Program Overview

Program Overview

Introduction

The University of Washington Palliative Medicine Fellowship Program utilizes comprehensive inpatient, outpatient, long term care, hospice, and community experiences in several facilities.  A diverse patient population enhances the experience and training.  There are strong faculty role models in research, education, and clinical care to develop the skills for future leaders of palliative medicine.

The patient populations fellows encounter and engage in care are extremely diverse, from failed bone marrow transplant patients, immigrant, refugee, and socio-economically deprived persons,  veterans, and profoundly ill children.  Fellows not only care for patients of diverse cultural and socioeconomic backgrounds, but also of diverse age, level of debility, and condition.

Palliative Care Consultation Services

The Palliative Care Consultation Services (PCCS) at UWMC, HMC, SCH, and the VA see patients referred from any inpatient service team in medicine or surgery services.  PCCS helps the patient, family and care team with goal-setting and care directives, assesses patient appropriateness for and interest in hospice care, advises the primary care team on symptom management and care planning, provides information and emotional support to patients and families, and facilitates discharge planning to community hospices and other agencies. The PCCS team follows patients from initial referral until death or discharge to community-based services.

Fellows over several months will spend time in inpatient consultation in hospital settings. Fellows interview and examine patients with life-threatening illness, participate in family meetings in which goals of care and advance care planning are discussed, accurately document these discussions, goals, and directives in the medical record, and communicate as well as work effectively with other members of the interdisciplinary team.  This is an intensive experience which is usually emotionally and existentially taxing.  By participating on the Palliative Care Consultation Teams, fellows observe and learn about the strengths and limits of their attending mentors and other palliative care providers (e.g., nurses, social workers, clergy).

By participating on the Palliative Care Consultation Teams, fellows observe and learn about professional behavior and application of ethical principles, from faculty and other palliative care providers.

Fellows are encouraged to attend Ethics Forum, a monthly conference about various medical ethics topics. Several of our core faculty members are nationally known medical ethicists, namely Dr. Pearlman and  Dr. Vig.   Adherence to ethical principles is necessary when end of life care and other difficult management issues are discussed, particularly for patients who often are not able to speak for themselves.  Inpatient consultation experiences will promote professional behavior, responsibilities, and application of ethical principles.

Health services utilization and financial aspects of palliative medicine are routinely addressed during inpatient consultation months, and are a frequent topic of palliative medicine grand rounds and journal club. Since fellows actively participate in these activities, their competence in these areas are incorporated into their evaluations on inpatient consultation months.

During consultation and hospice visits, fellows gain experiential knowledge by seeing teaching skills modeled by hospice staff and faculty. These skills are expanded in more formal settings such as grand rounds, professional development seminars, team meetings and journal club. By experiencing the talents of faculty and hospice team members during consultation and visits with patient and families, and by engaging in these activities as an active team member, fellows improve their skills by modeling and feedback from other team members. Formal feedback is also available in formal evaluation via MedHub, however more value in terms of timely, practice-altering feedback likely comes during real clinical encounters. Fellows are expected to develop overt, codified plans to engage in self-reflection and self-assessment. Inpatient consultation experiences, as well as other rotations and conference activities, furthers life-long learning principles and self-identified learning and self-improvement goals.

HMC Palliative Care Clinic

Fellows are assigned to Wednesday afternoon clinics.  Faculty members are likewise assigned to one of these two clinic times.  Fellows have clinic every other week. New patients get long appointments to allow staff to perform assessments.  Nurses will also do lab draws, wound care, I&O catheterizations, IV starts with hydration, EKGs, medication treatments, and injections.

There is usually an attending assigned to the clinic for entire day.  It is expected that the attending will personally see each patient and write a chart note if billed at a level three, four or five.  The attending must cosign the billing forms.  Fellows must enter into ORCA all clinic notes, as well as review and sign all notes.

The clinic dietician, and social worker, share the same workspace during clinic times and are available for immediate consultation.

The clinic nurse manager fields numerous patient phone calls, assists with medication management, and follows up on lab results needing urgent attention.  She is extremely helpful in getting patients scheduled for appointments and triaging questions/care issues to the appropriate provider. Be sure to notify her, as well as the appointment desk for schedule changes and vacation times. Pharmacists  are present during all clinic times to counsel patients, refill meds and help with medication issues.  They will follow-up on drug levels and adjust medication doses if alerted to this issue.  They also function as the anticoagulation clinic.

Long Term Care (LTC) Contracted Facilities

Patients discharged from the Palliative Fellow Program training hospitals; HMC, UWMC, VA, Childrens to affiliated community nursing homes are followed by the UW Medicine Long Term Care Service (LTCS) directed by W McCormick MD.

The Long Term Care Service follows over 700 patients in 15 area nursing homes or other LTC settings.  LTCS is composed of 6 MDs and 6 ARNPs with 3 support staff.   Patients seen by PCCS in hospital receive follow-up in LTC settings: inpatient electronic medical records are available via high-speed access in all affiliated nursing homes.  Nursing home documentation is entered into the UW EMR, as are house calls for purposes of continuity and follow up.

One affiliated facility is Bailey Boushay House, a skilled nursing facility and day health center for persons with AIDS and other life-threatening illnesses.  In existence for 20 years, Dr. McCormick has served as Medical Director of this facility since it opened, and has coordinated student, resident and fellow training in the facility during this time.   Bailey Boushay House is a nationally recognized institution for excellence in palliative care.

Interdisciplinary Team (IDT))

Interdisciplinary team meetings at several training venues offer fellows the opportunity to build skills as team members and as team leaders.  For example, at Providence Hospice of Seattle, the IDT consists of 20-30 members – 6 hospice teams; social worker, nurse, aide, chaplains, pharmacist, occupational therapist, grief support staff, staff from volunteers division and Safe Crossings for children close to hospice clients, Medical Director, a manager, and trainees from several disciplines; medical students, social work students.

All hospice clients are discussed every other week regarding their clinical and psychosocial condition as well as that of loved ones.  The fellows learn the dynamics of IDT, the function of members, and provide direct input as a team member and leader in the roles of hospice physician and Medical Director, respectively.

Teaching Skills

Fellows gain important teaching skills in several venues during the fellowship.  During consultation and hospice visits, they gain experiential knowledge by seeing teaching skills modeled by hospice staff and faculty.  These skills are expanded in more formal settings such as grand rounds, professional development seminars, team meetings and journal club.

By experiencing the talents of faculty and hospice team members during consultation and visits with patient and families, and by engaging in these activities as an active team member, fellows improve their skills by modeling and feedback from other team members.  Formal feedback is also available in formal evaluation via MedHub, however more value in terms of timely, practice-altering feedback likely comes during real clinical encounters.

Conferences

Grand Rounds
Resident Conferences
Palliative Care Rounds
Ethics Seminar