An Advocacy and Professionalism

module for Nephrology trainees

Lorraine Bell MD FRCPC Program Director Pediatric Nephrology

Director Pediatric Renal Transplantation Director Pediatric Transition to Adult Care

McGill University Health Centre

lorraine.bell@mcgill.ca

I have no conflicts of interest to disclose, financial or otherwise

Professional

Scholar Manager

Communicator

Collaborator

Health Advocate

Medical Expert

The Teaching and ITER Dilemmas

How well do we teach

and

How well do we assess

The Advocate Role

The Professional Role

in Nephrology?

Cannot Assess

Unsatisfactory Borderline Satisfactory Superior

Health advocate

Identifies patients’ determinants of health; adapts assessment and management

Identifies communities of patients at risk and responds

Professional

Demonstrates integrity, honesty, compassion, and respect for diversity

Understands medical, legal, and professional obligations of the nephrologist

Understands and applies principles of clinical ethics

The ITER Dilemma

Cannot Assess

Unsatisfactory Borderline Satisfactory Superior

Health advocate

Identifies patients’ determinants of health; adapts assessment and management

Identifies communities of patients at risk and responds

Professional

Demonstrates integrity, honesty, compassion, and respect for diversity

Understands medical, legal, and professional obligations of the nephrologist

Understands and applies principles of clinical ethics

The ITER Dilemma

Development of Advocacy and Professionalism module for nephrology trainees Interactive 4-session (8-hour) module Piloted last year with McGill Nephrology

trainees (3 pediatric, 2 adult)

The Teaching and ITER Dilemmas

Module Philosophy and Format Learning through participation Readings, reflection Workshops Case discussions (residents’ and “pre-created”) Group work, “formal” debate, and option for role

plays Propose 2 personally relevant projects involving

Community and Patient Advocacy in Nephrology

1st Session Theme

Introduction to components of CanMEDS concepts of advocacy and professionalism

Overlaps in Advocacy and Professionalism

Exploration of the “Determinants of Health”

Application to case studies

Overlap of Advocate

1. Identify / Respond to Determinants of health Health needs

2. Promote health for Individual patient,

communities, populations

Professional Responsible to

society

Promote public good in health care

Altruistic

Disclose errors, adverse events

http://www.count-me-in.ca/forums/slides/inclusion2.html

2nd Session Theme Initiation, withholding or withdrawal of dialysis

National Survey Questions

0 10 20 30 40 50 60 70 80 90 100

Determine when to refer to a hospice

Respond to request to stop dialysis

Help with reconciliation and goodbyes

Assess and manage depression at eol

Tell patient he/she is dying

Treat pain

During your fellowship were you explicitly taught to

% Nephrology residents who received explicit teaching

Holley et al: AJKD 2003: End-of-life care training in nephrology: national survey of nephrology fellows

Comparison of teaching in different areas

Holley et al: AJKD 2003: End-of-life care training in nephrology: national survey of nephrology fellows

2nd Session Theme Initiation, withholding or withdrawal of dialysis

Role of palliative care Review of Clinical Practice Guideline:

“Shared decision-making in appropriate initiation of and withdrawal from dialysis”

Case analy

Case analyses

October 2010 (2nd edition) Renal Physicians Association www.renalmd.org

3rd Session Theme

Analysed in terms of Ethics: Health care professionals duties

Respect for autonomy Beneficence Nonmaleficence Justice

Harmful Behaviours of patient To patient only To dialysis unit function To other patients/ staff

Hashmi &Moss: Nature Clin Prac Nephrol 2008

The difficult dialysis patient

Mr Eyfru Straityiu 25 year old man - hemodialysis x 18 months

Failed kidney/ pancreas transplant

Frequent “flyer” in ER Severe hypo/ hyper-glycemic episodes Severe volume overload and pulmonary edema urgent dialysis

Difficult dialysis unit behaviors Verbally abusive Often late disrupting schedule Upsets other patients Skips treatments

Mr Eyfru Straityiu Explored issue in term of Medical factors

Patient preferences Quality of life issues Contextual features Patient and coping mechanisms Personnel and response Health care system

4th Session Theme Moral, ethical and societal issues of organ sales and “transplant tourism”

Debate

“A legal and regulated market for donors to sell kidneys for transplantation should be established”

Professional

Scholar Manager

Communicator

Collaborator

Health Advocate

Medical Expert

Evaluation of Advocacy and Professionalism

Module

Participant self-assessment Understanding of Before After P

Median Mean (SD)

Median Mean (SD)

Community Advocacy 2 2.2 (0.8)

4 3.6 (0.9)

0.005

Determinants of Health 2 1.6 (0.5)

4 4 (0) <0.001

Elements of Professionalism 3 2.6 (0.9)

5 4.4(0.9)

<0.001

Issues contributing to “difficult” patient (4)

2.5 2.3 (1.0)

4 4 (0) 0.03

Ethical, societal issues of organ sales; Tx tourism (4)

2 2.0 (0.8)

5 4.8 (0.5)

<0.001

“Comfort” with decision to withhold/withdraw dialysis (3)

2 2.3 (0.6)

4 3.7 (0.6)

0.06

Overall knowledge of topics covered

2 2.2 (0.4)

4 4.0 (0) <0.001

Participant self-assessment Understanding of Before After P

Median Mean (SD)

Median Mean (SD)

Community Advocacy 2 2.2 (0.8)

4 3.6 (0.9)

0.005

Determinants of Health 2 1.6 (0.5)

4 4 (0) <0.001

Elements of Professionalism 3 2.6 (0.9)

5 4.4(0.9)

<0.001

Issues contributing to “difficult” patient (4)

2.5 2.3 (1.0)

4 4 (0) 0.03

Ethical, societal issues of organ sales; Tx tourism (4)

2 2.0 (0.8)

5 4.8 (0.5)

<0.001

“Comfort” with decision to withhold/withdraw dialysis (3)

2 2.3 (0.6)

4 3.7 (0.6)

0.06

Overall knowledge of topics covered

2 2.2 (0.4)

4 4.0 (0) <0.001

Conclusions Need for curriculum content related to the non

medical expert CanMEDS roles

Current module filled one of several gaps in our nephrology teaching in this area

Format adaptable to other specialties /subspecialties with domain relevant content

The secret of the care of the patient

is in caring for the patient

Peabody, Francis W (1927) The Care of the Patient The Journal of the American Medical Association