Introduction
The Palliative Medicine Residency is a coordinated one-year (13-rotation/year) training program that provides the trainee with a broad clinical experience in a variety of institutional and community settings.
It is accredited by the College of Family Physicians of Canada and is under the Family Medicine Department at McGill University.
The program includes rotations on the palliative care services at McGill University’s teaching hospitals. Each is somewhat different in their approach and services and should provide a good range of clinical experiences, including in-patient palliative care, outpatient clinics (lymphedema/day hospital/cancer rehab, cancer cachexia/cannabis and cancer pain clinics), consult service and home care. Rotating through these settings, the trainee develops clinical skills in dealing with pain and various symptom management situations, as well as the psychological, emotional, and spiritual needs of terminally-ill patients and their families. The trainee sees patients who have access to the full spectrum of cancer care from diagnosis, to cure, to terminal care. Non-cancer patients with challenging symptom control problems are also seen.
Trainees will also do continuity of care clinics within family medicine as part of their year with us.
There is a mandatory month in medical oncology and one in radiation oncology for those trainees who have not had training in these previously.
There are two (2) elective months in palliative care. (three or four for trainees who have already completed training in medical oncology and/or radiation oncology). A popular elective has been pain service but can also be organized in geriatrics, neuro-palliative care, family medicine with POCUS (point of care ultrasound), home care and other rotations of choice relevant to your future career plans.
During the selective month, the resident will have the possibility of pursuing a particular aspect of palliative medicine of his/her choice. Possible rotations could take place in a hospice, at the outpatient palliative care clinic (Day Hospital), on consult service, a palliative care unit, pediatric palliative care or be a research month as part of your research project. The rotation can be organized either at a McGill affiliated hospital, another university affiliated hospital or in a community hospice. The overall goal of this rotation is for the resident to be able to explore various settings of palliative care to aid in the resident’s career choices.
The resident will be able to:
- Develop expertise dealing with pain, symptom management, psychological, emotional & spiritual needs of those with advanced life-threatening illness to be able to provide primary and consultant palliative care services.
- Gain experience on inpatient units, consultation service, home care and clinics.
- Pursue basic academic and research goals with a network of residents and professionals from across Canada.
Being able to speak in both French and English are assets to be able to apply to this program.
Specific Objectives
Competencies of the Enhanced Skills Year in Palliative Medicine
General Goals
The overall goals of the program are:
- To train physicians with added competency in the area of palliative medicine who will provide primary and consultant palliative care services.
- To provide clinical and basic academic training for physicians who will be going on to academic careers in palliative medicine.
Educational Objectives of the Program
Successful residents will acquire a broad-based understanding of the principles, philosophy, and core knowledge, skills and attitudes of palliative care medicine, superimposed on the principles and competencies of generalist family medicine.
Four Principles of Family Medicine
- The family physician is a skilled clinician.
- Family medicine is a community based discipline.
- The family physician is a resource to a defined practice population.
- The patient-physician relationship is central to the role of the family physician.
