Transforming health care globally… through palliative care

Challenges in Teaching Palliative Medicine Frank D. Ferris, MD, FAAHPM, FAACE Institute for Palliative Medicine at San Diego Hospice University 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 / Attitudes 2.Knowledge 3.Skills 4.Behavior Change Experience 5.Patient / Family 6.Organization / Society Increase palliative care capacity Dixon J. Evaluation and the Health Professions, 1978 Ferris et al. Knowledge Insufficient for Change, 2001

How will you teach…?

How People Learn Memory: Short  intermediate  long-term Memory: Short  intermediate  long-term 3 major facts / hour 3 major facts / hour Information retention per unit time Information retention per unit time 10 minutes new information 2 minutes rest to process it

Principles of Learning in Healthcare Practical Practical Participatory Participatory Multiple demands Multiple demands Hank Slotnick, PhD, North Dakota

Reading / Online Retention ? 1.Awareness / Attitudes 2.Knowledge 3.Skills 4.Behavior Change Experience 5.Patient / Family 6.Organization/Society

Lectures Retention ? 1.Awareness / Attitudes Lectures 10 % 2.Knowledge 3.Skills 4.Behavior Change Experience 5.Patient / Family 6.Organization/Society

Group Learning Retention ? 1.Awareness / Attitudes Lectures 10 % 2.Knowledge Small-group Cases 25 % 3.Skills Role-play 35 % 4.Behavior Change Experience 5.Patient / Family 6.Organization/Society

Effective presentations ‘ theater ’ Movement MovementBodyHands Voice VoiceToneVolumeSpeed Eye contact Eye contact Minimize distractions Minimize distractions

Who will you teach…?

1° Basic Skills All Healthcare Professionals 1° Advanced Skills Cariology, Geriatrics, Oncology, Etc. 2° Expert skills Palliative Care Consultants / Teams 3° Academic Palliative Care Palliative Care Skills...

Community Volunteer Spiritual counselor Nurse Bereavement counselor Physical therapist Pharmacist Physician Psychologist Social worker Family PATIENT Interdisciplinary Care

What will you teach…?

PC Skills... 1° Basic Skills All Healthcare Professionals

‘ Buzz ’ Groups 1 – 2 1 – 2

General Doctors ?

1999

EPEC 1999 National consensus of 280 ethics, hospice, palliative care experts National consensus of 280 ethics, hospice, palliative care experts Linda 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 plenary sessions 4 plenary sessions 12 modules 12 modules Open, train-the-trainer model Open, train-the-trainer model Widely accepted Widely accepted Standard of practice ‘ inside ’ Standard of practice ‘ inside ’

First 15 Months in the USA Robinson K, Sutton S, von Gunten CF et al, J of Palliative Medicine 2004 Sample 200 of first 585 trainers touched Sample 200 of first 585 trainers touched 120,000 professionals in 15 months 120,000 professionals in 15 months Estimated patients & families affected Estimated patients & families affected Per Clinician 585 Clinicians Patients / DayPatients / Year K 1.4 M K14 M

US Palliative Medicine Specialists > certified specialists > certified specialists 80 % started training with EPEC 80 % started training with EPEC

End-of-Life Nursing Education Consortium Curriculum…

Nurses ?

ELNEC – Nursing Curricula, 2002 Oncology Version: Open AdaptableReproducible Google: ELNEC

Palliative Care Skills... 1° Advanced Skills Cariology, Geriatrics, Oncology, Etc.

Doctors seeing Advance Illnesses ?

The EPEC-O Curriculum is produced by the EPEC TM 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 Project EPEC-O TM 2007

EPEC-O 2007 National consensus of > 80 oncology experts 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 oncologist a palliative care expert

Multiple Issues that Cause Suffering

Core Skills for Providing Palliative Care

EPEC-O modules - 3 plenaries, 2 how to teach 32 modules - 3 plenaries, 2 how to teach Syllabus, slides Open, adaptable Video vignettes Teaching strategies Annotated bibliography Hyperlinks to references online

2007 Free CD / DVD Free CD / DVD American Society of Clinical Oncology ( ASCO ) provides education credits American Society of Clinical Oncology ( ASCO ) provides education credits Online modules Online modules Translations TranslationsSpanishUkrainian

IPM Interdisciplinary Curriculum Will you translate any of these curricula ?

A multi-year education strategy to build palliative care capacity

Time ( yr )  Sensitization Courses ( Basic & Advanced ) Visiting Scholars ( Expert Identification ) Fellowships ( Experts ) Leadership ( Leaders ) Scholars in Residence ( Education & Research )

Nursing & Medical Trainees Nursing students 9 schools 9 schools UCSD Medical students Residents Family practice Family practice Internal medicine Internal medicine Psychiatry Psychiatry Experiential ‘ bedside training ’ Observational visits Observational visits Structured program Structured program Electives Electives

PC in Curricula / Exams In US Boards In US Boards In several specialty exams In several specialty exams 10 % of Medical Oncology Exam

Physicians Practicing in San Diego 10 % trained at UCSD School of Medicine 33 % did their medical residency in San Diego

Practicing Clinicians Continuing education – optional or compulsory ? Continuing education – optional or compulsory ? In California 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 Oncology Cardiology Cardiology Geriatrics Geriatrics Elder Care Elder Care Nephrology Nephrology

Many Domestic & International Partners

In-Country Courses 3-5 day, 2 & 3 week 2004 – Jordan – Jordan – Mongolia – Jordan 50 Georgia 50 Georgia 50 Mexico 75 Mexico – Georgia – 75 Vietnam 75 Vietnam 75 Saudi Arabia 150 Saudi Arabia – Ukraine 95 Egypt 105 Egypt 105 Slovenia 50 Slovenia – Ukraine 36 Salzburg 40 Salzburg 40 MECC 50 MECC – Georgia 75 Vietnam 100 Vietnam 100 Cyprus 55 Cyprus 55 Turkey 52 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 ) 1 week ( 5 days ) Classroom Classroom Interactive didactic 2 Jordan Courses, Amman, Jordan 3 weeks ( 15 days ) 3 weeks ( 15 days ) 1 week classroom 1 week classroom Interactive didactic 2 weeks bedside training 2 weeks bedside training

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