Tertiary Inpatient Palliative Care within Region-Wide Services: A Retrospective Examination of Psychosocial and Medical Demographics at Admissions.

Palliative care offers symptom relief and improved quality of life. Tertiary palliative care units (TPCUs) focus on complex suffering under the care of specialist palliative physicians and interdisciplinary teams. The Intensive Palliative Care Unit (IPCU) is a TPCU integrated in well-developed region-wide palliative services in Calgary, Canada. We compared the population accessing the IPCU to published data from other Canadian sites. METHODS: A retrospective chart review was conducted using 8 sample months over a 2-year period. We gleaned psychosocial and medical demographics alongside the self-reported symptom burden on the Edmonton Symptom Assessment System. Descriptive statistics were calculated. RESULTS: Adults (n = 117) with cancer admitted to the IPCU were 5-10 years younger, had later-stage cancer, and had higher discharges to preferred locations than other published Canadian TPCUs. Up to two months before admission, most commonly reported symptoms were consistent with the outpatient literature although with higher reported intensity. DISCUSSION: With more advanced disease, younger age, and elevated symptom burden before admission, the IPCU still discharged patients to preferred locations at higher rates than other sites. This may be due to integration in the region's organized palliative care services. CONCLUSION: With proper integration, a TPCU may be able to improve quality of life and reduce deaths in hospitals.

Same storm, different boat: The global impact of COVID-19 on palliative care.

OBJECTIVE: The COVID-19 pandemic has had a complex and profound impact on the provision of palliative care globally. To support learning from palliative care providers and researchers worldwide, the Education Subcommittee of International Psycho-Oncology Society (IPOS) Palliative Care Special Interest Group developed a webinar with presentations by and discussion with eight international palliative care leaders. METHODS: Presentations were content rich; the speakers used both quantitative (e.g., sharing recent statistical findings) and qualitative (e.g., narrative storytelling, anecdotal experiences) approaches to portray the effect of COVID-19 in their region. Subsequent to the webinar, the committee collectively identified five themes conveyed by the presenters through consensus. RESULTS: The themes included: (1) altered accessibility to palliative care, with socio-economic status impacting virtual health availability; (2) reduced opportunities to preserve dignity, as survival has been prioritized over preserving the humanity of patients and their loved ones; (3) complicated grief and bereavement arising from social distancing requirements; (4) greater awareness of the importance of sustaining health provider well-being; and (5) the development of valuable innovations across nations, institutions, disciplines, and communities. CONCLUSIONS: Overall, the webinar facilitated valuable connection for global learning and identified opportunities for research and clinical interventions. In an ongoing crisis that has exacerbated isolation, we will need to continue to learn and lean on one another as a global community to navigate ongoing challenges of the COVID-19 pandemic.

Residents' transformational changes through self-regulated, experiential learning for professionalism.

Purpose: Postgraduate trainees ('residents") are required to convey professional behaviours as they navigate complex clinical environments. However, little is known about experiential learning for professionalism. Thus, we asked residents about professionalism challenges within the clinical learning environment: 1) how challenges were identified, 2) what supported successfully addressing challenges and 3) the impact of addressing challenges to further inform resident education. Method: From 2015-2016, twenty-five residents across specialties and multiple university affiliated teaching hospitals participated in appreciative inquiry informed audio-taped semi-structured interviews. Transcripts were categorized deductively for the 2015 CanMEDS Professional Role element addressed (commitment to patients, society, the profession, and physician health). A pragmatic research paradigm focussed descriptive data analysis on actions and outcomes. Results: Residents actively identify opportunities for experiential learning of professionalism within the clinical workplace- addressing conflicting priorities with interprofessional clinicians to ensure excellent patient care, providing informal feedback regarding peers' and other healthcare clinicians' professionalism lapses and by gaining self-awareness and maintaining wellness. There were no descriptions of commitment to society. Values, relationships, and reflection supported professional behaviours. Many described transformative personal and professional growth as an outcome of addressing professionalism challenges. Conclusions: Residents self-regulated experiential learning for professionalism often results in transformational changes personally and professionally. Elucidation of how residents successfully navigate power dynamics and conflict to provide excellent patient care and feedback for professional regulatory behaviour will support professionalism education. An interprofessional research lens will be valuable to explore how best to incorporate commitment to society within clinical environments.