Six Essential Skill Dimensions
- Patient-centered approach
- Clinical reasoning skills
- Communication skills
- Professionalism
- Selectivity
- Procedures
CanMeds FM Key Competencies
1. Family Medicine Expert
- Practices generalist medicine within their defined scope of professional activity
- Performs a patient-centered clinical assessment and establishes a management plan
- Plans and performs procedures and therapies for assessment and/or management
- Establishes plans for ongoing care and timely consultation when appropriate
- Actively facilitates continuous quality improvement for health care and patient safety, both individually and as part of a team
- Establishes an inclusive and culturally safe practice environment
- Contributes generalist abilities to address complex, unmet patient or community needs, and emerging health issues, demonstrating community-adaptive expertise
2. Communicator
- Develops rapport, trust, and ethical therapeutic relationships with patients and their families
- Elicits and synthesizes accurate and relevant information from, and perspectives of, patients and their families
- Shares health care information and plans with patients and their families
- Engages patients and their families in developing plans that reflect the patient’s health care needs, values and goals
- Documents and shares written and electronic information about the medical encounter to optimize clinical decision making, patient safety, confidentiality, and privacy
3. Collaborator
- Works effectively with others in a collaborative team-based model
- Cultivates and maintains positive working environments through promoting understanding, managing differences, minimizing misunderstandings, and mitigating conflicts
- Recognizes and facilitates necessary transitions in care with other colleagues in the health professions, including but not limited to shared care, transfer of care, and/or handover of care to enable continuity and safety
4. Leader
- Contributes to the improvement of comprehensive, continuity-based, and patient-centered health care delivered in teams, organizations, and systems
- Engage in the stewardship of health care resources
- Demonstrate collaborative leadership in professional practice to enhance health care
- Manages career planning, finances, and health human resources in practice
5. Health Advocate
- Responds to an individual patient’s health needs by advocating with the patient within and beyond the clinical environment
- As a resource to their community, assesses and responds to the needs of the communities or populations served by advocating with them as active partners for system-level change in a socially accountable manner
- Identifies specific needs of underserved patients and populations, including reducing barriers and improving access to culturally appropriate care
6. Scholar
- Engages in the continuous enhancement of their professional activities through ongoing learning
- Teaches students, residents, the public, and other health care professionals
- Integrates best available evidence into practice considering context, epidemiology of disease, comorbidity, and the complexity of patients
- Contributes to the creation and dissemination of knowledge relevant to family medicine
7. Professional
- Demonstrates a commitment to patients through clinical excellence and high ethical standards
- Demonstrates a commitment to society by recognizing and responding to societal needs in health care
- Demonstrates a commitment to the profession of adhering to standards and participating in physician-led regulation
- Demonstrates a commitment to physician health and well-being to foster optimal patient care
- Demonstrates a commitment to reflective practice
Priority Topics in Palliative Medicine
- Pain
- Families
- Advance Planning & Goals of Care
- Working as a Team
- Nausea/Vomiting/Bowel Obstruction
- Imminent Death
- Despair and Suffering
- Community Resources
- Breathlessness
- Delirium
- Anxiety & Depression
- Palliative Sedation Therapy
- Maintaining the Clinician’s Well-Being
- Emergencies
- Medical Assistance in Dying
- Anorexia/Cachexia/Nutrition/Fatigue
- Non-malignant illness
Core Professional Activities
- Most Responsible Physician
- Consults
- Being a Teacher and Scholar
- Being a Researcher
- Ethical Dilemmas
- Prognostication
- Resiliency in Practice
- Community Setting
- Family Meeting
- Symptom Management
- End-of-Life Care
- Team Integration
Program Description
Duration
The Enhanced Skills Year is based on a 13 rotation-year. Nine of those rotations are on palliative medicine services. Those residents who will not have had previous exposure to medical oncology or radiation oncology will have to do a mandatory month in each of these. There is one selective which must take place in a palliative service of the resident’s choice and two electives. These three rotations are designed to complement the previous clinical experiences and respond to the resident’s anticipated career needs.
Clinical Experiences
Over the course of the thirteen period residency, the trainee will gain clinical experience in homecare, community and hospice settings, pain clinics, anorexia-cachexia and lymphedema clinics, consult services and tertiary level palliative care units. This experience will take place in a variety of McGill University affiliated settings.
Training Sites
Training will occur at the Royal Victoria Hospital, the Jewish General Hospital, Mount Sinai Hospital, Lachine and/or St. Mary’s Hospital, the West Island Palliative Care Residence and/or St. Raphael Palliative Care Home and Day Centre
Curriculum
Trainees will take part in the following small group learning activities:
- ABCs teachings at the Jewish General Hospital.
- Core teaching sessions are given by our attending physicians.
- National Academic Half Days (webinars) with Palliative Medicine residency programs across Canada.
