Hospice and Palliative Medicine Fellowship Curriculum

PALLIATIVE CARE CONSULT SERVICE
Wake Forest Baptist Medical Center has 1,535 licensed beds system-wide and 885-beds on the main campus, which includes level 1 trauma center, Brenner Children’s hospital, and Comprehensive Cancer Center with 60,023 admissions in the most recent year reported. It is the largest employer in Forsyth County with more than 19,000 employees system-wide. The fellow will participate in a consult service that receives over 1200 consults per year. The fellow will develop skills in consultative palliative care, symptom management, communication, inter-disciplinary care, transition management and end-of-life care.  The consult service consists of a staff of faculty physicians, nurse practitioners, physician assistants, supportive care nurses, social workers, chaplains, and pharmacists.

ONCOLOGY AND RADIATION ONCOLOGY ROTATION
Fellows will spend 1 week rotating with faculty within the oncology clinic and radiation oncology. The goal of this rotation is to provide fellows with the opportunity to 1) gain better knowledge of common side effects/adverse effects related to the treatment of common oncological cancers and 2) learn basic concepts in the practice of radiotherapy and understand the common side effects along with the role of radiation on pain/symptom management.

GERIATRIC MEDICINE AND NEUROLOGY ROTATION
Fellows will spend 1 week rotating in a variety of consult clinics to gain better knowledge of the treatment of a variety of neurological conditions, including specialty care of patients with dementia. Fellows with rotate in the Kulynych Geriatric Consult Clinic through Geriatric Medicine, the Neurology Movement Disorder clinic, the ALS clinic, and the post-stroke clinics along with the geriatric trauma consult inpatient service to learn a variety of tools to bring to caring for older adults on the palliative consult service.

ANESTHESIA PAIN AND ADDICTION MEDICINE
Fellows will rotate with the Wake Forest Anesthesia Chronic Pain Service, both in the inpatient consult service and outpatient clinic. The fellow will gain confidence in all forms of pain control and be exposed to cutting-edge research in pain management. The purpose of this rotation is to have fellows learn when referral to an interventional pain specialist is appropriate and how these techniques can be used in the management of palliative care patients.

Fellows will also rotate in Addiction Medicine where they will gain exposure to Suboxone (Buprenorphine) clinic, gain a better understanding of Addiction and Substance Use Disorders, and learn what resources are available for patients with substance use disorders.

Brenner Children's Hospital is the 144-bed “hospital within a hospital’’ located on the main campus of Wake Forest Baptist Medical Center. It is a Level 1 Pediatric Trauma Center and has a pediatric emergency department and pediatric and neonatal intensive-care units. More than 4,500 children are admitted to Brenner Children’s Hospital every year and more than 21,000 pediatric subspecialty visits occur at hospital-based outpatient clinics. The fellow will gain expertise in palliative care of pediatric patients through rounding with the pediatric palliative care team, participating in transitions of care between inpatient and outpatient care, and conducting family meetings.

PALLIATIVE CARE CONSULT SERVICE
Novant Health is a not-for-profit integrated system of 15 medical centers with 2,683 beds system-wide. Forsyth Medical Center is a 901-bed hospital, the largest hospital in the Novant Health system which also includes locations in Clemmons, Thomasville, and Kernersville. The consult team was started in 2004 and sees over 2000 new consults per year and on average sees 30 inpatient palliative care encounters per day. There is also an Oncology Supportive Care Clinic. The interdisciplinary team consists of 3 physicians, 5 advanced practice providers, social worker, chaplain, and case manager. Novant Health Forsyth Medical Center was the first hospital in NC to achieve Advanced Certification in Palliative Care through Joint Commission and is also a Charter member Global Palliative Care Quality Alliance. The fellow will develop skills in consultative palliative care, symptom management, communication, inter-disciplinary care, transition management and end-of-life care.

INPATIENT PALLIATIVE CARE UNIT
This is a 19 bed acute inpatient palliative care unit. It was started in 2001. The fellow will develop skills in complex symptom management, communication, inter-disciplinary care, transition management and end-of-life care in an acute inpatient palliative care unit.

 

Hospice of the Piedmont is a not-for-profit, Medicare-certified, hospice with two inpatient facilities (located in High Point and Asheboro) that provide acute and residential care to hospice patients. The fellow will gain extensive knowledge about the hospice medical director role, be responsible for rounding on patients daily in the inpatient unit and doing home visits, attending IDT meetings and participating in family discussions to provide high-quality patient care.

INPATIENT HOSPICE HOME
Trellis is a large, not-for-profit, Medicare-certified, hospice with an average daily census of 500+ patients. It has a 40-bed inpatient facility that provides acute and residential care to hospice patients. The fellow will gain extensive knowledge about the hospice medical director role, be responsible for rounding on patients daily in the inpatient unit and doing home visits, attending IDT meetings and participating in family discussions to provide high-quality patient care.

Bermuda Village is conveniently located less than 10 minutes from Winston Salem within the gated retirement community of the Bermuda Run Country Club. Bermuda Village offers all levels from independent living to acute rehabilitation to skilled nursing, along with a wellness clinic.

During this rotation, the fellow will learn the nuances of palliative care needs of the elderly, such as progression and management of neurologic illness (e.g., dementia, ALS, Parkinson’s), assessment and management of chronic non-cancer pain, wound care, geriatric syndromes (incontinence, delirium, non-cancer related functional decline, frailty), advance care planning, and policies and regulations of long-term care settings.

