#4: Member experiences blog: Getting involved in PalliSIM as a foundation doctor

Bio:

Hi ! We are Sally and Rachel, two foundation doctors working in London and Thames Valley, respectively, and have chosen to share our experiences of the work that we are doing on improving palliative care education for foundation trainees through simulation training.

 

 

Recognising the dying patient:

As was the case for many, our first months as doctors were shaped by the presence of COVID-19. Alongside the usual FY1 learning curves of ward round etiquette and discharge paperwork, we were also mastering the art of doffing, the one-shot ABG and the correct pronunciation of tocilizumab. 

 

Sally recalls her first experience of breaking bad news and dealing with death:  “It was on my second day on the COVID ward when a patient was assessed by the consultant as ‘acutely dying’. My SpR kindly offered to call the family but was called away to clinic almost immediately as the ward round finished. I was left with no escape when three members of the patient’s family turned up at the ward door.

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I explained our impression to the family as best I could. My panic drove out any sense of compassion or care. I concluded with ‘there’s nothing more we can do’ – untrue, unhelpful and more likely to have been borrowed from an episode of Scrubs than the result of any ‘comms skills’ learnt at medical school. I distinctly remember thinking that, somehow, I should have practiced this conversation beforehand, as I would have unquestionably done so for a chest drain or lumbar puncture”.

 

Simulation-based medical education (SBME) is increasingly recognised as an integral part of training for all healthcare professionals (1,2). Foundation SIM sessions can be fun - a chance to catch up with colleagues, revisit the grooves of med school knowledge and gain confidence for when a real asthma attack/sepsis/MI/upper GI bleed occurs on the wards.

 

In managing her first dying patient, however, Sally was not alone in feeling ‘thrown in the deep end’ (3). Recognising dying, breaking bad news and prescribing complex, controlled medications for symptom control remains some of the most feared tasks of any junior doctor (3). The efficacy of SBME is well-established (1,2), however, there is a lack of rigorous evaluation of using SBME to train doctors in the skills of palliative care (4-7). Recently, a SBME palliative care curriculum has been designed for Internal Medicine Trainees, in-keeping with their mandated competencies, and this is currently undergoing national adoption and evaluation (8). However, no such equivalent exists for foundation doctors, despite recognised inconsistency in the provision of palliative care education in the undergraduate curriculum (9,10). Moreover, the skills of palliative care skills map directly onto the ‘Higher Level Outcomes’ of Foundation Professional Capabilities, whilst teaching on ‘End of Life Care’ and ‘Integration of Acute Illness into Chronic Disease Management’ is a mandatory requirement of the Foundation Doctor Core Curriculum, with simulation highly recommended by the UK Foundation Programme as a teaching methodology (11). Meanwhile, it is the foundation doctor who is most likely to be present on the ward at visiting time and thus most likely asked to update friends and family at the bedside.

 

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PalliSIM:

PalliSim Network is a collaborative of generalist and palliative medicine doctors, nurses and allied health professionals with a background in medical education and simulation, led by the amazing Dr Anna Bradley (palliative medicine consultant) and Dr Tammy Tran (palliative medicine specialty registrar).  We were fortunate to find PalliSIM as foundation doctors and have been working with the group for almost 2 years. Members share a common goal: to enhance palliative medicine education through simulation at undergraduate and postgraduate level. Since starting in London in February 2022, PalliSIM has grown rapidly with members from hospitals and hospices across the United Kingdom. 

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Foundation SIM Scenario:

As part of our work with Pallisim we have been developing a palliative care simulation scenario, with the aim of improving education for foundation doctors around caring for patients at the end of life. The rationale for the scenario was inspired by our own experiences of the difficulties of caring for dying patients, the literature that supports this, as well as the foundation programme curriculum which includes: recognising dying, sensitive communication, involving the patient/those important to them and delivering individualised care (11). Furthermore we acknowledged the widespread appreciation for simulation training  and that despite core simulation training days for foundation doctors, there are currently no scenarios centred on end of life care in the areas we work in.