We are also mandated by the Postgraduate Medical Education Office to oblige you to complete the online course, "Teaching Residents to Teach (Triple T Course)". In order to ensure excellence in your role as a teacher, this is a mandatory course as part of your residency training if not already completed in Family Medicine residency.
There will be a formative exam (at 6 months) and an evaluation exam (at 12 months) based on the core teachings that you do throughout the program.
Core teaching sessions given by our attending physicians. Topics include:
- Anorexia/Cachexia
- Assessing Bereavement Risk
- Asthenia/Fatigue
- Breakthrough and Incidental Pain
- End of Life Care for the Cardiac Patient
- Cultural Issues
- Delirium
- Dypsnea & Other Respiratory Diseases
- End-stage Renal Disease
- Ethics
- Hematology
- HIV
- Ketamine
- Legal Aspects of End of Life
- Lymphedema
- Malignant Bone Pain
- Malignant Bowel Obstruction
- Management of Intrathecal Pumps
- Management of Pressure Ulcers and Oncologic Wounds
- Methadone
- Music Therapy
- Nausea and Vomiting
- Neuropathic Pain
- End-of-Life Pulmonary Disease
- Palliative Care in Indigenous & Remote Communities
- Palliative Care in the Home
- Palliative Emergencies
- Palliative Sedation
- Paraneoplastic Syndromes
- Pathophysiology & Terminology of Pain
- Prognosis
- Psychological Issues in Palliative Care
- Social Work in Palliative Care
- Spiritual Issues
- Strategies to Enhance the Effectiveness of Family Meetings
- Terminal Phase
- Volunteers in PC
- WHO Ladder: Opioids
- Wound Bed Preparation
Medical and Radiation Oncology
The resident with no previous training in either oncology or radiation oncology will spend one month each in medical oncology and radiation oncology rotations. These will take place at the McGill University Health Center (Glen Site - Royal Victoria Hospital). The general goals of these rotations are to increase the resident's knowledge and skills regarding the care of cancer patients, the management of common complications of cancer, as well as to increase the resident's understanding of cancer patients' experiences at various stages of the disease.
Selective Month
During this month, the resident will have the possibility of pursuing a particular aspect of palliative medicine of his/her choice. Possible rotations could take place in a hospice, at the outpatient palliative care clinic (Day Hospital), on consult services, a palliative care unit, or be a research month as part of their research project. The rotation can be organized either at a McGill affiliated hospital, another university-affiliated hospital or in a community hospice. The overall goal of this rotation is for residents to be able to explore various settings of palliative care to aid in the resident's career choices.
Supportive Care Counselling
This training seeks to help you develop your communication skills as an end-of-life care physician. The topics covered will include psychological assessment, diagnosis, counselling skills, and case conceptualization. It is also intended to assist trainees to become aware of personal ideas, attitudes and viewpoints in order to better understand the impact of death on themselves, individuals, and the family. The training is largely an experiential learning forum following an action-reflection pedagogical model.
By the end of the course, fellows should be able to:
- Learn about their personal beliefs, attitudes, values with respect to communication with patients at the end of life and their families.
- Learn about the personal beliefs, attitudes, and values of other class members with respect to death, dying and bereavement.
- Examine personal coping patterns, strategies, and behaviours.
- Understand death, dying and bereavement from a multidimensional and interdisciplinary perspective.
- Describe psychological aspects of death, dying, and bereavement.
- Describe clinical approaches to working with the terminally ill and the bereaved.
- Describe personal and professional growth.
Additionally, residents will be able to attend National Academic Half Days teleconferences with Palliative Medicine residency programs across Canada.
Residents will present a case during the MUHC Palliative Care Comité d’Experts meeting (larger group, held quarterly).
Residents are encouraged to teach to more junior learners:
- The Postgraduate Medical Education Office obliges you to complete the online course, "Teaching Residents to Teach (Triple T Course)" if not already completed in Family Medicine residency.
- You will lead one "Palliative Care Visit" which is part of the 1st year Physicianship course whereby a group of six medical students accompanied by their Osler Fellow (mentor) meet with a physician.
