Stanford Medicine Palliative Consult Service

Overview

The Stanford Hospital Palliative Care inpatient consult service provides consultation on acute inpatients in Stanford Hospital, a large academic teaching hospital that serves both as a local hospital as well as a tertiary care center for the surrounding counties. During this rotation, the fellow will work with an interdisciplinary palliative care team (advanced practice nurses, social work, chaplain) in providing consultation under the supervision of an attending palliative medicine physician. Over 140 new patients are seen by the consult service each month focusing on symptom management and evolving goals of care discussions. This rotation provides HPM fellows with ample opportunities to deliver medical care for palliative care patients from a diverse milieu of cultural, economic, and social backgrounds, and continue to develop their palliative skills which complements their other inpatient and out-patient palliative care clinical experiences.

Care Team

Attending Physicians:

• Rebecca Aslakson, MD, PhD
• Keri Brenner, MD
• Josh Fronk, DO
• Josef Hannah, DO
• Stephanie Harman, MD,
• Shireen Heidari, MD
• Felicia Hui, MD
• Torrey Simons, MD, PhD
• Grant Smith, MD
• Winnie Teuteberg, MD

Advanced Practice Providers

• Sarah Betts, NP
• Connie Carr, NP
• Natalie Dickson, CNS
• Amy Holm, NP
• Saba Safari, NP
• Colleen Vega, CNS

Social Worker: Lucia Hollowell

Chaplain: Anna Nikitina

Inpatient Consult Rotation Director – Shireen Heidari, MD

Program Manager – Heather Shaw, NP

Admin Assistant – Gizelle Snowden-Jones

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 optimal 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 the medical record in a timely and appropriate manner.

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

1. 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 lifelong 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.
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 successful 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:

1. The fellow will provide clinician education to consulting teams as opportunities arise regarding common palliative care issues. Education may be provided in one-on-one teaching, mini-didactic sessions with trainees, or by 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

1. 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 inter-professional 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 interdisciplinary 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 interdisciplinary team teaching sessions on Wednesday mornings as well as reflection rounds on Friday mornings.
3. Instruction by the supervising Attending Physician and other interdisciplinary members of the care team in the context of daily work, which may include but is not limited to mini-didactic sessions, formal and informal case presentations. Expected that at least one patient interaction per day will start with learning goals and conclude with debrief and immediate feedback.
4. Direct observation of clinical care modeled by other clinicians, including the supervising physician and other interdisciplinary clinicians doing consults.
5. In addition, this rotation will include fiscal aspects of running a palliative care service, including learning to bill and code for clinical services by observation of the Attending Physician and discussion of levels of care towards the end of the year (please note that our 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 related to palliative care patients in an intensive care setting and in an acute care setting.

Level of Supervision and Progression of Learning Objectives Throughout Year

• Direct observation by the supervising attending for patient care on consultations
  and inter-professional team meetings. Generally, the fellow will be paired with the 7 day attending for continuity.
• Each patient is presented to the supervising attending who also independently
  evaluates the patient.

Expectations of fellows:

• Build progressive responsibility throughout the year, more supervision in early rotations, ultimately to lead team rounds, staff with APPs/residents by end of the year (with attending observing plan formation).
• No hard caps on patients, start with 3-4 at the beginning and work upwards. Up to attendings and fellows to work together on what learning edge is for each fellow, with the goal of being able to manage own service at end of the year.
• Up to fellow to signal to attending and team when need help covering pager (family meetings, etc.) or more time to complete consults
• Fellow to identify learning goals and check in with attending at the beginning and end of each week, to allow for targeted learning and feedback.

Expectations of attendings:

• All attendings to check in with fellow at the beginning and end of each week, check in on learning goals, provide targeted feedback. This is in addition to real-time observation and feedback throughout the week.
• 5 day attending paired with a resident, may also staff with fellow
• 7 day attending paired with fellow, and med student if applicable
• Provide sign out to oncoming attending on patients as well as trainee learning goals and progress
• Attendings all available for staffing of overnight calls while on service. If fellow is getting called regarding a new patient, will staff with 5 day attending during the week, and 7 day attending over the weekend.

Proposed Progression of Fellow Learning Objectives over 6 Rotations (modeled after milestone focus):

In general, the fellows each spend approximately 3 months or 6 rotations at Stanford. For the 2020-2021 academic year, fellows will be rotating at Stanford for two weeks at a time.

