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Despite requirements for palliative care training during fellowship, there is a paucity of recent data regarding the attitudes, knowledge, and skills of hematology/ oncology fellows in palliative care.
Our aim was to assess fellows' attitudes toward and quality of training in palliative care during fellowship and perceived preparedness to care for...
Citations
... At present, the medical curriculum for future oncologists in France provides insufficient training in palliative care skills, with the result that many of them lack knowledge and experience. [47][48][49] Another finding of this study was that the prognostic scales we asked about were not widely used, with only slightly more than a quarter of respondents (27.2%, (n = 80)) declaring that they used them. The low rate of use can naturally be a corollary of the fact that they were not widely known among our respondents, but may also be partially due to the constraints that their use involves. ...
Background
Prognostic scales exist to estimate patient survival in advanced cancer. However, there are no studies evaluating their use and practice. The objective of this study was to evaluate in a nationwide study the proportion of oncologists and palliative care physicians who had knowledge of these scales.
Methods
A descriptive, national, cross-sectional study was conducted via an online questionnaire to oncologists and palliative care physicians across France.
Results
Palliative care physicians had better knowledge of the scales than oncologists (42.3% (n = 74) vs. 27.8% (n = 33), p = 0.015). The Palliative Performance Status (PPS) and Pronopall Scale were the best-known (51.4% (n = 55) and 65.4% (n = 70), respectively) and the most widely used (35% (n = 28) and 60% (n = 48), respectively). Improved training in the use of these scales was requested by 85.4% (n = 251) of participants, while 72.8% (n = 214) reported that they did not use them at all. Limited training and lack of consensus on which scale to use were cited as the main obstacles to use.
Conclusion
This is the first national study on the use of prognostic scales in advanced cancer. Our findings highlight a need to improve training in these scales and to reach a consensus on scale selection.
... The hepatologists reported improved self-efficacy after completing the course in the areas of providing caregiver support, conducting goals of care discussions, and delivering psychosocial care; these are traditional gaps in specialist training. (25) Additionally, many of the hepatologists incorporated their course learnings into their interactions with non-study patients. We conclude that PCA:Hep was successful in training a cohort of hepatology providers with the primary PC skills required to deliver the intervention in the PAL-LIVER study. ...
Palliative care (PC) benefits patients with serious illness including end‐stage liver disease (ESLD). As part of a cluster randomized trial, hepatologists were trained to deliver primary palliative care to patients with ESLD using an online course, Palliative Care Always: Hepatology (PCA:Hep). Here we present a multimethod formative evaluation (feasibility, knowledge acquisition, self‐efficacy, and practice patterns) of PCA:Hep. Feasibility was measured by completion of coursework and achieving a course grade of >80%. Knowledge acquisition was measured through assessments before and throughout the course. Pre/post‐course surveys were conducted to determine self‐efficacy and practice patterns. The hepatologists (n = 39) enrolled in a 12‐week online course and spent 1‐3 hours on the course weekly. The course was determined to be feasible as 97% successfully completed the course and 100% passed. The course was acceptable to participants; 91.7 % reported a positive course experience and satisfaction with knowledge gained (91.6%). The pre/post knowledge assessment showed an improvement of 6.0% (pre 85.9% to post 91.9%, 95% CI [2.8, 9.2], P = 0.001). Self‐efficacy increased significantly (P < 0.001) in psychological symptom management, hospice, and psychosocial support. A year after training, over 80% of the hepatologists reported integrating a variety of PC skills into routine patient care. Conclusion: PCA:Hep is feasible, acceptable, and improves learner knowledge and confidence in palliative care skills. This is a viable method to teach primary PC skills to specialists caring for patients with ESLD.
... The ACGME requires a "structured continuity ambulatory clinic experience that exposes [fellows] to the breadth and depth of medical oncology." 3 Current literature in oncology fellowship training has investigated integrating geriatric and palliative training into the curriculum, 4,5 and there has also been research on the structure of oncology fellowship didactic seminars. 6 However, continuity clinic experiences in oncology fellowship training have not yet been explored. ...
