Stanford Medicine Palliative Consult Service

Stanford Medicine Palliative Consult Service
OVERVIEW

The Stanford Hospital Palliative Care in-patient consult service provides consultation on acute in-patients in Stanford Hospital, a large academic teaching hospital that serves both as a local community hospital as well as a tertiary care center for the surrounding counties. During this rotation the fellow will work with an inter-disciplinary palliative care team in providing such consultation under the supervision of an attending hospice and palliative medicine physician. Over 100 new patients are seen each month. This rotation provides HPM fellows with ample opportunity to deliver medical care for palliative care patients of both genders from a diverse milieu of cultural, economical, and social background, which complements their in-patient palliative care consult experience based at the VA Palo Alto.

ACGME DOMAINS

Patient Care

  • Goals
    Fellows 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. Gather relevant information from all sources necessary to address the questions of the clinicians involved in the care of the patient and to adequately address patient and family needs, including a proper review of available medical records, test results, history & physical examination, and discussions with relevant stakeholders in the patient’s care regarding their perceptions, concerns, and goals of care.
    2. Develops an initial assessment of the patient’s condition and a set of recommendations to present to clinicians, patients, and families, as appropriate. Recommendations should address both the explicit questions asked in the consult, as well as address any additional concerns identified in the process of consultation with particular attention to symptom management, goals of care, and decisions regarding care options.
    3. Follow-up with involved clinicians, patients, and families, to ensure proper implementation of plans and outcomes. Revise clinical recommendations, as appropriate, based upon this re-evaluation.
    4. Provide education to patients, families, and clinicians, as appropriate regarding palliative care matters within the fellow’s scope of expertise.
  • Objectives
    1. Fellow consultation notes will reflect a comprehensive assessment of the patient’s condition and appropriate recommendations for care.
    2. Fellows will follow-up with clinicians, patients, and families regarding care initiated as a result of consult recommendations and document such follow-up in a timely and appropriate manner in the medical record.

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. Fellows are expected to:
  • Competencies
    1. Demonstrate an appropriate understanding of the underlying physiology of major symptoms, commonly seen on a palliative care consult service, such as pain, dyspnea, nausea & vomiting, and delirium, and the relationship of these physiologies to choices of therapeutic agents used for palliation.
    2. Demonstrate an understanding of factors affecting prognosis in patients with serious, life-limiting or terminal illnesses.
  • Objectives
    Be able to explain to the attending physician and other clinicians the connection between specific recommendations for medications or medication changes and the patient’s underlying physiology and support such explanations with evidence-based references.

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. Locate, appraise and assimilate evidence from scientific studies related to their patients’ health problems.
    2. Participate in the education of patients, families, students, fellows and other health professionals, as documented by evaluations of a fellow’s teaching abilities by faculty and/or learners.
  • Objectives
    1. Will demonstrate the ability to perform a literature search on a topic arising during the month, related to a specific patient case and present this at a teaching conference to peers.
    2. Will demonstrate under observation by the attending physician teaching of at least one clinician, student, patient, or family member and will receive feedback from the attending regarding educational techniques used.

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 physicians, other health professionals, and health related agencies.
    2. Act in a consultative role to other physicians and health professionals.
  • Objectives
    The fellow will provide clinician education to consulting teams regarding common palliative care issues as opportunities arise. Education may be provided in one-to-one teaching, mini-didactic sessions with trainees, or the provision of handouts, including relevant articles and Fast Facts.

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. Compassion, integrity, and respect for others.
    2. Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
  • Objectives
    Be able to describe how the goals of care of patients and families seen on the consult service might be affected by their personal and cultural backgrounds.

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. Work in interprofessional teams to enhance patient safety and improve patient care quality.
  • Objectives
    1. Will demonstrate understanding of patient movement between other hospital systems, skilled nursing facilities, and Stanford Hospital with emphasis on Stanford Hospital as a tertiary care center and consequently, a limited resource.
    2. Will make timely referrals to non-physician members of the palliative care consult team to address psychosocial and educational needs and thus improve patient care.
TEACHING METHODS

The primary vehicle for learning during this rotation will be through the direct provision of care under supervision by the Attending Physician of the Stanford Palliative Care Service in the context of an interdisciplinary team. This experiential learning will be supplemented by:

  1. Formal ongoing weekly fellowship didactic sessions.
  2. Observation of and participation in daily interdisciplinary palliative care clinical meetings, weekly Stanford Intensive Care Unit multi-disciplinary clinical rounds, bi-monthly Stanford Palliative Care Administrative Advisory Group meetings, monthly Ethics committee meetings.
  3. Ad hoc instruction by the supervising Attending Physician and other inter-disciplinary members of the care team in the context of daily work, which may include but is not limited to mini-didactic sessions, formal and in-formal case-presentations.
  4. Direct observation of clinical care modeled by other clinicians, including the supervising physician and other inter-disciplinary clinicians doing consults.
  5. In addition this rotation will also include fiscal aspects of running a palliative care service including learning to bill and code for clinical services by observation of the Attending Physician (please note that our first year clinical fellows cannot bill for patient care services).
  6. Directed reading, both self-directed and reading as suggested by the Attending Physician. In such reading the emphasis will be on reviewing literature that discusses the evidence base for care options as relate to palliative care patients in an Intensive Care Setting and in an acute care ward setting.
LEVEL OF SUPERVISION
  • Direct observation by the supervising attending for patient care on consultations and inter-professional team meetings.
  • Each patient is presented to the supervising attending who also independently evaluates the patient.
ASSESSMENT METHODS

Initial meeting to determine training goals:

 

  • The fellow will have an initial meeting with the supervising attending physician during which both 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 at the end of the rotation 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. Informally, the supervising physician will solicit feedback regarding the fellow’s performance from Stanford Hospital patients, families, Stanford house-staff and other clinicians, as deemed appropriate. During this feedback session the Attending Physician will solicit fellow feedback regarding the rotation. Fellow evaluation process and follow-up: At the end of the Stanford block rotation (duration = one month), Med Hub sends an automated reminder to the Stanford Attending Physician to evaluate the fellow (using a global rating scale) who worked in that particular rotation. The 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 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 block 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 and both bedside (at the patient’s home setting) and clinical rounds based teaching experiences. Fellows will be observed by faculty during a clinical interaction and their skills will be evaluated by faculty using global rating scales and specific in-patient consult competency assessment checklists (attached).The supervising attending will directly observe the fellow performing at least one major patient care intervention such conducting a family meeting during the month and will observe the fellow’s presentation of recommendations to the Stanford interdisciplinary care team, referring house-staff and other sub-specialty attendings.

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.

Rotation specific assessment checklists:

The in-patient consult competency assessment rotation specific checklist is specifically designed to evaluate specific competencies related to this rotation. Attending physician will use this checklist to evaluate fellows at the end of each block rotation. These evaluations will be captured using an online database and collated and used to provide formative and summative feedback to the fellow.