EXPERIENCE BASED CURRICULUM TO EXPERIENCE BASED CURRICULUM TO ACHIEVE COMPETENCE IN ACHIEVE COMPETENCE IN

PALLIATIVE MEDICINEPALLIATIVE MEDICINE

RODNEY TUCKER, MDRODNEY TUCKER, MD

PALLIATIVE MEDICINE FELLOWSHIP DIRECTORPALLIATIVE MEDICINE FELLOWSHIP DIRECTOR

UAB CENTER FOR PALLIATIVE CAREUAB CENTER FOR PALLIATIVE CARE

OBJECTIVESOBJECTIVES

Introduce the evolved process of Introduce the evolved process of developing a traditional experience-based developing a traditional experience-based curriculum to achieve competence in curriculum to achieve competence in palliative medicinepalliative medicine

Review a tailored training sequence for a Review a tailored training sequence for a 12 month fellowship emphasizing 12 month fellowship emphasizing increasing autonomyincreasing autonomy

Description of UAB site specific rotations Description of UAB site specific rotations and subsequent assessment methodsand subsequent assessment methods

Future challengesFuture challenges

History of the UAB PMFTPHistory of the UAB PMFTP

First fellow completed training in 2000First fellow completed training in 2000 Currently training 9Currently training 9thth and 10 and 10thth fellows fellows 100% ABHPM pass rate (6/8 have taken)100% ABHPM pass rate (6/8 have taken) 9/10 faculty are ABHPM certified (6/10 9/10 faculty are ABHPM certified (6/10

faculty also boarded in Geriatrics)faculty also boarded in Geriatrics) Received 2 year AAHPM and NHF award Received 2 year AAHPM and NHF award

in 2005in 2005 ABHPM voluntary accred in 2006ABHPM voluntary accred in 2006

Palliative Care SectionPalliative Care Section

Christine Ritchie, MDChristine Ritchie, MD Director of Center for Director of Center for

Palliative CarePalliative Care Rodney Tucker, MDRodney Tucker, MD

Medical Director- UAB Medical Director- UAB PM ProgramsPM Programs

Amos Bailey, MDAmos Bailey, MD Medical Director- Medical Director-

BVAMC Safe HarborBVAMC Safe Harbor Elizabeth Kvale, MDElizabeth Kvale, MD

Out-patient Medical Out-patient Medical DirectorDirector

Cynthia Baker, MDCynthia Baker, MD Charlotte Williams, MDCharlotte Williams, MD Carol Griffin, MDCarol Griffin, MD Tracey Humbert, MDTracey Humbert, MD Sandra Broeren, MDSandra Broeren, MD Heather Herrington, Heather Herrington,

MDMD

Experience Based- What does Experience Based- What does that mean to us?that mean to us?

Rotational, didactic, and special Rotational, didactic, and special seminars designed to expose fellows seminars designed to expose fellows to a wide variety and mixture of to a wide variety and mixture of clinical and classroom experiences clinical and classroom experiences necessary to achieve competence in necessary to achieve competence in palliative medicine domainspalliative medicine domains

STEP ONESTEP ONE

Determine core experiences Determine core experiences to provide clinical to provide clinical

opportunities for training opportunities for training purposespurposes

Rotational experiencesRotational experiences

In-patient PM In-patient PM consultationconsultation UAB PM Consult UAB PM Consult

ServiceService BVAMC PM Consult BVAMC PM Consult

ServiceService Children’s Hospital Children’s Hospital

of Alabama PM of Alabama PM consultationconsultation

In-patient careIn-patient care UAB Palliative and UAB Palliative and

Comfort Care UnitComfort Care Unit BVAMC Safe Harbor BVAMC Safe Harbor

UnitUnit

6-8 months per 6-8 months per yearyear

Interdisciplinary Interdisciplinary team focusteam focus

Rotational Experiences Rotational Experiences

Out-patient Out-patient Continuity clinics Continuity clinics (Average one clinic (Average one clinic per week)per week) UAB Supportive and UAB Supportive and

Palliative Care ClinicPalliative Care Clinic 2 sessions per month2 sessions per month

UAB HIV/AIDS UAB HIV/AIDS Treatment ClinicTreatment Clinic

2 sessions per month2 sessions per month

BVAMC clinic BVAMC clinic consultation serviceconsultation service

12 months continuity 12 months continuity experienceexperience

Development of own Development of own patient populationpatient population

Multi-disciplinary Multi-disciplinary teamteam

Rotational ExperiencesRotational Experiences

Out-patient/ Home Hospice Out-patient/ Home Hospice Community Based Hospice Organizations Community Based Hospice Organizations

with educational agreementswith educational agreements 2-3 months/year- Focused rotation2-3 months/year- Focused rotation Ongoing Hospice Patient management Ongoing Hospice Patient management

by fellows with 12 month continuityby fellows with 12 month continuity IDT focusIDT focus Majority observed home visits done Majority observed home visits done

during these monthsduring these months

Rotational ExperiencesRotational Experiences

Pain management rotationPain management rotation Out-patient and in-patient interventional Out-patient and in-patient interventional

focusfocus 1 month per year1 month per year Undisciplinary with some IDT component Undisciplinary with some IDT component

in out-patient sectionin out-patient section

Rotational ExperiencesRotational Experiences

ElectiveElective Fellow specific depending on area of Fellow specific depending on area of

interestinterest Can be Heme/Onc consult, Geriatric Can be Heme/Onc consult, Geriatric

Psychiatry, long term care setting, Psychiatry, long term care setting, Neurology, clinical visitorship to another Neurology, clinical visitorship to another institution, research and writing, etc.institution, research and writing, etc.

