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The Evolution of the Pioneering Palliative Care Center at Medical College of Wisconsin

2008; Wolters Kluwer; Volume: 30; Issue: 15 Linguagem: Inglês

10.1097/01.cot.0000335061.78875.ae

1548-4688

AMY ROTHMAN SCHONFELD,

Patient Dignity and Privacy

By the early 1990s, oncologist David E. Weissman, MD, had come to the realization that although many physicians involved in cancer care were well trained in the clinical aspects of patient care, such as chemotherapy and radiation therapy, many were deficient in providing symptom management, psychosocial support for patients or families, or dealing with end-of-life issues. His feeling was that physicians from many fields maintained attitudes that interfered with good patient care or did not have the communication skills needed to carry out difficult conversations with seriously ill patients or their families. At that time, the movement for palliative medicine was being advanced in Canada and Great Britain, but there were only a handful of programs in the United States. That is why, in 1993, Dr. Weissman founded one of the first academic palliative care programs in the United States, the Palliative Care Center at Medical College of Wisconsin.Figure. David: E. Weissman, MD: “In palliative medicine, what stands in the way of good patient care isn't so much knowledge deficits as issues about attitude. We focus on how to address these attitudes, whether in the classroom or at the bedside.”At first, the center offered only a small hospital-based consultation service run by Dr. Weissman and a nurse; by last year, the service had grown so that consultations were made on more than 720 new inpatients and 160 new outpatients. In addition, a specialized inpatient unit and an outpatient clinic have been added to augment the clinical service. The center has grown into a world-renowned innovative center combining clinical care, education, research, and community outreach. The center provides educational programs in palliative care for medical students and residents, and offers a one-year postgraduate fellowship. 6 Palliative Care Leadership Centers It has become a national resource for palliative medicine, being designated as one of six Palliative Care Leadership Centers (offering site visits, hands-on training, and technical assistance to other facilities wanting to establish or improve their palliative care services), and is the recipient of a grant to help other medical schools develop curricula and faculty trained in palliative medicine. Medical College of Wisconsin is one of the few medical schools that have a required classroom-based course in palliative medicine and medical ethics during the first two years. During the third year students begin clinical experience in palliative care, and fourth-year students take a one-month palliative medicine elective. “We start role-playing in the second year,” Dr. Weissman said. “Students are trained in giving bad news and in helping families define and achieve their goals.” The curriculum developed at MCW was deemed so successful that it recently was awarded a grant from the Robert Wood Johnson Foundation to help other medical schools implement similar programs. Through the Medical School Palliative Care Education Project, six medical schools were chosen out of 57 schools that applied to receive help from Dr. Weissman and his colleagues in developing programs in palliative care training for third- and fourth-year medical students. A second goal of the grant is to establish a faculty development program in palliative care at these schools, with the hope that the training will become self-sustaining. During a site visit, Dr. Weissman or one of his colleagues offers workshops on curriculum design and faculty development to about 20 interested faculty members. “We talk about the ‘hot-button’ issues—those issues that are hardest to teach,” he said. “For instance, in palliative medicine, what stands in the way of good patient care isn't so much knowledge deficits as issues about attitude. “For example, some physicians think that if they tell a patient they are going to die, the patient will just lose hope. Other physicians think if they give an opiate analgesic, that will accelerate death. We focus on how to address these attitudes, whether in the classroom or at the bedside. We also discuss how to engage learners who don't want to learn.” Although it is not a requirement, many interns and residents in internal medicine, oncology, family practice, and other programs take rotations in palliative medicine. An important goal is to improve communication skills, whether when delivering a poor prognosis or unfavorable test results, or discussing goals of care, do-not-resuscitate orders, or advance directives. Fellowship in Palliative Care In 2006, hospice and palliative medicine (HPM) was recognized as a medical specialty by the American Board of Medical Specialties. Those eligible for board certification must meet one of two criteria: completion of a fellowship in HPM or completing extensive clinical experience (800 hours of clinical involvement including at least two years and 100 