Background:
At the University of Florida (UF), hematology-oncology (HO) fellows participate in 2 general types of continuity clinic as part of their fellowship training. One clinic, at the Veterans Hospital (VA), allows fellows to care for patients with a variety of hematology oncology diagnoses in a general clinic setting. The other clinic, located at the university site, is disease or system specific (such as breast or GI clinic). Considerable research supports the value of continuity clinic in residency and fellowship training, but the differences in having a general versus specialized clinic for HO fellows have not been explored. The purpose of this study was to investigate the perceived differences of general versus specialized continuity clinics by recent HO graduates from UF. Specifically, we were interested in learning which features of a continuity clinic they felt were most impactful for their current clinical practice.
Methods:
An anonymous survey was sent to the last 6 graduating classes of HO fellows at UF, between years of 2013 and 2018. The survey contained short demographic questions, followed by 5 open ended questions pertaining to the differing continuity clinic experiences. Graduates were asked about their opinions of both the general and specialized clinics during their training at UF. Survey responses were reviewed and coded for common themes by the authors.
Results:
Of 28 graduating fellows surveyed, 13 responded to the survey (response rate 46%). In thematic review of survey responses, the most common themes that emerged concerned autonomy, level of supervision, and the diversity of the patient population. A majority of respondents felt they had more autonomy and personal responsibility at the VA general clinic, but less direct supervision than at the specialized clinics. They also believed they got a broader exposure to different disease types at the VA general clinic. Surveyed participants also commented on the quality of educational seminars and activities, preceptor expertise and teaching, and ability to observe cutting edge practice and clinical trials.
Conclusions:
Graduated oncology fellows from UF believe that there is a balance that exists between having autonomy and ownership of their patients versus having adequate supervision. Many believe that having "controlled autonomy" and "as much independence as is safe for patients" is key to a meaningful continuity clinic experience during oncology fellowship training.
... In addition to this, the quality of PC education was rated lower than fellowship education in general [6]. A subsequent national survey of hematology/oncology fellows by Thomas and colleagues (2015) found increased rates of PC education during fellowship; however, over 25% still reported no teaching in assessing prognosis, timing of hospice referrals, or conducting family meetings [7]. These studies demonstrate continued need for improved PC education in hematology/ oncology fellowships, but ambiguity remains regarding how efforts should be focused. ...
Background
Palliative care (PC) education for fellows in hematology/oncology (H/O) training programs is widely accepted, but no studies to date have assessed PC education practices and values among program leadership.Methods
Program Directors and Associate Program Directors of active H/O fellowship programs in the U.S.A. were surveyed.ResultsOf 149 programs contacted, 84 completed the survey (56% response rate), of which 100% offered some form of PC education. The most frequently utilized methods of PC education were didactic lectures/conferences (93%), required PC rotations (68%), and simulation/role-playing (42%). Required PC rotations were ranked highest, and formal didactic seminars/conferences were ranked fifth in terms of perceived effectiveness. The majority felt either somewhat (60%) or extremely satisfied (30%) with the PC education at their program. Among specific PC domains, communication ranked highest, addressing spiritual distress ranked lowest, and care for the imminently dying ranked second lowest in importance and competency. Solid tumor oncologists reported more personal comfort with pain management (p = 0.042), non-pain symptom management (p = 0.014), ethical/legal issues (p = 0.029), reported their fellows were less competent in pain assessment/management (p = 0.006), and communication (p = 0.011), and were more satisfied with their program’s PC education (p = 0.035) as compared with hematologists.Conclusions
Significant disparities exist between those modalities rated most effective for PC education and those currently in use. Clinical orientation of program leadership can affect both personal comfort with PC skills and estimations of PC curriculum effectiveness and fellows’ competency. H/O fellowship programs would benefit from greater standardization and prioritization of active PC education modalities and content.