Objectif: Il est attendu des stagiaires postdoctoraux (résidents) d'adopter des comportements professionnels dans les environnements cliniques complexes dans lesquels ils évoluent. Cependant, on sait peu de choses sur l'apprentissage expérientiel des comportements professionnels. Nous avons donc interrogé les résidents sur les défis qu'ils rencontrent en lien avec le professionnalisme dans leur environnement d'apprentissage clinique : 1) quels sont les problèmes qu'ils considèrent comme étant liés au professionnalisme, 2) qu'est-ce qui les a aidés à relever ces défis avec succès et 3) quels sont les effets de leur réaction à ces problématiques et quelles leçons peut-on tirer de ces résultats pour mieux adapter la formation des résidents. Méthode: Entre 2015 et 2016, 25 résidents de diverses spécialités et hôpitaux universitaires ont participé à des entretiens semi-structurés qui ont été menés selon une méthode d'interrogation appréciative et qui ont été enregistrés sur bande audio. Les transcriptions ont été catégorisées de manière déductive par rapport au rôle du professionnel du référentiel CanMEDS 2015 (engagement envers les patients, la société, la profession et la santé des médecins). Fondée sur un paradigme de recherche pragmatique, l'analyse des données descriptives ciblait les actions et les résultats. Résultats: Les résidents décèlent activement les occasions d'apprentissage expérientiel du professionnalisme dans le milieu de travail clinique et ils réagissent par exemple en abordant les priorités divergentes avec les cliniciens d'équipes interprofessionnelles de façon à assurer l'excellence des soins aux patients, en fournissant des commentaires informels à leurs pairs et à d'autres cliniciens sur les comportements non professionnels de ces derniers, en prenant conscience d'eux-mêmes et en privilégiant le bien-être. Ils n'ont pas proposé de description de l'engagement envers la société. Les valeurs, les relations et la réflexion sont les facteurs qui ont soutenu l'adoption de comportements professionnels. Un grand nombre de répondants ont déclaré avoir vécu une croissance personnelle et professionnelle transformatrice grâce à l'action qu'ils ont prise pour résoudre un problème de professionnalisme. Conclusions: L'apprentissage expérientiel autorégulé du professionnalisme par les résidents entraîne souvent des changements transformationnels pour eux sur les plans personnel et professionnel. Une compréhension approfondie de la gestion réussie des rapports de pouvoir et des conflits par les résidents leur permettant d'assurer la qualité des soins aux patients et de donner une rétroaction à leurs collègues sur la conformité de leur comportement professionnel contribuerait grandement à l'enseignement du professionnalisme. L'adoption d'une approche de recherche interprofessionnelle serait utile pour explorer la meilleure façon d'intégrer l'engagement envers la société dans l'environnement clinique.

Virtue and care ethics & humanism in medical education: a scoping review.

PURPOSE: This scoping review explores how virtue and care ethics are incorporated into health professions education and how these factors may relate to the development of humanistic patient care. METHOD: Our team identified citations in the literature emphasizing virtue ethics and care ethics (in PubMed, NLM Catalog, WorldCat, EthicsShare, EthxWeb, Globethics.net , Philosopher's Index, and ProQuest Central) lending themselves to constructs of humanism curricula. Our exclusion criteria consisted of non-English articles, those not addressing virtue and care ethics and humanism in medical pedagogy, and those not addressing aspects of character in health ethics. We examined in a stepwise fashion whether citations: 1) Contained definitions of virtue and care ethics; 2) Implemented virtue and care ethics in health care curricula; and 3) Evidenced patient-directed caregiver humanism. RESULTS: Eight hundred eleven citations were identified, 88 intensively reviewed, and the final 25 analyzed in-depth. We identified multiple key themes with relevant metaphors associated with virtue/care ethics, curricula, and humanism education. CONCLUSIONS: This research sought to better understand how virtue and care ethics can potentially promote humanism and identified themes that facilitate and impede this mission.

Reflecting on Palliative Care Integration in Canada: A Qualitative Report.

