate differential diagnosis, and order an appropriate

6 350 LeGrand et al. Vol. 20 No. 5 November 2000 evaluation. Inherent in this teaching is an understanding of the decision making process in advanced disease. Fellows need to know how to decide when and what to do in different phases of a person s life. Pharmacologic and non-pharmacologic interventions can then be pursued. Fellows must learn prevention and management of any and all side effects of medications used in Palliative Medicine. They must be cognizant of the use of medications for more than one indication simultaneously. Disease-Specific Knowledge Because our fellows come from various backgrounds and must deal with patients from different specialty groups, it is important that they be exposed to basic information about certain common diseases. A working knowledge of the most common malignancies, their natural history, and common complications is needed. To effectively treat complications, knowledge of various cancer therapies hormone, chemotherapy, and radiation is needed. As the field expands to include patients with less clearly defined disease progression, knowledge of the treatment of end-stage congestive heart failure and chronic obstructive pulmonary disease is important. Fellows should be exposed to the symptom complexes associated with AIDS and the complications of the medications used. Palliative Medicine in the pediatric population is included in the curriculum although no pediatric patients are treated in the program at this time. Psychosocial Issues Palliative medicine is a multidisciplinary field and, therefore, fellows must be knowledgeable about psychosocial issues and skilled in interacting with other professional disciplines. Family conferences are critical and fellows have frequent opportunities to develop these skills. A guideline for the family conference has been developed and its use encouraged (Table 2). The curriculum also includes teaching on family dynamics in illness; cultural and religious differences in approach to lifethreatening illness; and bereavement for family, staff, and the individual. Fellows must be aware of the spiritual needs of patients and facilitate appropriate spiritual guidance. They should understand the role of ancillary staff, such as music therapy and art therapy, in helping patients and families prepare for major life changes. Cost Containment In this world of managed care, it is imperative that all fellows be aware of the difficult cost issues involved in caring for this population. This includes not only knowledge of the comparable costs of different medications but also how to use them most efficiently. Rational prescribing protocols are introduced and encouraged. Fellows learn appropriate use of inpatient time and the role of post-acute care home health services in facilitating discharge. This should always be done in a fashion that is sensitive to the needs of the family and the safety of the patient. Rehabilitation Maintenance of physical functioning is an important part of good Palliative Medicine. Fellows need to know the role of physical therapy, occupational therapy, speech therapy, and others not Table 2 Family Conference Agenda Physician Social Worker Nurse Diagnosis Assess family (needs/risks) How-to of care Extent of disease Identify resources Physical status Acuity of disease Emotional needs ADL Illness course Family concerns Emergencies Resuscitation status Complication risks Main symptoms Medications Discharge date Prognosis ADL activities of daily living

7 Vol. 20 No. 5 November 2000 Palliative Medicine Fellowship Program 351 only in recovery or maintenance of function but also in evaluating safety, evaluating the need for assistance devices, and caregiver training. Hospice Fellows need to be comfortable in discussing hospice with families and facilitate early referrals. They should be sensitive to the different needs of patients once in a hospice setting and tailor subsequent evaluation appropriately. Knowledge of current regulatory limitations and the effect of acute care admissions on hospice is important. Fellows must become comfortable with phone triage and decision making/management from nursing assessment in the field. Research The PMP is committed to research and therefore requires a research project of clinical fellows. It is important for professional development to be involved in a project that leads to an article for publication. Given their clinical duties, they are not expected to write a protocol but to participate with an attending in gathering data, analyzing data, and writing for publication. Previous fellows have published articles varying from case reports, 2 to prospective symptom reviews, 3 to controlled therapeutic trials. 4 Discussion Palliative medicine specialty training has a longer history outside the United States. In November 1987, the Royal Colleges of Physicians of both the United Kingdom and Ireland recognized Palliative Medicine as a medical specialty. It has been a recognized medical specialty in Australia and New Zealand since United Kingdom Model As in the PMP, doctors from many specialties General Practice, Oncology, Internal Medicine, and Anesthesiology are eligible for specialty training. This training is for 4 years, with one year of this period spent in specialties in which the physician has less experience and one year in research. Specialty training exists at the registrar and senior registrar level. 6 A Certificate of Completion of Specialist Training is given to those successfully completing the program. Australian Model The Royal Australian College of Physicians supervises specialty training in Palliative Medicine as a sub-specialty of Internal Medicine. The program is for three years, which includes six months of oncology training. In New Zealand, one year of oncology (which includes six months of radiation therapy), is required. 7 The Sydney Institute of Palliative Medicine also facilitates postgraduate training in Australia that can lead to specialty certification. Program length varies from 3 months to over 2 years with one-third of trainees planning a career in Palliative Medicine. To obtain certification, trainees must have completed three years of clinical experience plus months on a teaching hospital palliative care service. Experience in Oncology and HIV care is considered advantageous. 8 Canadian Model Canada has a long tradition of academic palliative medicine but until recently it was not a recognized specialty. Privately supported fellowship programs have existed in two centers Ottawa and Alberta. Effective July 1999, the Royal College of Physicians and the College of Family Physicians have jointly approved a one-year fellowship program leading to an accreditation of additional skills, but not certification, requiring formal examination. 9 Cleveland Clinic Model The Palliative Medicine program at the Cleveland Clinic has developed what we believe is a satisfactory model for clinical fellowship programs in this field in the United States. Accreditation of postgraduate medical education in the United States is by the ACGME. At present, Palliative Medicine is not a recognized specialty and therefore training is not ACGMEapproved. The American Board of Hospice and Palliative Medicine has established a board examination but it is not currently recognized by the American Board of Medical Specialties. Despite this, the Cleveland Clinic Foundation has been very supportive of this innovative program. Challenges One of the major problems encountered in developing this program is meeting the needs