... The published literature demonstrates clear deficiencies in palliative care and pain management skills among pediatrics residents, internal medicine residents, and adult hematology/oncology fellows. [6][7][8][9][10] Pain management is a required American College of Graduate Medical Education (ACGME) competency for PHO fellows, though the requirements do not specify what level of competence must be achieved or how this should be measured. The 2019 program requirements state only that "fellows must demonstrate competence in the methods of physiologic support of the patient, including. . . ...
Background
Deficits in knowledge and comfort related to pain management have been demonstrated in adult hematology/oncology fellows. No such evaluation has been undertaken in pediatric hematology/oncology (PHO) trainees.
Procedure
An IRB‐approved survey was administered to PHO fellows throughout the United States (US) to assess comfort with opioid dosing, attitudes related to the use of opioids, and knowledge of basic concepts including weight‐based dosing, incomplete cross‐tolerance, and management of side effects.
Results
Email addresses were obtained for 132 fellows from 37 programs. Seventy‐eight (59%) fellows participated. No significant difference was demonstrated between training level and comfort with dosing opioids in an opioid‐naive patient, though a smaller proportion of first‐year fellows (65%) reported comfort compared to more senior fellows (85.2% of second‐year fellows, 80.6% of third‐ and fourth‐year fellows). First‐year fellows correctly answered a mean of 5.05 ± 0.43 out of 10 objective knowledge questions; second‐year fellows answered 5.74 ± 0.35 correctly, and third‐ and fourth‐year fellows 5.58 ± 0.30. The majority of respondents chose an appropriate dose of intravenous morphine based on weight (92%), and identified a low‐dose naloxone drip as an appropriate intervention for opioid‐induced pruritis (91%). However, the remainder of the questions had a correct response rate of 15‐68%.
Conclusion
This study characterizes PHO fellows’ knowledge and comfort with prescribing opioids. Despite high levels of reported comfort, PHO fellows in all levels of training demonstrated knowledge gaps. PHO fellows may benefit from further education in pain management.
... [1] Another potential explanation for missed diagnoses is a lack of provider education on depression screening in complex cancer patients and limited palliative care resources. [17] The criteria required to meet a diagnosis of depression may also differ based on the provider and the situation. Due to the retrospective nature of our study, information analyzed was previously documented in the patients' ...
Objective Depression has historically been an underdiagnosed and undertreated condition with a large impact on patient quality of life. Screening and diagnosis of depression may differ for various reasons, making proper diagnosis and treatment difficult. Methods In this retrospective cohort study, we analyzed the associations between the prevalence of depression and patient-specific factors in gynecologic and breast cancer patients who had received a palliative care consult. This study was conducted in a single institution that specializes in women and infant care. The primary objective was to quantify the prevalence of depression among palliative care patients. The secondary objective was to determine patient specific factors associated with a diagnosis of depression. Results Over the course of the one year inclusion period, a total of 73 patients met inclusion criteria. The prevalence of depression in this study was found to be 54.8%. A diagnosis of anxiety was associated with the presence of depression (77.5% vs 25%, p < 0. 0001). Cancer of the fallopian tube was also independently associated with depression (12. 5% vs 0, p = 0. 44). Conclusion The prevalence of depression for palliative care patients, specifically for patients with gynecologic and breast malignancies, in this study was higher than estimates of depression prevalence for the general population. The results of this study may indicate that a greater awareness of the need for screening and treatment of depression is necessary in this population, in order to properly diagnose and treat patients with depression.
... Palliative care skills can be taught and learned. 7,11 Repackaging what we teach our fellows is a useful and important venture. More time in teaching palliative care principles recognizes this education as one of the most important and therapeutic tools in cancer medicine. ...
... It may be prudent to compare where palliative care and geriatric oncology overlap and how they differ in teaching. Furthermore, as palliative care is also often inadequately taught in oncology [19,20], there is potential for geriatric oncology and palliative medicine to learn from each other about how to best integrate successfully within oncology and/or to collaborate synergistically to advance their respective agendas. ...
