This proposal is
submitted by an established group
of medical educators with expertise
in adult learning, and in palliative
care (see Appendix
II for description of PC). This
planning grant responds to a long
standing need for effective case based
and systems responsive palliative
care education, not only at the end
of life but also for severe chronic
illness and acute life threatening
illness. In addition, the recent passage
of AB487 in the State of California
"requires physicians and surgeons
to complete a mandatory continuing
education course in the subjects of
pain management and the treatment
of terminally ill and dying patients
by December 31, 2006." This planning
grant would be used as a springboard
for a full-scale implementation grant
leading to a web-based program within
two years.
1. Does the proposal
describe a collaboration that will
address a difficult and instructional
problem (e.g., bottleneck courses)?
Yes. This is a difficult instructional
problem with limited expertise at
most campuses. At UCD there is distributed
throughout the medical school ten
to twenty hours over four years of
integrated and progressive palliative
care and pain management education
by the co-investigators. This includes
discussions in psychiatry, oncology,
and the clinical years. However, the
medical school has insufficient hours
to provide individualized needs. In
addition, beyond the medical school
including post-graduate years no instruction
is ongoing. The different types of
students who need such instruction
are listed in Appendix IA. The diversity
of the students mandates a diverse
menu of opportunities, which could
be achieved using web-based learning.
In addition, the menu could be organized
by field of interest (Appendix
1B) or by special interest groups
that cut across specific interests
(Appendix 1C).
2. Does the proposal
reflect sufficient pre-planning so
the grant funds can be used productively
to determine feasibility or the development
of implementation proposal?
Yes, we are an established group of
educational investigators who now
wish to use web-based education. The
mini-planning grant will be used to
develop multi-campus meetings with
Dr. Wilkes' collaborators at UCLA
and Dr. Meyers' collaborators nationally
as well as a series of selected investigators
at UC Davis. Dr. Wilkes has confirmed
that Dr. Jerome Hoffman, director
of the doctoring program at UCLA will
join the project. In addition, we
will approach Dr. Bruce Ferrell at
the UCLA geriatrics and palliative
care program and Dr. Steven Pantilat
at UCSF who has a K23 grant in end
of life care for hospital based medicine.
This mini-grant
is highly responsive to the call.
The core faculty submitting this proposal
has established collaborations and
expertise. For example, Dr. Meyers
and Dr. Nesbitt have multiple grants
together. Dr. Fishman and Dr. Meyers
have a collaborative clinical and
educational program in palliative
care education established. Dr. Wilkes
has already established collaborations
with Dr. Nesbitt and they have a new
grant from CDC to do web based education
in screening for illness.
The planning mini-grant
is very appropriate for this group.
Two of the investigators, Drs. Nesbitt
and Wilkes are already expert in the
field of web-based learning. Dr. Wilkes
and Dr. Malathi Srinivasan are experts
at the evaluation of education programs
and will provide outcomes data. The
other two investigators Drs. Meyers
and Fishman are well-established educators
in the area of palliative care and
pain management. Dr Meyers received
an NIH/NCI R25 for palliative care
education in 1994 and has received
a highly favorable score for a second
R25. These four nationally recognized
faculty would put together a more
mature proposal by the time full proposals
are due by April 18, 2002. We anticipate
a core group of modules for every
student followed by an expanded menu
that students could interact with,
depending on their field of interest
(Appendix IB).
3. Does the proposal
define a set of planning objectives
that have a reasonable chance of leading
to a full-scale implementation grant
proposal?
The objectives of this mini-planning
grant are the following:
a. Establish the core and elective
modules for web-based palliative care
education.
b. Review the technology available
including video clips, interactive
exams, didactic and web-links to enhance
education.
c. Develop outcome measurements for
the core proposal and the follow-up
proposals.
d. Review existing web-based programs
and pursue. This pre-proposal has
been well received both internally
as well as at the National Cancer
Institute for the potential for expanded
funding as a cancer education grant.
The preliminary data developed during
this planning mini-grant, which support
both the full-scale implementation
grant as well as a possible NCI R25
grant.
e. Evaluation of a web-based curriculum
on palliative care.
Our a prior hypothesis
is that a web-based curriculum is
an effective and flexible method of
communicating content to learners.
For instance, a controlled study by
Dr. Douglas Bell at UCLA compared
the efficacy of traditional paper
instruction versus web-based instruction
in teaching evidence based medicine,
and found comparable learner content
mastery in both mediums, but higher
learner satisfaction in the web-based
group.
This web-based palliative
care program will follow David Kern's
six-step method for curriculum development
in medical education. We have already
completed step one, a general needs
assessment in palliative care education,
as discussed in the introduction.
We will conduct a targeted needs assessment
of learners and patients, using facilitated
small group methods. The investigators
will then formulate broad curricular
goals with specific measurable objectives
and "critical success" measures.
Content validity will be obtained
through content analysis, expert judgment
and literature review. To improve
rating reliability, behaviors will
be defined as concretely as possible.
Step four, identification of educational
strategies (theory, content and methods),
has been discussed. The philosophy
of web-based education draws on the
best of androgogic education, with
attention to behavioral and cognitive
educational theory. The web-based
curriculum will include both content
and content testing. Therefore, learners
will have the opportunity for both
formative and summative feedback.