 

Our scenario was inspired by work that Rachel started at Oxford University Hospitals with Dr Mary Miller to develop an educational resource on simulating a patient journey of recognising dying, communication with the family and reviewing a dying patient.

 

The scenario we have written together centres on the aim of recognising dying, in which foundation doctors are expected to assess an elderly patient who is deteriorating despite being at their ceiling of care, assess the patient for reversibility and recognise that they may be entering the last stages of their life. We hope that the scenario will improve foundation doctor confidence in considering that a patient may be dying, communicating this sensitively and in a timely manner with family members, and starting pre-emptive medications for symptom control.

 

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Next steps:

Our next steps are to look at opportunities for both incorporating the session into the pan-London foundation simulation curriculum, as well as filming the material, in the hope that this can then be used as an educational resource in settings without simulation faculty.

 

If you would like more details on this project or to hear more about/be involved with the work of Pallisim, we would love to hear from you:

pallisimnetwork@gmail.com

 

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References:

 

1. Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 2011;306:978–88.

2. Zendejas B, Brydges R, Wang AT, Cook DA. Patient outcomes in simulation-based medical education: a systematic review. J Gen Intern Med. 2013 Aug;28(8):1078-89. doi: 10.1007/s11606-012-2264-5. PMID: 23595919; PMCID: PMC3710391.

3. Bharmal A, Morgan T, Barclay S 48 Junior doctors and end of life care: a systematic review and narrative synthesis BMJ Supportive & Palliative Care 2018;8:378.

4. Skedsmo, K., Nes, A.A.G., Stenseth, H.V. et al. Simulation-based learning in palliative care in postgraduate nursing education: a scoping review. BMC Palliat Care 22, 30 (2023). https://doi.org/10.1186/s12904-023-01149-w

5. Smith MB, Macieira TGR, Bumbach MD, Garbutt SJ, Citty SW, Stephen A, Ansell M, Glover TL, Keenan G. The Use of Simulation to Teach Nursing Students and Clinicians Palliative Care and End-of-Life Communication: A Systematic Review. Am J Hosp Palliat Care. 2018 Aug;35(8):1140-1154. doi: 10.1177/1049909118761386. Epub 2018 Mar 8. PMID: 29514480; PMCID: PMC6039868.

6. Evans L, Taubert M. State of the science: the doll is dead: simulation in palliative care education. BMJ Support Palliat Care. 2019 Jun;9(2):117-119. doi: 10.1136/bmjspcare-2018-001595. Epub 2018 Sep 25. PMID: 30254018.

7. Tropea J, Bicknell R, Nestel D, Brand CA, Johnson CE, Paul SK, Le BH, Lim WK. Simulation training in non-cancer palliative care for healthcare workers: a systematic review of controlled studies. BMJ Simul Technol Enhanc Learn. 2020 Aug 13;7(4):262-269. doi: 10.1136/bmjstel-2019-000570. PMID: 35516824; PMCID: PMC8936877.

8. Dewhurst F, Howorth K, Billett H, et al Palliative care simulation for internal medicine trainees: development and pilot study. BMJ Supportive & Palliative Care  Published Online First: 16 September 2021. doi: 10.1136/bmjspcare-2021-003272

9. Teaching palliative care (PC) to medical students; are we developing safe practitioners? BMJ Support Palliat Care 2015;5:106.1–106.doi:10.1136/bmjspcare-2014-000838.12 

10. McMahon D, Wee B Medical undergraduate palliative care education (UPCE) BMJ Supportive & Palliative Care 2021;11:4-6.

11. The UK Foundation Programme Curriculum 2021, Health Education England. Available from https://www.gmc-uk.org/-/media/documents/fp-curr-oct22-v7_pdf-101343583.pdf [accessed 4th June 2024]