advocacy and professionalism in nephrology
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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
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
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
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