Studies have identified integrated interdisciplinary care as a hallmark of effective palliative care. Although models attempt to show how integration may function, there is little literature available that practically explores how integration is fostered and maintained. In this study we asked palliative care clinicians across Canada to comment on how services are integrated across the healthcare system. This is an analysis of qualitative data from a larger study, wherein clinicians provided written responses regarding their experiences. Content analysis was used to identify response categories. Clinicians (n = 14) included physicians, a nurse and a social worker from six provinces. They identified the benefits of formalized relationships and collaboration pathways with other services to streamline referral and consultation. Clinicians perceived a need for better training of residents and primary care physicians in the community and more acceptance, shared understanding, and referrals. Clinicians also described integrating well with oncology departments. Lastly, clinicians considered integration a complex process with departmental, provincial, and national involvement. The needs and strengths identified by the clinicians mirror the qualities of successfully integrated palliative care programs globally and highlight specific areas in policy, education, practice, and research that could benefit those in Canada.

Missing in Action: Reports of Interdisciplinary Integration in Canadian Palliative Care.

Palliative care has an interdisciplinary tradition and Canada is a leader in its research and practice. Yet even in Canada, a full interdisciplinary complement is often lacking, with psychosocial presence ranging from 0-67.4% depending on the discipline and region. We sought to examine the most notable gaps in care from the perspective of Canadian palliative professionals. Canadian directors of palliative care programs were surveyed with respect to interdisciplinary integration. Participants responded in writing or by phone interview. We operationalized reports of interdisciplinary professions as either "present" or "under/not-represented". The Vaismoradi, Turunen, and Bondas' procedure was used for content analysis. Our 14 participants consisted of physicians (85.7%), nurses (14.3%), and a social worker (7.1%) from Ontario (35.7%), British Columbia (14.3%), Alberta (14.3%), Quebec (14.3%), Nova Scotia (14.3%), and New Brunswick (7.1%). Psychology and social work were equally and most frequently reported as "under/not represented" (5/14, each). All participants reported the presence of medical professionals (physicians and nurses) and these groups were not reported as under/not represented. Spiritual care and others (e.g., rehabilitation and volunteers) were infrequently reported as "under/not represented". Qualitative themes included Commonly Represented Disciplines, Quality of Multidisciplinary Collaboration, Commonly Under-Represented Disciplines, and Special Concern: Psychosocial Care. Similar to previous reports, we found that (1) psychology was under-represented yet highly valued and (2) despite social work's relative high presence in care, our participants reported a higher need for more. These finding highlight those psychosocial gaps in care are most frequently noted by palliative care professionals, especially psychology and social work. We speculate on barriers and enablers to addressing this need.

Towards collective moral resilience: the potential of communities of practice during the COVID-19 pandemic and beyond.

This paper proposes communities of practice (CoP) as a process to build moral resilience in healthcare settings. We introduce the starting point of moral distress that arises from ethical challenges when actions of the healthcare professional are constrained. We examine how situations such as the current COVID-19 pandemic can exponentially increase moral distress in healthcare professionals. Then, we explore how moral resilience can help cope with moral distress. We propose the term collective moral resilience to capture the shared capacity arising from mutual engagement and dialogue in group settings, towards responding to individual moral distress and towards building an ethical practice environment. Finally, we look at CoPs in healthcare and explore how these group experiences can be used to build collective moral resilience.

Communities of practice: acknowledging vulnerability to improve resilience in healthcare teams.

The majority of healthcare professionals regularly witness fragility, suffering, pain and death in their professional lives. Such experiences may increase the risk of burnout and compassion fatigue, especially if they are without self-awareness and a healthy work environment. Acquiring a deeper understanding of vulnerability inherent to their professional work will be of crucial importance to face these risks. From a relational ethics perspective, the role of the team is critical in the development of professional values which can help to cope with the inherent vulnerability of healthcare professionals. The focus of this paper is the role of Communities of Practice as a source of resilience, since they can create a reflective space for recognising and sharing their experiences of vulnerability that arises as part of their work. This shared knowledge can be a source of strength while simultaneously increasing the confidence and resilience of the healthcare team.

Living in two worlds: Becoming and being a doctor among those who identify with "not from an advantaged background".