Background:
Most oncology trainees are not taught about the needs of older patients, who make up the majority of patients with cancer. Training of health care providers is critical to improve the care of older adults with cancer. There is no consensus about which geriatric oncology (GO) competencies are important for medical oncology trainees. Our objective was to identify GO competencies medical oncology trainees should acquire during training.
Materials and methods:
A modified Delphi consensus of experts in oncology medical education and GO was conducted. Experts categorized at what training stage proposed competencies should be attained: internal medicine, oncology, or GO training. Consensus was obtained if two thirds of experts agreed on the training stage at which the competency should be attained.
Results:
A total of 78 potential competencies were identified, of which 35 (44.9%) proposed competencies were felt to be appropriate to be acquired during oncology training. The majority of the identified competencies pertained to prescribing of systemic therapy (n = 12) and psychosocial and supportive care (n = 13). No competencies related to geriatric assessment were identified for acquisition during oncology training.
Conclusion:
Experts in oncology education and geriatric oncology agreed upon a set of GO competencies appropriate for oncology trainees. These results provide the foundation for developing a GO curriculum for medical oncology trainees and will hopefully lead to better care of older adults with cancer.
Implications for practice:
The aging population will drive the projected rise in cancer incidence. Although aging patients make up the majority of patients diagnosed with cancer, oncologists rarely receive training on how to care for them. Training of health care providers is critical to improving the care of older adults with cancer. The results of this study will help form the foundation of developing a geriatric oncology curriculum for medical oncology trainees.
... Furthermore, most rated the quality of education inferior to overall oncology training. In similar study by Thomas et al, 23 approximately 44.9% of participants completed a PC rotation and reported better teaching of pain management, communicating a poor prognosis, and conducting timely hospice referrals. However, the participants also rated their oncology training as being better than end-of-life training. ...
... Some of the questions were adapted from previously published studies of oncology trainee perception to assess attitudes and beliefs toward PC. [22][23][24] This study was approved by the UT MDACC institutional review board. ...
... In contrast to studies by Buss et al 22 and Thomas et al, 23 the results of our survey showed that more than 60% of fellows perceived a better ability to prescribe opioids, identify and treat opioid adverse effects, and rotate opioids. This is particularly interesting in this time of opioid overdose epidemic. ...
Purpose:
The primary aim of this study was to determine the attitudes and beliefs of hematology and medical oncology (HMO) fellows regarding palliative care (PC) after they completed a 4-week mandatory PC rotation.
Methods:
The PC rotation included a 4-week standardized curriculum covering all PC domains. HMO fellows were provided educational materials and attended all didactic sessions. All had clinical rotation in an acute PC unit and an outpatient clinic. All HMO fellows from 2004 to 2017 were asked to complete a 32-item survey on oncology trainee perception of PC.
Results:
Of 105 HMO fellows, 77 (73%) completed the survey. HMO fellows reported that PC rotation improved assessment and management of symptoms (98%); opioid prescription (89%), opioid rotation (78%), and identification of opioid adverse effects (87%); communication with patients and families (91%), including advance care planning discussion (88%) and do-not-resuscitate discussion (88%); and they reported comfort with discussing ethical issues (74%). Participants reported improvement in knowledge of symptom assessment and management (n = 76; 98%) as compared with efficacy in ethics (n = 57 [74%]; P = .0001) and for coping with stress of terminal illness (n = 45 [58%]; P = .0001). The PC rotation educational experience was considered either far better or better (53%) or the same (45%) as other oncology rotations. Most respondents (98%) would recommend PC rotations to other HMO fellows, and 95% felt rotation should be mandatory.
Conclusion:
HMO fellows reported PC rotation improved their attitudes and knowledge in all PC domains. PC rotation was considered better than other oncology rotations and should be mandatory.
... Although oncology fellows gain significant exposure to end-oflife discussions, 2 fewer than half of oncology fellows benefit from structured rotations on palliative care services. 3 Even within such rotations, it is unclear how involved oncology fellows (or oncologists in general) remain with their patients after transitions to hospice. ...
