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9. Educating Health Care Professionals
Pages 328-349

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From page 328...
... Tina Heyl-Martineau, parent, 2001 Whether the issue is insensitivity to feelings and emotions, inattention to pain and other symptoms, or inadequate information, children and families suffer when they encounter pediatricians and other professionals who are ill-prepared to offer them competent, consistent, and compassionate palliative, end-of-life, and bereavement care. Although education alone cannot ensure such care, undergraduate, graduate, and continuing health professions education is necessary to provide an essential foundation of scientific knowledge, ethical understanding, and technical and interpersonal skills.
From page 329...
... basic elements of competence-building education in pediatric palliative and end-of-life care, of-life care, deficiencies in current professional education in palliative and endresponses to those deficiencies, and directions for further changes in health professions education. The committee recognizes that educational reforms, albeit a commonly urged strategy for changing clinicians' attitudes and practices, are often difficult to achieve and that documentation of their success (especially over the long-term)
From page 330...
... Clinicians who specialize in pediatric critical care or oncology should be more intensively prepared for their extensive involvement with seriously ill or injured children and their families. Because the number of child deaths is very small compared to the number of adult deaths, attention to end-of-life issues in pediatric education may seem peripheral to some, especially given the competition for time
From page 331...
... For example, education in pain assessment, prevention, and management will have to consider the particular challenges of assessing symptoms in infants and preverbal children and in prescribing analgesic medications given the frequent lack of research-based information on doses for children at different developmental stages. The development of a group of specialists in pediatric palliative care clearly has begun.
From page 332...
... Given the range of professionals involved and skills needed, no single set of competencies in pediatric palliative and end-of-life care can comprehend all relevant issues. Beyond the basics, education must prepare clinicians who specialize in care for children with life-threatening medical problems for the special clinical, psychological, and other challenges of such care.
From page 333...
... . Other strategies emphasize coping mechanisms as part of initial training and continuing education programs.
From page 334...
... By the time medical students end their fourth year, they will have been directly involved with hospitalized patients, typically with little preparation for the interpersonal aspects of caring for gravely ill individuals and their families. One educator's survey of fourth-year medical students suggested that students sometimes became involved with dying patients as a result of an attending or resident physician's discomfort or lack of concern.
From page 335...
... Several subsequent surveys have documented continued deficiencies in medical school and residency programs. For example, results from the 1997-1998 survey of medical schools by the Liaison Committee on Medical Education (LCME)
From page 336...
... Himelstein and Kane report on a recent survey of pediatric residency program directors and pediatric residents in training. In contrast to the routine annual surveys by the LCME and AMA, this survey generated a low response rate from program directors (22 percent)
From page 337...
... Some hospices offer rotations or other experiences for medical students and other health professionals in training. For example, in a recent survey of approximately 4,000 hospices, about 10 percent reported training for pharmacists, who can be a valuable resource for professionals treating adults and children with symptoms of advanced disease (Herndon et al., 2001~.
From page 338...
... Health Professions Textbooks Medical textbooks have traditionally paid little attention to the description or management of either the end stages of diseases such as cancer and heart disease or the symptoms and distress commonly experienced by gravely ill or dying patients. One study of four widely used general medical textbooks concluded that they had little that was helpful to say about endof-life care and that discussions of specific diseases usually dealt with "only prognostication and medical treatments to alter the course of the disease" (Carron et al., 1999, p.
From page 339...
... INITIATIVES TO IMPROVE EDUCATION FOR PEDIATRIC PALLIATIVE AND END-OF-LIFE CARE General Changing health professions education is not easy. Deans of health professional schools, department chairs, residency program directors, certification and accreditation bodies, textbook authors, and other leaders face an avalanche of demands for new topics or perspectives to be included in curricula, residency program requirements, and other elements of health professions education.
From page 340...