Amedisys Hospice is a for-profit hospice agency with locations across the United States. They are unique to our experiences for our fellows due to the fact that they do not have an inpatient unit. This allows our fellows to see the extent of hospice care that can be provided in the community, especially within nursing home facilities. The fellows will learn from the interdisciplinary team about the unique benefits and challenges with providing care within a nursing home facility, and how Amedisys partners with each patient, family, and care team they work with.

Longitudinal care of hospice and palliative care patients is provided in the WFBMC Supportive Care Oncology Clinic where the fellow will spend one half-day every week throughout the twelve-month fellowship training program. The fellow will manage patients at all disease stages with multiple physical, psychosocial, spiritual, and existential issues as part of a multidisciplinary team. The fellow will follow new patients longitudinally in the ambulatory setting as well as across settings if the patient is admitted to the hospital or goes to hospice.

Participation in scholarly activities during the clinical fellowship is required and the fellow will have a block rotation dedicated to the development and initiation of scholarly work based upon their interests which will be conducted throughout the year guided by faculty mentorship.

Several elective opportunities are open to the fellow based upon interests including:

• Interventional pain management
• Interventional radiology
• Clinical oncology
• Geriatric medicine
• Critical care medicine
• Pediatric palliative care
• Surgical oncology
• Geriatric psychiatry
• Integrative medicine
• PACE medicine rotation
• Transitional care
• Pain management

Quarter	Rotation	Weeks
Misc. (incorporated throughout each quarter)	Orientation	1
	Vacation	2
	Conference	1
	Research	4
	Elective	4
	Wake Inpatient PC	12
Total 24
Hospice	Inpt Hospice	4
	Home Hospice	4
Total 8
Pain/Oncology	FMC PC/IPU	2
	Onc	1
	Pain/Addiction	2
Total 5
Geriatrics/LTC	BV	2
	Hospice LTC	2
	FMC PC/IPU	2
	Geri/Neuro	1
Total 7
Mastery	FMC PC/IPU	2
	Spiritual Rotation	1
	Pediatrics	3
	Inpt Hospice	2
Total 8
Total: 52 weeks

Core Lecture Series
The core lecture series meets 1-2 hours, 3 weeks per month and covers core topics related to hospice and palliative medicine throughout the year.

Case Conference
Case Conference is a monthly, one-hour meeting with the Palliative Care Team and Geriatric fellows where fellows are expected to present interesting and challenging patient cases, analyze specific issues of the case, and solicit thoughts and guidance from members of the Palliative Care Team and Geriatric fellows. Audience may include palliative care team, care transitions team, and geriatrics faculty.

Journal Club
The Geriatrics and Palliative Care Journal Club is health monthly for one-hour with the gerontology, geriatrics and palliative medicine team where fellows present and discuss journal articles related to the field of the gerontology, geriatrics and hospice and palliative medicine. Fellows will receive assistance in proper journal article critique. In addition, there is a separate, monthly journal club for the palliative medicine team to discuss recent articles that have been published in the field of hospice and palliative medicine.

Psychosocial Case Conference
Psychosocial Case Conference will be monthly for one hour. The goal of this conference is to allow fellows a chance to debrief on challenging encounters from an emotional perspective and receive input from peers. It also allows for discussion of everyone’s emotional reactions, caring for patients with life-limiting illness, and work-life balance issues. At this conference, fellows will have the opportunity to discuss complex patient care issues, to evaluate their current approach to treatment with specific clients, examine issues of transference and countertransference and gain support/assistance from other multidisciplinary psychosocial providers in the development of psychosocial plans of care.

Narrative Medicine
Narrative Medicine is a monthly, one-hour meeting that uses close-readings and various arts and media to delve into areas of interest that will help build tools to cope with the difficult and often emotional encounters we have daily with patients.  The goal of this hour is to provide an open, non-judgmental forum to explore these topics through a different lens.

Self-Care Activities
Self-Care Activities will occur on a regular basis. Fellows will complete wellness survey and self-care plan and revisit this throughout the year. The emotional nature of working closely with patients and families at one of the most difficult times of their lives can be challenging. While rewarding and satisfying for much of the time, it can be overwhelming and difficult to face at other times. Thus caring for oneself is important along with a good life-work balance.

American Academy of Hospice and Palliative Medicine Annual Assembly
The fellow will have the opportunity to attend the AAHPM Annual Assembly in the spring. This is an excellent educational experience for attendees. Participants are expected to provide a brief presentation that highlights this educational experience to the Palliative Care Team.

Foundations in Pain Management
Foundations in Pain Management consist of key topics presented by faculty experts in pain management at the beginning of the year to give our fellows a jump start in pain management. Topics include:

• Pathophysiology of Pain
• Psychogenic Pain
• Basic Opioid Conversions
• Opioid Drills
• Opioid Side Effects
• Adjuvant Pain Treatments
• Radiotherapy for Pain Management
• Buprenorphine
• PCAs
• Methadone
• Ketamine
• Fentanyl
• Integrative Medicine for Pain
• Regional Nerve Blocks
• Substance Use Disorders and Addiction

Hospice Medical Director Series
The Hospice Medical Director Series is a session series that covers key topics related to being a hospice medical director and occurs throughout the fellowship year.