First two rotations (Weeks 1-4) – Introduction to SHC and interdisciplinary palliative medicine consultation

Faculty Responsibility:

The attending physician(s) will be responsible for the palliative medicine fellow’s educational experience while rotating on the service. The attending(s) will seek out the fellow at the beginning of his or her rotation to help target learning to the fellow’s specific goals. The attending will oversee the fellows’ clinical work and provide regular feedback based on 1:1 observation throughout the rotation. For each rotation, the attending(s) will complete a formal, written summative evaluation in MedHub. Depending on how rotation cycles match up, attending(s) may instead give verbal feedback in place of a formal, written evaluation. 

Structure:

The fellow’s first day at Stanford will be spent paired with and observing members of the interdisciplinary team to get a better sense of each role and how best to work with the team for the coming year.

• Part day with APN (NP or CNS)
• Part day with SW (including Family Guidance specialist when available)
• Part day with chaplain (when available)
• Part day with attending (either attending on service)

During first two (2) weeks on service, another member of the team will carry the pager to allow fellow to focus on orienting to team and SHC. It is recommended that the team member who is taking consults for the day model good pager etiquette and procedures in addition to open consultation. When the fellow does start carrying the pager, it is not the responsibility of the fellow to triage every page, but to forward the page to the person responsible for the patient. In addition, team members will cover the pager while fellow is in teaching, clinic, or off, and will help cover pager if fellow is expected to be in an extended family meeting and lets the team know.

• During first week on service, fellows expected to field new consults with the attending to receive feedback specifically about consultation etiquette (i.e. what questions to ask, how to guide conversation, etc). Fellows expected to field consults independently by the end of the block.
• As we consider goals of care discussions to be a procedure, fellows can expect to shadow the attending(s) during goals of care (GOC) conversations in their first rotation and progressively become more independent as the year progresses. Expectation that attending will be present and lead GOC conversations until fellow appropriately ready to move into a more active role and eventually autonomy.
• When a fellow begins to take an active role in GOC conversations, it is recommended that there is an identifiable learning focus for the fellow to work on. A learning focus may be communication skill based (i.e. Ask-Tell-Ask, “Tell me more,” etc.) or more about the process (i.e. Introducing palliative care, breaking bad news, POLST discussions, etc.) with specific attention given to this learning focus. A learning focus may be identified or encouraged by the attending; however, fellows are expected to take an active role as an adult learner and self-identify areas for improvement. From the fellow perspective, his or her objective for a GOC conversations should be practice and implementation of the identified learning objective. The attending is responsible for the success of the GOC conversation itself. Fellows should feel comfortable and expect the attending to take control of GOC conversations to navigate it further to success (similar to how an attending would assist with procedure completion even if a fellow started the initial incision).
• Clear expectation that an attending will be in attendance for all GOC conversations, whether they take place in:
  • 1) Formal family meetings or
  • 2) Bedside as part of routine consultation
• Expectation (and time allotted) for immediate debrief and feedback at the conclusion of each GOC conversation. At a minimum, ensure that positive attention and reinforcement is given for completion of each learning objective. Discuss other learning points when appropriate and time permitting.
• In-person rounds with attending on all patients at some point during the day.
• Similar to teaching, encourage that fellow receive direct feedback from attendings on service throughout each rotation.

Communication learning objectives:

• Introducing palliative care to patients
• Familiarity with different communication skills and ability to identify them when used by others.
• Self-identified use of 4-5 communication skills. Recommend that fellow has utilized at least one skill of each type: 1) Emotion Skills 2) Information Skills 3) Relationship Skills
• Recognize SPIKES and REMAP constructs as relates to GOC conversations and delivering bad news.
• Able to effectively hand-off communication back and forth with attending during GOC conversations.
• Be able to recognize emotion and start to practice variety of ways to address (i.e. NURSE)
• Is able to work effectively with IDT.

Medical Content learning objectives:

• Pain Management
  • Opioid conversions.
  • Beginning to work on developing long and short acting opioid regimens
  • Beginning to develop PCA regimens.
  • Appropriately use non-opioid pain medications independently and as adjuvants.
• Constipation Management
• Nausea Management
  • Demonstrates an understanding of the differential diagnosis of nausea.
  • Beginning to work on nausea regimens.
• Develop a working understanding of hospice, its structure, billing, and limitations.