... The Residency Review Committee for Pediatrics, a subcommittee of the Accreditation Council for Graduate Medical Education, establishes requirements for the more than 200 pediatric residency programs. Box 9.2 lists requirements that specifically mention terminal conditions, death, some aspect of symptom management, or decisions about life-sustaining medical interventions.
From page 341...
... More generally, a basic principle of education is repetition and reinforcement of not one-time exposure to important concepts. To use an analogy, "You give the immunization in the first year of medical school, but then you've got to boost them at two, and then you've got to boost them again at four and at six." To this end, many opportunities exist to use palliative care and end-oflife issues as powerful illustrations in teaching other concepts, principles, and techniques during the didactic and clinical components of undergraduate medical education and the similar stages of nursing and other health professions education.
From page 342...
... . proving pat~ent-p" Scan communication, encouraging teamwor" ~ among health professionals, and extending students' experiences into physician office, nursing home, home, and other community settings.
From page 343...
... EDUCATING HEALTH CARE PROFESSIONALS 343 techniques have the additional goals of improving the effectiveness of education by engaging students more directly in the learning process, strengthening problem-solving and reasoning skills, increasing the connections between scientific knowledge and clinical practice, and better preparing students for lifelong learning. Evaluations of the strategies summarized here and in Appendix G
From page 344...
... Patients and Families as Teachers A social worker raised the astounding idea that instead of using actors or social workers, why not have standardized parents be actual parents, who went through the same training about giving feedback {to residents]
From page 345...
... During a similar exercise several weeks later, the researchers found improvements in information and counseling skills. Hospice and Inpatient Palliative Care Experiences As noted earlier, some hospices offer educational programs not only to their own staffs and volunteers but also to health professions students and community providers.
From page 346...
... As described above, a survey of directors of pediatric residency programs suggests that such experiences are rare, even for clinicians who routinely care for children who die. Mentors and Role Models One objective of developing a cadre of palliative care specialists is to provide established clinicians and clinicians-intraining with role models and mentors.
From page 347...
... The initiative focuses specifically on preparing nurse educators to bring education in end-of-life care to nursing schools and continuing education programs in a variety of settings (AACN, 2002~. A pediatric version of ELNEC has been pilot tested (Personal communication, Betty Ferrell, Ph.D., City of Hope Medical Center, July 8, 2002~.
From page 348...
... . Recommendation: Medical, nursing, and other health professions schools or programs should collaborate with professional societies to improve the care provided to seriously ill and injured children by creating and testing curricula and experiences that · prepare all health care professionals who work with children and families to have relevant basic competence in palliative, end-of-life, and bereavement care; · prepare specialists, subspecialists, and others who routinely care for children with life-threatening conditions to have advanced competence in the technical and psychosocial aspects of palliative, end-of-life, and bereavement care in their respective fields; and · prepare a group of pediatric palliative care specialists to take lead responsibility for acting as clinical role models, educating other professionals, and conducting research that extends the knowledge base for palliative, end-of-life, and bereavement care.
From page 349...
... Likewise, varied incentives will be needed to reinforce educational initiatives including residency program requirements and inclusion of questions in licensure and certification examinations. Recommendation: To provide instruction and experiences appropriate for all health care professionals who care for children, experts in general and specialty fields of pediatric health care and education should collaborate with experts in adult and pediatric palliative care and education to develop and implement · model curricula that provide a basic foundation of knowledge about palliative, end-of-life, and bereavement care that is appropriate for undergraduate health professions education in areas including but not limited to medicine, nursing, social work, psychology, and pastoral care; · residency program requirements that provide more extensive preparation as appropriate for each category of pediatric specialists and subspecialists who care for children with life-threatening medical · ~ cons ltlons; · pediatric palliative care fellowships and similar training opportu· ~ nltles; · introductory and advanced continuing education programs and requirements for both generalist and specialist pediatric professionals; and · practical, fundable strategies to evaluate selected techniques or tools for educating health professionals in palliative, end-of-life, and bereavement care.


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