Transforming health care globally… through palliative care

www.PalliativeMed.org www.IPCRC.net

Challenges in Teaching Palliative Medicine

Frank D. Ferris, MD, FAAHPM, FAACEInstitute for Palliative Medicine

at San Diego HospiceUniversity of California San Diego

University of Toronto

Objective…A Road Map

to Build Palliative Care Capacity

in Sweden through education…

Call to Action…

Train ALL healthcare professionals

to provide palliative care…

Dixon 6: Goals of Education & Implementation

1. Awareness / Attitudes2. Knowledge3. Skills4. BehaviorChange Experience5. Patient / Family6. Organization / Society

Increase palliative care capacityDixon J. Evaluation and the Health Professions, 1978Ferris et al. Knowledge Insufficient for Change, 2001

How will you teach…?

How People Learn• Memory:

Short intermediate long-term• 3 major facts / hour• Information retention per unit time

10 minutes new information2 minutes rest to process it

Principles of Learning in Healthcare

• Practical• Participatory

• Multiple demands

Hank Slotnick, PhD, North Dakota

Reading / OnlineRetention ?

1. Awareness / Attitudes

2. Knowledge3. Skills4. Behavior

Change Experience5. Patient / Family6. Organization/Society

LecturesRetention ?

1. Awareness / Attitudes

Lectures 10 %2. Knowledge

3. Skills

4. BehaviorChange Experience

5. Patient / Family6. Organization/Society

Group LearningRetention ?

1. Awareness / Attitudes

Lectures 10 %2. Knowledge

Small-group Cases 25 %3. Skills

Role-play 35 %4. Behavior

Change Experience5. Patient / Family6. Organization/Society

Effective presentations‘ theater ’

• MovementBodyHands

• VoiceToneVolumeSpeed

• Eye contact• Minimize distractions

Who will you teach…?

1° Basic Skills

All HealthcareProfessionals

1°Advanced Skills

Cariology,Geriatrics,Oncology,

Etc.

2°Expert skills

Palliative CareConsultants /

Teams

3°Academic

Palliative Care

Palliative Care Skills...

Community

VolunteerSpiritual counselor

Nurse

Bereavementcounselor

Physicaltherapist

Pharmacist

Physician Psychologist

Socialworker

Family

PATIENT

Interdisciplinary Care

What will you teach…?

PC Skills...

1° Basic Skills

All HealthcareProfessionals

‘ Buzz ’ Groups• 1 – 2 • 1 – 2

General Doctors ?

1999

EPEC 1999• National consensus of 280 ethics,

hospice, palliative care expertsLinda Emanuel, Principal

Aim: To teach all physicians and other members of the interdisciplinary

team the core skills of palliative care

Not intended to make every clinician a palliative care expert

EPEC 1999

• 4 plenary sessions• 12 modules• Open, train-the-trainer model• Widely accepted• Standard of practice ‘ inside ’

First 15 Months in the USARobinson K, Sutton S, von Gunten CF

et al, J of Palliative Medicine 2004

• Sample 200 of first 585 trainers touched• 120,000 professionals in 15 months• Estimated patients & families affected

Per Clinician Per Clinician 585 CliniciansPatients / Day Patients / Year Patients / Year

10 2.4 K 1.4 M100 24 K 14 M

US Palliative Medicine Specialists

• > 3.000 certified specialists• 80 % started training with EPEC

End-of-LifeNursing

Education Consortium

Curriculum…

Nurses ?

ELNEC – Nursing Curricula, 2002

Oncology Version:

OpenAdaptable

Reproducible

Google:ELNEC

Palliative Care Skills...

1°Advanced Skills

Cariology,Geriatrics,Oncology,

Etc.

Doctors seeing Advance Illnesses ?

The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

Education in Palliative and End-of-life Care - Oncology

The

ProjectEPEC-OTM

2007

EPEC-O 2007

• National consensus of > 80 oncology experts

Aim: To teach all oncologists and other members of the

interdisciplinary cancer care team the advanced skills of palliative care

Not intended to make every oncologista palliative care expert

Multiple Issues that Cause Suffering

Core Skills for Providing Palliative Care

EPEC-O 2007

• 32 modules - 3 plenaries, 2 how to teachSyllabus, slides

Open, adaptableVideo vignettesTeaching strategiesAnnotated bibliographyHyperlinks to references online

2007 • Free CD / DVD• American Society

of Clinical Oncology ( ASCO ) provides education credits

• Online modules• Translations

SpanishUkrainian

• www.IPCRC.net

IPM Interdisciplinary

Curriculum

Will you translate any of these curricula ?

A multi-yeareducation strategy to build palliative care

capacity...

www.PalliativeMed.org www.IPCRC.net

Time ( yr ) 3 5 7 9 11

Sensitization

Courses ( Basic & Advanced )

Visiting Scholars ( Expert Identification )

Fellowships ( Experts )

Leadership ( Leaders )

Scholars in Residence ( Education & Research )

Nursing & Medical Trainees

Nursing students

• 9 schoolsUCSD Medical

studentsResidents

• Family practice

• Internal medicine

• Psychiatry

Experiential ‘ bedside training ’

• Observational visits• Structured program• Electives

PC in Curricula / Exams• In US Boards• In several specialty exams

10 % of Medical Oncology Exam

Physicians Practicingin San Diego

• 10 % trained at UCSD School of Medicine

• 33 % did their medical residency in San Diego

Practicing Clinicians• Continuing education – optional or

compulsory ?• In California

To get a new license, since 2002, obligatory to demonstrate training in palliative / end-of-life care

To renew license in 2006, 12 hours education in pain & palliative care ( AB 487 )

Conference Presentations• Oncology• Cardiology• Geriatrics• Elder Care• Nephrology

Many Domestic & International Partners

In-Country Courses 3-5 day, 2 & 3 week

2004 – Jordan 322005 – Jordan 722006 – Mongolia 752007 – Jordan 50

Georgia 50 Mexico 75

2008 – Georgia – 75 Vietnam 75 Saudi Arabia 150

2009 – Ukraine 95 Egypt 105 Slovenia 50

2010 – Ukraine 36 Salzburg 40 MECC 50

2011 – Georgia 75 Vietnam 100 Cyprus 55 Turkey 52

First dose of oral morphine – Al Basheer Hospital

1-week Classroom vs. 3-weeks Bedside Training

2 Open Society Institute ( OSI ) Courses, Salzburg

• 1 week ( 5 days )• Classroom

Interactive didactic

2 Jordan Courses, Amman, Jordan

• 3 weeks ( 15 days )• 1 week classroom

Interactive didactic• 2 weeks bedside

training

P < 0.001

P < 0.001

P < 0.001

Day 1 After Course

Day 1 After Course

Jordanian Physician…

“During the first week [ in the classroom ] I felt that I will not benefit… and it will not do any change in my practice.

BUT, after starting practical session a huge and unexpected change happened… I will do every efforts I have to practice this knowledge in my real life.”

1st International Palliative Medicine Physician