Subsequent mid-year rotations (Weeks 5-8) – Development of assessments and plans with self-monitoring of skills

Structure:

• Fellows are to meet with attendings on service at beginning of rotation to identify specific learning objectives.
• Takes consults independently.
• Fellows are able to manage some GOC conversations independently.
• Recommended that one of the inpatient attendings will be in attendance for all GOC conversations. Attendings will encourage the fellow to maintain the conversation as much as possible utilizing various communication skills and techniques. It is encouraged to have fellows identify specific learning objectives for each encounter. It is not uncommon for the attending to serve solely as an observer for many of the conversations during this phase of the fellows’ education year. Following GOC conversations, there is continued expectation for immediate debrief and feedback. Ensure positive reinforcement is given for the completion of each learning objective. Discuss other learning points when appropriate and time permitting.
• Expected that one of the inpatient attendings will be in attendance for all GOC conversations in which Ethics is involved or other high-stakes issues are occurring (i.e. Disagreement between service attendings, risk management involved, etc.)
• Attending(s) may round independently without fellows present; however, fellows will continue to staff all patients with the attending(s).

Communication learning objectives:

• Able to self-identify use of the core communication skills.
• Beginning to be able to give communication feedback to other learners and discuss communication questions with attending even if attending had not been present at the family meeting.
• Can run some family meetings independent of the attending’s participation.
• Beginning to work on skills to work with consulting teams and teach primary palliative medicine knowledge and skills.

Medical Content learning objectives:

• Continues to increase proficiency with pain and nausea regimens.
• Starts to work with and recommend methadone for management of pain or dyspnea where appropriate.
• Can offer a treatment plan for most symptoms as described by patient.
• Increased focus on delirium, depression, and anxiety regimens.
• Able to offer guidance for end of life care, including but not limited to palliative extubation, VAD discontinuation, and the End of Life Option Act.
• Able to discuss issues and treatment options around hydration and nutrition.
• Introduction to palliative extubation (recommend being present for case when able), advanced ethics cases

Final rotations (Weeks 9-12) Taking a leadership role

Structure:

• Fellows expected to lead IDT rounds in the morning.
• Fellows are to meet with attendings on service at the beginning of rotation to identify specific learning objectives. This will allow for attendings to provide targeted feedback in the areas the fellow is looking to grow in.
• Able to manage most GOC conversations independently. Attendings are not expected to attend all GOC conversations as previously done. Attendings are encouraged to be in attendance for GOC conversations in which Ethics is involved or other high-stakes issues are occurring based on fellow skill level (i.e. Disagreement between service attendings, risk management involved, etc.)
• Before the end of the block, residents will staff consults with the fellow.
• By the end of the block, fellows can round independent of the attending on their own patients

Communication learning objectives:

• Increasing proficiency with all core communication skills.
• Actively seek out challenging communication situations: for example, if it looks like it is going to be a straightforward family meeting, see how little one needs to talk. Or if less comfortable when someone else runs the meeting, deliberately let them do so and intervene only when absolutely necessary.
• Continue to work on skills to support consulting teams

Medical Content learning objectives:

• Round out symptom management skills for major symptoms
• Be sure to have a working tool kit for less common symptoms (pruritus, anorexia, xerostomia, etc.)
• Demonstrate nuanced management of pain using both opioid and non-opioid agents.
• Can offer a treatment plan for all symptoms present AND a back-up plan in case the patient or the team wants a different approach.

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.

Midpoint check in and feedback

Fellow and attending will meet to review how rotation is progressing thus far in relation to self-directed goals. This midpoint check in allows for adjustments and constructive feedback for fellow and attending prior to end of rotation.

End-of-rotation debrief (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 achieved. 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 = two weeks), Med Hub sends an automated reminder to the Stanford Attending Physicians 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 that will immediately take necessary remedial action as appropriate.

Specific evaluation methods used in this block rotation are:

Direct observation: Fellow competency will be evaluated using direct observation during patient care, discussion based on clinical care and both bedside 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 competency-based evaluation forms (standardized by GME) as a guide. The supervising attending will directly observe the fellow performing at least one major patient care intervention such as conducting a family meeting for immediate debrief and feedback per week, at least one observed encounter for targeted feedback per day, and will observe the fellow’s presentation of recommendations to the Stanford interdisciplinary care team, referring house-staff and other sub-specialty attendings. See level of supervision and proposed progression sections above.

Global rating scales: Stanford has a Med Hub online evaluation system that is specifically created for confidential and standardized evaluation of fellows and faculty using survey questions with ordinal responses along with text boxes for summative feedback.

Proposed Progression for Fellow Learning Objectives (both medical and communication objectives) – listed above in levels of supervision and progress