Ambulatory Care

OVERVIEW

The out-patient sub-specialty palliative medicine clinic experience takes place at the VA Palo Alto Health Care System. This weekly half day clinic meeting on Monday morning year long and fellows rotate through this clinic during their inpatient consult team block rotations and during their elective rotations. During this rotation the fellow, under the direct supervision of the attending physician, will be exposed to and have the unique opportunity to care for a cohort of ambulatory palliative care patients at various stages in the trajectory of their illnesses. Approximately 75-150 new patients are seen every year with a total of 250-300 ambulatory care visits.
There are two primary goals to this rotation:

  1. To familiarize the fellow with Hospice and Palliative Medicine (HPM) as it is provided in a out-patient clinic setting and
  2. To familiarize the fellow with administration and operational aspects of working in a out-patient setting.
ACGME DOMAINS

Patient Care

  • Goals
    The fellow must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows are expected to:
  • Competencies
    1. Review the specific reason(s) for consultation, conduct an appropriate review of the available medical records, and perform a systematic history and physical examination relevant to the palliative medicine clinic setting.
    2. Formulate an appropriate care plan and make recommendations regarding the palliative aspects of patient management (addressing bio-psycho-social aspects of care), schedule appropriate tests and follow-up, connect with referring physician as appropriate and document detailed consult notes in the medical chart.
  • Objectives
    1. The fellow will provide sub-specialty palliative care consultant services in an out-patient setting.
    2. The fellow will present assessments made and suggestions for the care plan to the supervising attending physician and, when appropriate, to the care team.

Medical Knowledge

  • Goals
    Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care in an out-patient setting. Fellows are expected to:
  • Competencies
    1. To learn to devise effective patient-centered strategies that comprehensively evaluate and manage the medical, functional, and social issues in the outpatient setting.
    2. Demonstrate an understanding of both the limitations and opportunities for the provision of palliative care in an out-patient setting, including both assessment and the use of therapeutics. Particular attention should be paid to medication choices, balancing therapeutic efficacy and ease of administration (with special attention to polypharmacy) in the home.
    3. Demonstrate an understanding of assessing initial as well as ongoing eligibility for hospice care for a variety of disease processes.
  • Objectives
    1. Recommendations for both assessment and therapy made by the fellow will reflect an understanding and appreciation for feasibility in the home setting.
    2. The fellow will assess patients evaluated and presented in terms of prognosis and hospice eligibility to the clinic attending and, when appropriate, the care team.

Problem-Based Learning & Improvement (PBLI)

  • Goals
    Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Fellows are expected to develop skills and habits to be able to:
  • Competencies
    1. Set learning and improvement goals.
    2. Participate in the education of patients’ families, and other health care professionals during clinic visits as documented in the patients’ medical chart.
  • Objectives
    The fellow will be observed by the supervising physician engaging in the education of patients, families, students or other health professionals at least once during the longitudinal yearlong clinic experience.

Interpersonal & Communication

  • Goals
    Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Fellows are expected to:
  • Competencies
    1. Communicate effectively with referring physicians, other health professionals, and health related agencies.
    2. Act in a consultative role to other physicians and health professionals.
  • Objectives
    The fellow will communicate assessments and recommendation to others involved in care of the clinic patient and her/his family as well as the consulting physicians in a manner that is clear and respectful of their relative responsibilities and duties relative to the patient.

Professionalism

  • Goals
    Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Fellows are expected to demonstrate:
  • Competencies
    1. Demonstrate responsiveness to patient needs that supersedes self-interest.
    2. Demonstrate sensitivity and responsiveness to a diverse clinic patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
  • Objectives
    1. The fellow will respond promptly to requests for a home evaluation or for consultation (provided under direction of the supervising physician) with hospice staff.
    2. The fellow will demonstrate sensitivity to various patients’ differing responses and coping strategies as they progress through the illness experience and transition (at various speeds and with various levels of acceptance) from heroic life prolonging curative measures of care to palliative goals of care.

System-Based Practice (SBP)

  • Goals
    Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Fellows are expected to:
  • Competencies
    1. Work effectively in various health care delivery settings and systems relevant to their clinical specialty.
    2. Incorporate considerations of cost awareness and risk-benefit analysis in patient care.
  • Objectives
    1. The fellow will demonstrate an ability to work effectively in a clinic setting as evidenced by collegial interactions with clinic staff and referring physicians.
    2. Recommendations for diagnostic procedures and therapeutics will reflect a thoughtful weighing of risk and benefit for out-patients who may be concurrently receiving both curative and palliative care.
TEACHING METHODS

The primary vehicle for learning during this rotation will be through the direct provision of care under supervision by the clinic attending. This experiential learning will be supplemented by:

  1. Formal weekly fellowship didactic sessions.
  2. Ad hoc instruction by the supervising clinic attending in the context of weekly clinics, which may include but is not limited to mini-didactic sessions, formal and in-formal case-presentations.
  3. Direct observation of clinical care modeled by the clinic attending.
  4. Directed reading, both self-directed and reading as suggested by the clinic attending. In such reading the emphasis will be on reviewing literature that discusses the evidence base for care options as relate to issues specific to out-patients who are receiving curative and/or palliative therapy.
LEVEL OF SUPERVISION
  • Direct observation by the clinic attending when providing care in clinic.
  • Each patient is presented to the clinic attending who sees the patient in conjunction with the fellow.
ASSESSMENT METHODS

Initial meeting to determine training goals:

The fellow will have an initial meeting with the clinic attending during which both clinic related programmatic competency goals and self-directed learner goals will be discussed.

End-of-rotation de-brief (formative feedback and block rotation evaluation):

The supervising attending will meet with the fellow every six months to provide formative and summative feedback, review the evaluation form with the fellow, and discuss to what extent programmatic and self-directed learning goals were obtained. During this feedback session the clinic attending will solicit feedback regarding the clinic experience.

Fellow evaluation process and follow-up:

Once every six months, Med Hub sends an automated reminder to the clinic attending to evaluate the fellow (using a global rating scale). Evaluations are captured and collated by the system and aggregate data for individual fellows across various block rotations is available to the program director and will be used for both formative and summative fellow evaluation. When a fellow receives a sub-par evaluation on the clinic rotation an automated trigger will send an alert to the program director who will immediately take necessary remedial action as appropriate.

Specific evaluation methods used in this longitudinal (six months) out-patient rotation are:

Direct observation: Fellow competency in will be evaluated using direct observation during patient care, and the results of direct questioning during clinical care. Fellows will be observed by faculty during a clinical interaction and their skills will be evaluated by faculty using global rating scales. The supervising attending will directly observe the fellow performing at least one major patient care intervention such as a “goals of care” discussion during the clinic experience.

Global rating scales:

Stanford has a Med Hub online evaluation system which is specifically designed to evaluate fellows and faculty using a survey questions with ordinal responses.