hours of participation with a hospice or palliative care team, and active care of at least 50 terminally ill patients [25 for pediatrics]). After 2013, physicians will no longer be allowed to be “grandfathered” in. Physicians eligible for HPM certification must be sponsored by one of 10 participating boards: the American Boards of Internal Medicine, Anesthesiology, Emergency Medicine, Family Medicine, Obstetrics and Gynecology, Pediatrics, Physical Medicine and Rehabilitation, Psychiatry and Neurology, Radiology, and Surgery). The first Certificate of Added Qualifications (CAQ) exam is scheduled for this October. In 2002, MCW began offering fellowships in hospice and palliative medicine. Today, about 50 to 60 such fellowships are offered in the United States. Fellows usually come directly out of a residency or are physicians seeking mid-career change, said Dr. Weissman. Sean Marks, MD, the current fellow in palliative medicine at MCW, began the fellowship directly after completing a residency in internal medicine. “I was exposed to the field in medical school and residency, and I liked the approach to care it offered, especially in regard to symptom management and the focus on quality of life for patients with serious medical illnesses. I found the interactions with patients very rewarding,” he said, adding that one of his goals is to bring his training to medically underserved areas around the world. Fellowship training includes working as part of interdisciplinary teams in the hospital consultation service, hospital inpatient unit, palliative care outpatient clinic, residential hospice, and home hospice, with additional elective opportunities. Fellows attend a lecture series on a broad array of relevant topics (see box) and participate in journal clubs, present grand rounds, and teach medical students and residents. Fellows are taught about medications and alternative techniques (e.g., nerve block and radiation) to minimize pain or help patients cope. One-on-One Counseling Sessions A unique and helpful component of the program is the opportunity to attend hour-long one-on-one counseling sessions with Jo Weis, PhD, a psychologist who specializes in dealing with terminally ill patients and their families. During the sessions, Dr. Marks has the opportunity to discuss how to deal with distressed patients and angry family members, as well as difficult colleagues. “Dr. Weis has helped me gain perspective on emotional issues. The counseling provides me with a safe place to talk about patient interactions and help me when I feel emotionally tied to a patient who is suffering,” Dr. Marks said. Mindful that palliative medicine is a new specialty, Dr. Marks may have to build up a palliative care practice from scratch, and he is therefore also honing his skills in practice management. He plans to attend a workshop focusing on the business aspects of palliative medicine practice offered by the Center to Advance Palliative Care (CAPC) (www.capc.org), an organization that aims to provide health care professionals with the tools, training, and technical assistance necessary to initiate and sustain successful palliative care programs in hospitals and other health care settings.Figure: Sean Marks, MD (right), the current fellow in palliative medicine at Medical College of Wisconsin, says that one of his goals is to bring his training to medically underserved areas around the world. He is shown here with Jo Weis, PhD, a psychologist who counsels not only patients and family members but also staff members.CAPC also sponsors the Palliative Care Leadership Centers (PCLC) initiative, in which the six so-designated exemplary leadership institutions serve as training centers for hospitals and hospices, offering workshops and faculty mentoring. Providing comfort and symptom relief to those who are seriously ill clearly benefits patients and their families. It also benefits the hospitals' bottom line, Dr. Weissman said. “When you do palliative care work in hospitals, you help establish goals of where the patient and family want to be and what is going to be done medically. It turns out that if you do that well, it ends up saving the hospital a lot of money—by tending to shorten hospital lengths of stay and using fewer resources. There are actually cost savings in providing good patient care.” Palliative Care Fellowship Lecture Topics at Medical College of Wisconsin Prognostication Self-care and Burnout Pain Assessment and Management Syndrome of Imminent Death Hospice Rules and Regulations/Advance Directives Artificial Hydration and Nutrition Nausea/Vomiting/Constipation Introduction to Spirituality Grief and Bereavement Dyspnea and Secretions Communication Skills: Breaking Bad News, Family Conference Family Function and Dysfunction Delirium Depression Ethics/Palliative Sedation Developmental Stages and Grief in Children National Resource As part of its mission to advance hospice and palliative medicine as an academic field, Medical College of Wisconsin maintains the End of Life/Palliative Education Resource Center (EPERC). The Web site (www.EPERC.mcw.edu) is a trove of invaluable resources for health professionals and educators.