We will then implement the curriculum
with a defined group of learners.
Step six, program
evaluation, will be broadly divided
into three sections: 1) Evaluation
of the utility of the method of education
(web-based curriculum). 2) evaluation
of the learner's mastery of the curricular
material and objectives, and 3) Evaluation
of the learner's and educator's satisfaction
with the method of education. We will
examine all three areas, since a learner
might use the web site, and master
some material, but find the method
of instruction cumbersome. A satisfaction
questionnaire will be generated through
modifying existing validated learner
satisfaction instruments for the palliative
care. Data will be analyzed by training
level and experience of learner. Confounders
in learning assessment, such as learner's
study habits and use of outside material
will be examined.
This pilot study
will allow us to demonstrate content
mastery and web site utility. However,
next steps involve following content
mastery of learners longitudinally,
and examining the practice patterns
of learners who have demonstrated
content mastery through chart review
and unannounced standardized patient
visits to clinic.
APPENDIX
I
A.
Users By Title
1. Physicians
2. Nurses
3. Social Workers
4. Pharmacists
5. Chaplaincy
6. Students
* Undergraduate Students
* Medical Students
* Graduate Medical Education Including
Residents/Fellows and Practicing Physicians
7. Lay Community
8. Basic Scientists
B.
By Disease/Condition (Field of Interest)
1. Cancer
2. AIDS
3. Advanced Lung Disease
4. Advanced Heart Disease
5. Geriatrics
6. Pediatrics
7. Social Work and Spirituality
8. Advanced Renal Disease
9I. Advanced Neurologic Degenerative
Disease
10. Special Populations: rural, VA,
correctional, others
11 . Cultural and Ethnic Issues
12. Defining Palliative Care
13. Application to Non-Lethal States
14. Catastrophic, Sudden and Unanticipated
Illness/Injury, with or without Death
as Probable Endpoint
C.
By Special Interest
1. Investigational Therapy
2. Integration of Palliative Care
Early in Illness - Chronic Illness
Management
3. Ethics and Prognostication and
PAD
4. Medical Education
5. Outcome Assessment
6. Cross-cultural Medicine
7. Correctional Palliative Care
8. Rural Palliative Care
9. Palliative Care in Patients Who
Lack Access
10. Health Services Research
* Quality of Life as an Outcome Measure
* Quality of Care as an Outcome Measure
11. Community Based Organizations
12. Hospice as a model of PC delivered
by an IDT
13. In-Patient Medicine
* Hospitals
* ICU
* Consults
14. Symptom management including pain,
nutrition/cachexia, dyspnea, others
15. Substance Department/Abusing Active
or Prior
16. Known
* Peds
* Women
* People of Color
* Geriatrics
17. Nursing Home Care
18. Grief/Bereavement
19. Communications
* Breaking Bad News
* Family Conferences
* Reassessment
* Team Communication
20. The V.A., Kaiser, Other Self-contained
Systems
21. Psychiatry
APPENDIX
II - PALLIATIVE CARE
To palliate is to
"reduce the violence" of
an event. Therefore, palliative care
is to reduce the violence of illness.
Another definition of palliative care
is the relief of emotional and physical
suffering by an interdisciplinary
team in which the focus of care is
the quality of life of the patient
and their family. Quality of life
is now defined both scientifically
using QOL instruments as well as clinically
including several domains defined
by the patient such as spiritual,
financial, and interpersonal well-being,
therapeutic effectiveness and management,
etc. There is a science and art to
palliative care. The science includes
the effective use of pain medications,
utilization of community resources
(grief and bereavement). The science
includes comprehensive care by the
IDT to resolve social and emotional
issues for the patient and family.
It includes adaptive survivorship
around grief and bereavement and knowledge
of practical resources. The art includes
the development of a compassionate
and creative clinician able to recognize
the needs of both the community as
well as the patient. The art includes
effective communication, the development
of longitudinal relationships, tolerance
for anxiety and ambivalence for the
provider to show up with regular visits,
being an attentive listener to the
patient with the skills and resources
to lead the discussion. The science
and art can be taught effectively.
While physician-assisted
suicide has become the topic for discussion
around the country, in fact there
is now recognized the potential for
personal and family growth at the
end of life.
Most people equate
palliative care with hospice. Hospice
is the ideal and effective way to
deliver IDT based systemic support
to patients, family and to provides.
However, palliative care is appropriate
at any point during illness, both
the acute and chronic. Palliative
care should be integrated and layered
into chronic illness starting at the
initial diagnoses and becoming a greater
aspect of care as disease progresses
and changes over years and decades.
This reflects a change in the goals
of treatment from cure to control
to comfort care as the disease makes
biology makes transitions. The ability
for the patient, the family and the
caregiver to respond to such questions
as: "What is the meaning of my
life in relationship to others?"
"What did I make of my life?"
And finally, "What does life
mean?" Often our interpersonal
and existential tasks facilitate closer
and effective transitions by family
and friends after death. This orderly
transition including bereavement and
funeral planning and resource needs
allows us the effective life review
for the patient to find meaning in
the experience of illness. Adjustment
to disease is incremental and the
experience seldom matches anticipation
or projection.