Specific career objectivesSpecific career objectives One month/yearOne month/year

STEP TWOSTEP TWO

Determine core subject matter Determine core subject matter and format in which to cover topic and format in which to cover topic

areas in palliative medicine areas in palliative medicine knowledge domainknowledge domain

Core DidacticsCore Didactics

UNIPAC “Crash Course”- Covered by UNIPAC “Crash Course”- Covered by program director in July- Tuckerprogram director in July- Tucker

Classic article readings- Discussion lead by Classic article readings- Discussion lead by faculty and guestsfaculty and guests Once weekly/ led by Fordham, et alOnce weekly/ led by Fordham, et al

Directed readings- Assigned text readings Directed readings- Assigned text readings (Oxford and Palliative Care & Supportive (Oxford and Palliative Care & Supportive Oncology) and discussion with attendingsOncology) and discussion with attendings Once weekly/ led by Bailey, et alOnce weekly/ led by Bailey, et al

Core DidacticsCore Didactics

Fellows Case Conference- Case Fellows Case Conference- Case presentations with pertinent article centered presentations with pertinent article centered on symptom managment, ethics, or self careon symptom managment, ethics, or self care Once monthly, InterdisciplinaryOnce monthly, Interdisciplinary

Palliative Medicine Journal Club- Critical Palliative Medicine Journal Club- Critical review of current literature articles using review of current literature articles using standard review instruments (Consort, etc.)standard review instruments (Consort, etc.) Once monthly, casual setting- Led by Kvale, et alOnce monthly, casual setting- Led by Kvale, et al InterdisciplinaryInterdisciplinary

STEP THREESTEP THREE

Determine supplemental Determine supplemental activities to cover gaps or activities to cover gaps or

expanded topics in palliative expanded topics in palliative medicinemedicine

Palliative Care Research Palliative Care Research ForumForum

Discussion time for PM faculty, Discussion time for PM faculty, visitors, fellows, and other housestaff visitors, fellows, and other housestaff to discuss potential or ongoing to discuss potential or ongoing research topicsresearch topics Twice monthly, optional for palliative Twice monthly, optional for palliative

care fellowscare fellows MultidisciplinaryMultidisciplinary

Special SeminarsSpecial Seminars

2-3 hour focused 2-3 hour focused seminars/workshopseminars/workshopss

Mandatory Mandatory attendanceattendance

Topics:Topics: Communication Communication

Style Preference and Style Preference and How to AdaptHow to Adapt

Academic Academic Presentation SkillsPresentation Skills

Topics:Topics: Hospice Financing Hospice Financing

and Administrationand Administration Building the Case Building the Case

for a Palliative Care for a Palliative Care ProgramProgram

Research Funding Research Funding and Grants 101and Grants 101

Media Relations & Media Relations & AdvocacyAdvocacy

STEP FOURSTEP FOUR

Match each activity with Match each activity with ACGME Competency DomainACGME Competency Domain

Curriculum & Competency Curriculum & Competency Cross ChecklistCross Checklist

Matches each activity/topic/seminar Matches each activity/topic/seminar with ACGME competency domainwith ACGME competency domain

Defines global objectives for each Defines global objectives for each activityactivity

See attached exampleSee attached example

STEP FIVESTEP FIVE

Determine appropriate Determine appropriate training sequence progressiontraining sequence progression

Training Sequence for Training Sequence for progressive fellow autonomy progressive fellow autonomy

and responsibilityand responsibility See attached training sequenceSee attached training sequence Divided into three sections to assist in Divided into three sections to assist in

providing theoretical structure to training providing theoretical structure to training experienceexperience 11stst sequence: Months 1-2 (Observe and question) sequence: Months 1-2 (Observe and question) 22ndnd sequence: Months 3-6 (Observe, question, sequence: Months 3-6 (Observe, question,

initiate)initiate) 33rdrd sequence: Months 7-12 (Initiate, question, sequence: Months 7-12 (Initiate, question,

complete)complete) Reviewed with fellows at onset of program Reviewed with fellows at onset of program

and at each quarterly reviewand at each quarterly review

STEP SIXSTEP SIX

Determine and Refine Determine and Refine evaluation processes and evaluation processes and

assessment toolsassessment tools

Evaluation/Assessment Tools Evaluation/Assessment Tools Current statusCurrent status

Monthly fellowship & Monthly fellowship & education committee education committee meeting that reviews meeting that reviews fellow progressfellow progress

Monthly Preceptor Monthly Preceptor evals- All facultyevals- All faculty

Monthly Rotation evals- Monthly Rotation evals- All fellowsAll fellows

Quarterly Quarterly documentation review- documentation review- Program DirectorProgram Director

Seminar evalsSeminar evals Filmed media interviewFilmed media interview

Procedure logs for Procedure logs for home visits, IDT home visits, IDT leadership, first 25 leadership, first 25 consults and family consults and family meetings, vent meetings, vent withdrawals, palliative withdrawals, palliative sedation, paracentesissedation, paracentesis

In-service exam at 6 & In-service exam at 6 & 12 months12 months

Grand Rounds Grand Rounds presentation-Once yearpresentation-Once year

End of year global End of year global program evaluationprogram evaluation

STEP SEVENSTEP SEVEN

Pray that all this will satisfy Pray that all this will satisfy ACGME requirementsACGME requirements

Evaluations and Assessements Evaluations and Assessements for the futurefor the future

360 degree evaluation to include 360 degree evaluation to include members of IDTmembers of IDT

Direct observation exercise (CEX)Direct observation exercise (CEX) Filmed mock patientFilmed mock patient Selection of two assessment Selection of two assessment

methods for each domainmethods for each domain