8 352 LeGrand et al. Vol. 20 No. 5 November 2000 of fellows of varying ages with different levels of experience and training, and different backgrounds, both medical and cultural. The needs of a fellow who has just completed training in Internal Medicine or Family Practice will be quite different from those of an experienced Oncologist with years of private practice experience. Tailoring programs specifically to the needs of each individual creates service staffing problems and fairness issues. Future Goals In July 1999, videotaping of fellows in patient and family encounters will begin. It is hoped that this will facilitate improvement in communication skills that can be assessed and documented. Incorporating this within the existing schedule, finding the time to review tapes in a one-on-one fashion, and making this a routine is an immediate goal. Developing measurement protocols to assess progress is also planned. The ultimate goal of the PMP is to work with others to obtain ACGME approval for Palliative Medicine as a specialty. We must define what our knowledge base is and what we require of a specialty-trained individual. Fellows are encouraged to complete the certifying boards offered by the American Board of Hospice and Palliative Medicine in preparation for subsequent recognition. We also need to determine the appropriate length of the fellowship. Currently, our fellows are appointed for one year with an opportunity to renew, but as noted earlier, two years are encouraged. An active fellowship program in Palliative Medicine can also become a springboard and model for similar training programs for other health care professionals (i.e., nurses, social workers, etc.) wanting to specialize in this field. It can be an effective resource for training medical students and residents who have an opportunity to rotate on the service, as well as benefit from teachers skilled in these subjects. Currently, fellows in Hematology/Oncology, Gynecologic Oncology, and pain management, and residents in Radiation Oncology, rotate on the PMP. There are plans for including Internal Medicine and Family Practice residents in future. Third- and fourth-year rotations for medical students are also available. The PMP is committed to defining this field as more than just end-of-life care. Patients may be symptomatic from the time of diagnosis, 10,11 or may have significant symptoms caused by disease-specific therapy even if it is ultimately effective. Improving the quality of life of these patients should be one of our goals. To achieve this and to improve the care of those whose lives are shortened by disease we should train physicians in active management of symptoms and complications, education of others, and in the scientific research that will yield therapeutic improvements. References 1. Goldstein P, Walsh D, Horvitz LU. The Cleveland Clinic Foundation Harry R. Horvitz Palliative Care Center. Support Care Cancer 1996;4: Sharma S, Walsh TD. Management of symptomatic malignant ascites with diuretics. Two case reports and a review of the literature. J Pain Symptom Manage 1995;10(3): Donnelly S, Walsh TD. The symptoms of advanced cancer in 1000 patients: identification of clinical priorities by assessment of prevalence and severity. J Palliat Care 1995;11(1): Nelson K, Glare P, Walsh TD. Crossover study of subcutaneous and intravenous morphine given by continuous infusion for chronic severe pain in advanced cancer. J Pain Symptom Manage 1997;13(5): Seely JF, Scott JF, Mount BM. The need for specialized training programs in Palliative Medicine. Can Med Assoc J 1997;157(10): Doyle D. Palliative Medicine Training for Physicians. J Neurol 1997;[Suppl 4]:S26 S Turner K, Lickiss JN. Postgraduate training in palliative medicine: the experience of the Sydney Institute of Palliative Medicine. Palliat Med 1997;11: Scott JF, MacDonald N, Mount B. Palliative medicine education: Oxford textbook of medicine. Oxford Medical Publications, 1998: Personal communication, The Royal College of Physicians and Surgeons of Canada. Specific Standards of Accreditation for a one year program of added competence in Palliative Medicine. 10. Degner LF, Sloan JA. Symptom distress in newly diagnosed ambulatory cancer patients and as a predictor of survival in lung cancer. J Pain Symptom Manage 1995;10(6): Hopwood P, Stephens RJ. Symptoms at presentation for treatment in patients with lung cancer: implications for the evaluation of palliative treatment. Br J Cancer 1995;71(3):