Palliative care education increases fellows’ knowledge, confidence in ‘deep, productive’ way
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Incorporating palliative care into a hematology/oncology fellowship improve fellows’ knowledge and confidence providing these services, according to research presented at ASCO Annual Meeting.
A pilot study evaluated 19 hematology/oncology fellows at Fox Chase Cancer Center who identified patients in their hematology/oncology practices who had palliative care needs.
The fellows referred these patients to a palliative care clinic and saw them — accompanied by attending physicians — in multiple settings, including in the palliative care clinic, in the hematology/oncology clinic and during hospitalizations.
Researchers monitored patient visits and fellows’ participation for feasibility. Fellows also completed surveys before and after the rotation to assess their confidence and knowledge.
All 19 fellows referred two to four patients to the palliative care clinic.
Fifty-one patients attended a combined 132 palliative care visits. Fellows participated in 125 (95%) of those visits, with 71% occurring in outpatient settings.
The fellows reported improved knowledge from the pre-intervention period to post-intervention period — with mean scores increasing from 6.44 to 7.92 on a 10-point scale (P = .01). Fellows also reported improvement in overall preparedness to provide palliative care, with scores increasing from 6.33 before the intervention to 7.75 after the intervention (P < .01).
In addition, fellows’ ratings of skill confidence increased in 14 of 26 palliative care areas, including titration of opioids, managing pain among patients with substance abuse disorder, knowing when to consider methadone and collaborating with an interdisciplinary team.
All 17 fellows who rated the acceptability of the intervention agreed or strongly agreed that the rotation brought about change in their clinical practice and increased their sense of engagement with their severely ill patients. Sixteen (94%) rated the rotation as “valuable or extremely valuable.”
“This study reiterates the importance of palliative care skills in hematology/oncology training,” researcher Jessica Bauman, MD, chief of the division of head and neck medical oncology, program director of the hematology/oncology fellowship training program, and associate professor in the department of hematology/oncology at Fox Chase Cancer Center, told Healio. “Integrating these educational models enabled our fellows to learn these palliative care skills in a deep and productive way.”
Healio spoke with Bauman about the motivation for this intervention, how it performed and whether the program may serve as a model for other fellowship programs.
Healio: How problematic is lack of access to specialty palliative care for patients with advanced cancer?
Bauman: Many comprehensive cancer centers have well-integrated palliative care teams. However, many people across the country do not have access to such a center and do not have regular access to palliative care, so it’s a major problem. Additionally, there are not enough people training in palliative care to meet the needs of patients who would benefit from it. Palliative care clinicians do not only treat cancer — they are often needed for patients with other serious illnesses, such as kidney, liver or lung diseases.
Healio: How is palliative care addressed in most hematology/oncology fellowship programs?
Bauman: The Accreditation Council for Graduate Medical Education — which oversees hematology/oncology fellowships — includes a handful of palliative care objectives in their requirements, but how that is conducted in fellowship varies by program. The most common approach includes doing a brief rotation with the palliative care team, if there is one available. Some programs might also integrate palliative care lectures in training.
Healio: What inspired the development of the intervention you studied?
Bauman: At Fox Chase, our fellows have had a palliative care rotation for many years but, interestingly, this rotation was not necessarily very well received. Palliative care was not always seen as the most important thing they needed to learn. When I became part of the program almost 10 years ago, we started thinking about how best to integrate this.
My colleague, palliative care physician Molly Collins, MD, had an epiphany while working with one of our oncology fellows. The fellow was seeing a patient who they already knew well. The patient had been admitted and had a palliative care consult. My colleague worked with that fellow intensely over about 2 weeks on many different aspects of care for this patient, including pain and symptom management, difficult goals-of-care conversations, prognostication and communication. Molly realized the fellow was so engaged in all of these learning points and had gotten so much from the teaching and interaction.
Molly said, “This is how we should be teaching palliative care.” She said we shouldn’t be making our fellows add a new rotation with different people; rather, we should integrate this learning into the patients they are already seeing. This makes them more engaged and interested, and the learning is so much deeper.
Healio: How did you evaluate this?
Bauman: We followed our fellows for 6 months. Before the rotation, we evaluated them on several different domains of medical knowledge and palliative care skills. We did the same measures after the rotation, and we tracked who they were seeing for feasibility.
At the end, we also did an exit interview to understand what they learned and what they valued from the rotation.
Healio: What did you find?
Bauman: First, the rotation was feasible. Our fellows participated in more than 90% of visits with the patients they referred. Surveys showed increased knowledge and skills in several domains, including communication, goals of care, prognostication, and pain and symptom management. Fellows also showed improvement in general knowledge of palliative care and confidence taking care of palliative care issues.
Fellows said the rotation was valuable and it helped them take care of their sickest patients. Fellows learned skills that could be translatable to their practices, and some specifically commented on how it created more meaning in their work. I believe this last point is particularly important, given the extent and impact of physician burnout.
Healio: Could this serve as a model for other programs?
Bauman: This is certainly a novel model, and that’s part of why we did this work. One of our next steps is to investigate how this can be translated to other fellowship programs and whether we can see these findings duplicated. Another question in future work will be how the patient experiences a program like this.
Reference:
- Bauman JR, et al. Abstract 9007. Presented at: ASCO Annual Meeting; May 31-June 4, 2024; Chicago.
For more information:
Jessica Bauman, MD, can be reached at jessica.bauman@fccc.edu.
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