Developmental Milestones Developmental Schematics

Concept of Developmental Milestones

During the course of the fellowship, residents should demonstrate progressive improvement in their knowledge and skills in palliative medicine.  We hypothesize that most learners acquire such expertise in a somewhat predictable fashion, while accounting for some variation based on individuals’ innate and acquired differences and learning styles.

Akin to pediatric developmental milestones, where children typically can be expected to acquire various abilities by certain chronological ages, the developmental milestones document outlines our mapping of how palliative care residents typically gain their enhanced skills on a timeline continuum, i.e. stage of training.  The goals and objectives for the fellowship program have been clustered along this timeframe.

Simplistically, mastery of the basics of pain and symptom management tends to occur in the early months of the fellowship year, while skills in managing particularly challenging cases of pain or other symptoms or less commonly encountered symptomatology tends to develop closer to the end of the year.  Basic comfort and skill in dealing with common psychosocial spiritual issues are attained early; skill in managing complex or difficult psychosocial spiritual concerns is gained later.  Expertise in handling those scenarios that challenge even experienced palliative care clinicians is hopefully gained near the end of the fellowship.  Skills in consultation, advocacy, and leadership tend to arrive late.

The developmental milestones document therefore serves as our reference point in attempting to determine if the resident is appropriately improving in expertise.

Direct Observation Process

We are currently piloting a direct observation process or evaluation as a longitudinal assessment of the resident’s progressive acquisition of skills and expertise.  A consistent evaluator performs assessments of the resident quarterly.

The resident is directly observed performing an assessment of a palliative patient/family and then required to present a case formulation and management plan.  The evaluator critiques the resident’s performance using a recording sheet that identifies actions that the resident should continue to do, should cease, begin, or consider implementing.   The evaluator also plots the resident along the developmental milestone continuum, making a global assessment of the maturity of the resident’s performance.   For example, the resident in his/her second month of the program may be functioning at the level of a more senior (e.g. Month 8) resident; or a senior resident may only demonstrate the skills that most 4-month old residents have already acquired.

The developmental milestones document is utilized in this fashion, as a gauge of time-appropriate acquisition of expertise.

It is our hope that the developmental milestones direct observation process will serve a number of functions:

• Provide formative evaluation feedback to resident
• Act as a final summative evaluation tool (albeit with acknowledged limitations)
• Identify those residents who are failing to gain expertise and skill
• Shed some academic light on the process by which learners gain competence in a defined area of practice

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PALLIATIVE CARE FELLOWSHIP: 
DEVELOPMENTAL MILESTONES

Month 0:            Assume minimal basic skills of the general physician

Month 2:            
A4:  Define palliative care and describe its basic principles
A1:  Describe current societal attitudes about death and dying
E1:  Articulate the philosophical basis of effective palliative/hospice care
A5:  Describe the physical, psychological, social and spiritual issues of dying patients and their families
B12: Participate in interdisciplinary care of patients, including family conferences
B11: Describe the roles of other disciplines in providing palliative care
E5:   Demonstrate integrity, honesty, and compassion in the care of patients
B13: Communicate effectively with other team members
A10: Describe his/her own concerns about dealing with dying patients and their families
A11: Demonstrate an awareness of how his/her own personal experiences of death and dying have influenced attitudes

Month 4:
B2:  Demonstrate a systematic approach to symptom assessment and all aspects of psychosocial needs, advanced knowledge of assessment and classification of pain, neurophysiology of pain, pharmacology of drugs used in pain and symptom mgmt, pathophysiology of other symptoms
B3:  Manage pain effectively
D4:  Access and use the relevant literature in helping to solve clinical problems
D5:  Apply critical appraisal skills to literature in palliative medicine
A6:  Demonstrate effective communication skills in dealing with terminally ill patients and their families, including skills in delivering bad news

Month 6:
B4:  Manage other physical symptoms especially dyspnea, constipation, skin care, mouth care, terminal agitation, delirium, nausea and vomiting
B5:  Demonstrate a good knowledge of cancer, its pathophysiology and current principles and management (Oncology Rotation)
A8:  Demonstrate an ability to work with the patient and family to establish common, patient-centred goals of care
B9:  Demonstrate skills in providing educational counseling to dying patients and their families
D2:  Develop a proactive approach to managing patient and family expectations and needs
C8:  Describe the community resources available to support patients in their homes
E2:  Demonstrate knowledge of the field of biomedical ethics and its principles
A12: Describe strategies for managing his/her own stress in dealing with the dying

Month 8:
B6:  Identify psychological issues associated with life-threatening illness and strategies that may be useful in addressing them, particularly anxiety and depression
B10: Identify the social and existential needs confronting the patient and families and strategies that may be useful in addressing them
A7:  Demonstrate a systematic approach to working with the families of dying patients, including bereavement counselling
B8:  Demonstrate skills in working with the families of dying patients
C6:  Describe the elements comprising good palliative home care (Community Rotation)
C7:  Be knowledgeable about and able to provide home visits to dying patients (Community Rotation)
C9:  Describe an approach to the last hours of care in the home and the responsibilities of the physician at the time of death
C10:  Describe the physician’s role in managing patients in their homes
E3:  Outline a general framework for ethical decision-making
A2:  Identify issues in death and dying relevant to different cultures, spiritual beliefs, and traditions

Month 10:
B7:  Describe the process of normal grief and differentiate from the features of atypical grief
E4:  Demonstrate an approach to managing the particular ethical issues at the end of life including withdrawing or withholding therapy, advance directives, euthanasia and assisted suicide
C1:  Describe the models of palliative care delivery and their utilization
C2:  Describe the societal and environmental factors relevant to the care of the dying
A3:  Describe current barriers in providing better care for the dying
C3:  Describe the barriers to effective care across settings
C4:  Describe the role of family physicians and specialists in the care of the terminally ill
C11:  Describe the role of palliative care consultants

Month 12:
B15: Act as a role model for other residents and physicians
D1:  Become a role model by demonstrating skilful care of the dying
B1:  Consultant level diagnostic and therapeutic skills for ethical and effective patient care
B16: Demonstrate effective consultation and communication skills in working with referring physicians
C5:  Demonstrate the ability to work effectively in institutional and community-based palliative care programs
B14: Demonstrate adequate skills in educating and learning from members of the interdisciplinary team
C12: Advocate for the needs of their home care patients
E6:  Act as an effective advocate for the rights of patients and family in clinical situations involving serious ethical considerations
D3:  Assist institutional and community palliative care programs in developing standards of care consistent with accepted standards
A9:  Demonstrate an ongoing commitment to a patient and family from the time of palliative medicine consultation for a terminal illness until a patient dies and to the family around the time of death

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PALLIATIVE CARE FELLOWSHIP: DEVELOPMENTAL SCHEMATICS