We aim to deepen understanding of the experiences of becoming and being a physician among those in medicine who are 'not from advantaged backgrounds'. Despite modest success with institutional efforts to increase the diversity of medical school students, individuals with this less visible dimension of diversity remain under-represented across North America and the UK. Further, little is known about their experiences and contributions following medical school entry. In-depth interviews were carried out with twelve participants, including eight medical students, a resident and three physicians to explore experiences in medicine among those who self-identify with 'not from an advantaged background'. Reflection on the meaning of those experiences was encouraged. Intersectional identifications were common in relation to 'not from an advantaged background'. For some, the latter was background to identification with upbringings that were rural, influence by ethnicity, personal or parental immigration, and parents who were single or had limited education. Themes that arose in relation to being and becoming a doctor for these participants included: (1) the hidden curriculum's contribution to silencing markers of socioeconomic under-privilege; (2) limited formal curriculum opportunities to discuss socio-economic difference; (3) professional identity construction including empathy for the varied challenges of low-income patients in clinical situations and (4) living in two worlds: with a tension between the medical world and one's original world of socializing with friends and family from a non-advantaged upbringing. This study offered a unique, welcome opportunity to reflect on professional identity development in relation to one's family's socio-economic status. Safe, inclusive pedagogical opportunities to discuss socio-economic status and its intersectional elements, may support professional identity development that includes empathy and responsiveness to health inequities. The open dialogue, although perhaps uncomfortable, may be valuable to enhance cultural humility among medical students. The assessment of such initiatives in relation to professional identity formation is an important next step.

An Axiological Analysis of One Medical School's Admissions Process: Exploring Individual Values and Value Systems.

PURPOSE: Values and value systems are fundamental to medical school admissions processes. An axiological analysis was carried out to explore the individual values and value systems found within the University of Calgary's Cumming School of Medicine's undergraduate admissions process. METHOD: A mixed-methods case study methodology was developed with a focus on applicant characteristics viewed as desirable, the relative value ascribed to applicant characteristics, the values that participants in admissions processes brought to bear, the values that were reflected in the artifacts and procedures used in support of admissions processes, and the values that were expressed at a system, program, or institutional level. The study employed a descriptive audit of admissions processes, a stakeholder survey, stakeholder interviews, and a discourse analysis of admissions materials (all carried out between June and September 2017). RESULTS: The study found that, despite a general sense of satisfaction with the rigor of the admissions process, there was less satisfaction with the final selection it produced. Participants wanted to see more attention paid to responsibilities to patients and society than to gender and ethnic balance. CONCLUSIONS: Those involved with medical school admissions need to be mindful of their value systems and use them to align intent with process and outcomes in selecting tomorrow's physicians. Axiological analysis of medical education processes can play a central role in reviewing and refocusing efforts on meeting an institution's social mission and medical education's social contract.

How clinicians integrate humanism in their clinical workplace-'Just trying to put myself in their human being shoes'.

INTRODUCTION: Humanism has been identified as an important contributor to patient care and physician wellness; however, what humanism means in the context of medicine has been limited by opinion and a focus on personal characteristics. Our aim was to describe attitudes and behaviours that enable clinicians to integrate humanism within the clinical setting. METHODS: We conducted semi-structured individual interviews with ten clinical faculty to explore how they enact and experience humanism in patient care and clinical teaching. Interpretive description was used to analyze the data qualitatively. RESULTS: Humanism in medicine was described through five themes representing core attitudes and behaviours: whole person care, valuing, perspective-taking, recognizing universality, and relational focus. Whole person care involved recognizing the multiple dimensions of personhood and sensitivity to others' needs; valuing involved respecting and appreciating others; perspective-taking consisted of considering others' perspectives, suspending judgment, and listening; recognizing universality involved acknowledging the shared human condition, finding common ground, transcending roles, and humility; and relational focus was described through multiple relationships between patients, families, clinicians and learners, becoming part of another's story, reciprocal influence, and accompaniment. CONCLUSIONS: Whereas previous descriptions of humanism have focused on clinicians' personal qualities, our research describes a number of attitudinal and behavioural foundations of humanistic care and teaching, grounded in the experiences of clinical faculty. In drawing attention to the holistic and relational elements of humanism, our work highlights how these foundational elements can be more explicitly integrated into patient care, workplace culture, and clinical education.

Outcomes From a Patient-Centered, Interprofessional, Palliative Consult Team in Oncology.

