Warum brauchen wir Faculty Development in der Palliativmedizin?

Die Notwendigkeit eines Faculty Developments für das Fach Palliativmedizin wurde von Dr. Susan D. Block 1998 eindrucksvoll und wissenschaftlich fundiert dargestellt. Relevante Abschnitte sind im Folgenden zusammengefasst:

Palliative Care Faculty Development Position Paper

Background
The education of health care professionals in the care of patients at the end of life and of their families is deficient.^1-3 Areas of inadequacy in both the medical and nursing professions include: pain and symptom control, psychosocial and spiritual support for the patient and family, communication, elicitation and implementation of patients' wishes for end-of-life care and other ethical issues, attention to cultural diversity in end-of-life care preferences, access to high-quality home care, and bereavement care. In addition, many physicians and nurses report dissatisfaction and discomfort with the care of terminally ill patients, particularly with the overuse of technology and the undertreatment of pain.⁴ Thus, there remains a critical need for the development of faculty capable of effectively modelling and teaching state-of-the-art pal-liative care in academic health centers.

Why is faculty development needed?
Educators recommend increased attention to teaching about palliative care during the clinical years and the development of palliative care learning opportunities in a wide variety of clinical settings (e.g., primary care, ICU, Emergency Department, nursing homes, hospice) and in multiple specialties (internal medicine, family medicine, paediatrics, neurology, oncology, critical care, surgery), yet faculty to carry out this teaching do not currently exist.¹ Faculty are not only unprepared in the content areas of palliative care, but are also untrained and unfamiliar with the particular educational approaches and processes that are effective in conveying key knowledge, attitudes, and skills to learners.

Several factors have contributed to the poor preparation of medical school faculty for their roles as educators about the end of life:

• Few faculty have adequate knowledge and skills for the practice of palliative care because this content, in general, was not well taught to them during their own medical education. Faculty who had little exposure to dying patients and to education about palliative care may not have developed a sense of competence in caring for the dying. A felt lack of competence in managing terminally ill patients might lead to avoidance of dying patients, as well as to an aversion to teaching about a topic that is troublesome, and for which they feel unprepared.
• Although physicians care for dying patients, they may not identify palliative care as a distinct discipline with a discrete knowledge base, associated clinical skills, and desirable (and teachable) attitudes.
• Comprehensive, integrated, interdisciplinary care of the dying, such as is practiced in hospice programs, has largely taken place outside of academic health centers, and thus faculty have little exposure to and understanding of this model of care.
• Finally, the cultures of academic health centers and medical education, in their emphases on curative treatment, tend to undermine attention to the human needs and concerns of patients and families facing the end of life.⁵

Moreover, there are few clinical sites suited to provide students with exemplary clinical experiences in palliative care since comprehensive integrated interdisciplinary care of the dying generally occurs outside the mainstream of most professional training programs. Even in institutions where there are faculty with clinical expertise in the discipline of palliative care, these faculty often lack teaching skills that will allow them to effectively transmit their expertise to learners.

In addition to developing expertise in the clinical field of palliative medicine, to be outstanding educators about end-of-life care, faculty need to develop expertise in the methods and processes for addressing the particular challenges that arise in teaching about palliative care.⁶ Medical faculty development efforts have documented high levels of receptivity by attending physicians to skills development assistance by other faculty.⁷

Teaching about care near the end of life holds special challenges. Effective teaching requires attention to the learner's personal experiences with and attitudes towards death and dying.⁸ Faculty members are unlikely to be comfortable addressing these issues unless they have first reflected on and explored their own feelings about death and dying. Faculty, like other physi-cians, are often uncomfortable in communicating with patients about end-of-life issues;⁹, this discomfort is often conveyed to students and residents by their teachers and can undermine even the most excellent educational programs on this topic. The tendency to avoid communication about difficult end-of-life issues must be addressed before faculty can become effective educators.

Previous work has established that faculty who participate in faculty development programs often return to their institutions and assume leadership roles in their institutions as "champions" for the area in which they have completed a faculty development program.

These individuals develop curricula, initiate new clinical rotations, organize new teaching venues, raise consciousness among peers, develop their own local faculty development programs to educate other faculty and to teach residents and students, and generally stimulate attention to a new, or emerging, field.

Structuring a faculty development program:
Based on the literature about effective faculty development programs¹⁰ and previous experiences, the Subcommittee identified the following as key issues that must be demonstrated by any faculty development model:

Curriculum Content based on identified needs of participants:

• a systematic approach to the scope and content of palliative care
• a systematic approach to the teaching of end-of-life communication skills
• a systematic approach to achieving educational goals
• a curriculum that integrates theory and practice
• a program that offers opportunities for practice and feedback
• a program that includes exposure to a variety of different types of teaching and different teaching philosophies
• commitment to an interdisciplinary model of end-of-life care
• attention to non-cancer diagnoses
• attention to care in a variety of clinical sites (hospital, long-term care, home, etc.)
• attention to pluralism and diversity
• a plan that balances attention to depth of coverage and breadth of coverage of key issues
• commitment to comprehensive teaching addressing knowledge, skills, and attitudes
• curriculum should be amenable to individualization based on the needs of the participant.

Experienced and knowledgeable faculty:

• a critical mass of knowledgeable and committed educators from multiple disciplines
• understanding of characteristics of teachers, setting, and context
• appreciation of the complexity of clinical and educational tasks
• commitment to building relationships among faculty and participants
• program evaluation capability linked to program objectives

References

1. Billings JA, Block SD. Palliative care in undergraduate medical education: Status report and future directions. JAMA 1997;278:733-738.
2. Billings JA. Medical education for hospice care: A selected bibliography with annotations. Hospice J 1993;9:69-83.
3. Field MJ, Cassell CK. Approaching Death: Improving Care at the End of Life. Institute of Medicine Committee on Care at the End of Life. National Academy Press, Washington, D.C. 1997.
4. Solomon MZ, O'Donnell L, Jennings B, Guilfoy V et al. Decisions near the end of life: Professional views on life-sustaining treatments. Am J Pub Health 1993;83:14-23.
5. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994;69:861-871.
6. Skeff KM, Stratos GA, Bergen MR, Albright CL et al. The Stanford Faculty Development Program: A dissemination approach to faculty development for medical teachers. Teaching and Learning in Medicine 1992;4:180-197.
7. Skeff KM, Stratos G, Campbell M, Cooke M, Jones HW. Evaluation of the seminar method to improve clinical teaching. J Gen Int Med 1986;315-322.
8. Hill TP. Treating the dying patient: the challenge for medical education. Arch Intern Med 1995;155:1265-1269
9. Johnston SC, Pfeifer MP, and the End-of-Life Study Group. Patient and physician roles in end-of-life decision making. J Gen Intern Med 1998;13:43-45.
10. Bland CJ, Stritter FT. Characteristics of effective family medicine faculty development programs. Family Medicine 1988;20:282-288.