Education and Palliative Care: A challenge for all disciplines Jim Hallenbeck, MD Kelley Skeff, MD, PhD.

Working Assumptions Historically, education focused on end-of- life (or palliative care) has been inadequate relative to need Historically, education focused on end-of- life (or palliative care) has been inadequate relative to need Educational deficiencies not just physician issues Educational deficiencies not just physician issues  Also problems for nurses, social workers, psychologists, chaplains and pharmacists

Evidence Base Physicians: Of 27 interns interviewed on Hospice rotation, only 1/27 recalled learning anything about pain in Med School* Physicians: Of 27 interns interviewed on Hospice rotation, only 1/27 recalled learning anything about pain in Med School* Nurses: Of over 5000 pages of nursing textbook pages reviewed, constipation addressed on only 12 pages ** Nurses: Of over 5000 pages of nursing textbook pages reviewed, constipation addressed on only 12 pages ** *Hallenbeck, **Ferrell

Educational Domains Death and Dying in the USA Death and Dying in the USA Pain Management Pain Management Non-Pain Symptom Management Non-Pain Symptom Management Communication Communication Difficult Decisions Difficult Decisions Psychosocial/Spiritual Care Psychosocial/Spiritual Care Venues of Care, System Issues Venues of Care, System Issues SFDC ELC (End-of-Life) Course

Palliative Care Fellowship Educational Domains Death and Dying in Society Death and Dying in Society Physical symptoms Physical symptoms Communication Communication System Issues System Issues Ethics and Legal Issues Ethics and Legal Issues Interprofessional Care Interprofessional Care Spirituality/Meaning Spirituality/Meaning Education Education Children and Palliative Care Children and Palliative Care Research methodology Research methodology

Barriers to Improved Education Educational Inertia – ‘we’ve always done it this way’ Educational Inertia – ‘we’ve always done it this way’ Competing vested interests Competing vested interests Cultural biases Cultural biases  In world of Medicine  In society at large Arrogance/ignorance phenomenon Arrogance/ignorance phenomenon

Ignorance… Domain PGY 1 (n =1284) PGY 2 (n =980) PGY 3,4 (n =1076) Faculty (n =1711) Total Test Pain Non-pain Communicati on Terminal Care Mean % Correct Survey of Internal Medicine residents and faculty Weissman et al.

Arrogance Interns admitted knowledge and skill deficits and were concerned about their competency = TENSION Interns admitted knowledge and skill deficits and were concerned about their competency = TENSION Residents and faculty less concerned about ability to practice and teach palliative care Residents and faculty less concerned about ability to practice and teach palliative care Many faculty – What ME worry? Many faculty – What ME worry? Despite minimal differences in knowledge…

Like a battery… So where’s the tension in the learner?

Tension – Overt and Covert Overt tension – what people verbally identify as the problem Overt tension – what people verbally identify as the problem Covert tension – unspoken, sometimes unconscious tension Covert tension – unspoken, sometimes unconscious tension

Dealing with Tension When tension is overt When tension is overt  Learners open to learning new knowledge and skills When tension is covert When tension is covert  Attitude objectives are primary, especially –  Making covert tension overt

Good news Clinicians become clinicians for the right reasons – they want to help people Clinicians become clinicians for the right reasons – they want to help people Both clinicians and lay public are bothered by the current state of affairs in healthcare – i.e. tension exists for positive change Both clinicians and lay public are bothered by the current state of affairs in healthcare – i.e. tension exists for positive change Many new exiting educational opportunities for training in end-of-life care exist Many new exiting educational opportunities for training in end-of-life care exist

Educational Opportunities EPEC (educating physicians about end-of-life care) EPEC (educating physicians about end-of-life care) ELNEC (end-of-life nursing education consortium) ELNEC (end-of-life nursing education consortium) ELC (end-of-life care) Stanford course ELC (end-of-life care) Stanford course VA Palliative Care Network/Learning Center at: VA Palliative Care Network/Learning Center at:

A Canary in a Coal Mine Most of the important educational issues in end-of-life care are important in ‘non-end- of-life’ care Most of the important educational issues in end-of-life care are important in ‘non-end- of-life’ care  Comfort  Respect  Good Communication It is not just the imminently dying who wish to be as comfortable as possible in their illnesses and who wish to be treated with respect