Background: Palliative care aims to improve suffering and quality of life for patients with life-limiting disease. This study evaluated an interdisciplinary palliative consultation team for outpatients with advanced cancer at the Tom Baker Cancer Centre. This team traditionally offered palliative medicine and recently integrated a specialized psychosocial clinician. Historic patient-reported clinical outcomes were reviewed. There were no a priori hypotheses. Methods: A total of 180 chart reviews were performed in 8 sample months in 2015 and 2016; 114 patients were included. All patients were referred for management of complex cancer symptomatology by oncology or palliative care clinicians. Patients attended initial interviews in person; palliative medicine follow-ups were largely performed by telephone, and psychosocial appointments were conducted in person for those who were interested and had psychosocial concerns. Chart review included collection of demographics, medical information, and screening for distress measures at referral, initial consult, and discharge. Results: A total of 51% of the patient sample were men, 81% were living with a partner, and 87% had an advanced cancer diagnosis. Patients were grouped based on high, moderate, or low scores for 5 symptoms (pain, fatigue, depression, anxiety, and well-being). High scores on all 5 symptoms decreased from referral to discharge. Pain and anxiety decreased in the moderate group. All 5 low scores increased significantly. Sleep, frustration/anger, sense of burdening others, and sensitivity to cold were less frequently endorsed by discharge. Conclusions: Patients who completed this interdisciplinary palliative consult service appeared to experience a reduction in their most severe symptoms. Visits to patients during existing appointments or having them attend a half-day clinic appears to have reached those referred. With interdisciplinary integration, clinicians are able to collaborate to address patient care needs. Considerations include how to further integrate palliative and psychosocial care to achieve additional benefits and ongoing monitoring of changes in symptom burden.

A practical approach to mentoring students with repeated performance deficiencies.

BACKGROUND: With the increasing use of competency-based evaluations we now have more and better ways to identify performance deficiencies in our learners. Yet the emphasis placed on identifying deficiencies appears to exceed that given to improving these deficiencies. AIMS: Here we describe the program at the University of Calgary for mentoring students with repeated performance deficiencies. We focus primarily on the key steps of mentoring and remediation, and establishing a program that provides consistency and accountability to this process. CONCLUSIONS: A small cohort of trainees with persistent performance deficiencies may need intensive remediation to reach the expected level of performance. Ultimately, not all learners will be successful in their remediation, but we feel that it is the responsibility of training programs to provide mentorship and an organized approach to remediation in order to maximize the chances of successful remediation.

Do single and partnered women with gynecologic cancer differ in types and intensities of illness- and treatment-related psychosocial concerns? A pilot study.

OBJECTIVE: We compared the psychosocial and psychosexual concerns of single and partnered women with gynecologic cancer, since relationship status and psychosocial context are known to affect sexuality, a life domain commonly affected by this cancer. METHOD: A cross-sectional convenience sample of 49 women (68% response), with ovarian (n=31), endometrial (n=12), and cervical (n=6) cancer, responded to a 72-item self-report Cancer Concerns Questionnaire and additional psychosocial questionnaires. RESULTS: Single (n=13) and partnered women (n=36) similarly reported prognosis as their highest concern, but single women (26% of the sample) reported that communication with the treatment team, treatment side effects, and prognosis were of greater salience to them than did partnered women. The latter group had greater sexuality and partner relationship concerns. CONCLUSION: These preliminary findings suggest that relationship status, whether partnered or single, influences current psychosocial concerns among women with gynecologic cancer, despite similar levels of illness- and treatment-related intrusions on important life domains.

A comparison of evaluations of male and female psychiatry supervisors.

OBJECTIVE: To assess whether male and female psychiatry supervisors are evaluated differently by psychiatry residents. METHODS: The University of Toronto Department of Psychiatry compiled anonymous supervisor evaluations completed semiannually by psychiatry residents over a period of 3 years. Male and female psychiatry supervisors' ratings were compared by using t-tests, effect estimates, and chi-square analyses. Results from these ratings were discussed in a resident focus group. RESULTS: Female psychiatry supervisors (n=76) were rated significantly lower than male supervisors (n=222), both overall (P<0.05) and in the areas of enthusiasm (P<0.05), clarity (P<0.05), and knowledge (P<0.001). CONCLUSIONS: Future studies comparing evaluations of supervision by male and female psychiatrists must control for academic rank, numbers of publications, and hours of teaching. Comparing evaluations of the various male-female supervisory pairs will be useful to assess for gender biases.