Research
As part of the Enhanced Skills PGY3 year, residents must learn to search the scholarly literature, read it critically within the limits of their scientific training, understand research ethics in Canada, and conduct and communicate a scholarly project. The program offers three options for the scholarly project.
The scholarly project component of the program must be judged to be satisfactory for successful completion of the program.
THE THREE OPTIONS
Option 1: Quality improvement project or scoping literature review
Option 1 is designed for Residents who wish to be palliative care clinicians, able to review the literature or carry out quality improvement projects, but who do not plan to be responsible for carrying out research projects.
Option 1 allows the Resident ½ day of protected time for the scholarly project per week.
Option 2: Scoping review + participation in an ongoing research project
Option 2 is designed for Residents who wish to participate as co-investigators in research projects during their career and/or develop a better understanding of the research process than will be obtained from Option 1. Availability of this option depends on the availability of research projects.
Option 2 allows the Resident 1 full day of protected time for research per week.
Option 3: Planning and carrying out a research project
Option 3 is designed for Residents who wish to participate as co-investigators in research projects during their career and/or develop a better understanding of the research process than will be obtained from Option 1. The project may be the idea of the Supervisor, the Resident, or both.
Option 3 allows the Resident 1 full day of protected time for research per week.
OBJECTIVES
Objectives common to all options
- Improve ability to critically assess the literature
- Develop a deeper appreciation of the contribution of research or quality improvement initiatives to the goals of palliative care
- Understand the principles for the ethical conduct of research
- Improve ability to communicate the results of a study or quality improvement project
Additional objectives
Option 1
- Improve ability to conduct a quality improvement project or learn how to conduct a scoping literature review
Option 2
- Learn how to conduct a scoping literature review
- Develop knowledge of part of the research process for a palliative care study and associated difficulties
Option 3
- Develop knowledge of the complete research process for a palliative care study and associated difficulties
REQUIREMENTS
Requirements common to all options
- Residents who have not already been trained to conduct a literature search must complete a workshop or similar training on searching the literature within the first quarter. Workshops on literature searches can be found through the McGill library website or by asking the McGill librarian for Family Medicine or a hospital librarian.
- Complete either the Tri-council Course on Research Ethics or the Québec online course on ethical principles in research (Levels 1 and 3). The courses are available in both English and French. Keep and submit the proof of completion provided.
http://ethique.msss.gouv.qc.ca/didacticiel/course/category.php?id=1&lang=en
- Present the scholarly project and conclusions drawn in three ways.
- Orally to Palliative Care McGill (the Supervisor, Research Director, and Program Director must be able to attend)
- In a written report. It should be in a format for submission for publication, when appropriate.
Please note that the final report does not need to be accepted by a journal to pass the scholarly component, but submission is strongly encouraged
- Orally at the Dept. Family Medicine, at the Tannenbaum Day for quality improvement projects, or during Enhanced Skills presentations for scoping reviews and research projects.
Evaluation Process
Monthly evaluations will be completed using the Online One45 evaluation specific to Palliative Medicine.
These evaluations are meant to be formative and will be compiled from a number of sources including fieldnotes specific to various Core Professional Activities and multidisciplinary team members for your inpatient palliative care rotations. Teaching staff will be filling out fieldnotes 3X per week.
There will be a formative exam (at six months) and an evaluation exam (at 12 months) based on the core teachings that you do throughout the program.
We really value your feedback as a trainee and expect evaluations of the rotations and staff physicians involved in your education. Completing these will allow you to see your own rotation evaluation online. These should be filled out by the end of the rotation.
At the beginning of the year residents are assigned a Faculty Advisor. Additionally, a resident may choose to have a different mentor, should he/she so desire. Please note that as the resident rotates through various palliative care services, the staff will be glad to help mentoring him/her. Residents meet with their faculty advisor on a regular basis and reviews their self-assessment tool as well as their fieldnotes. The purpose of these meetings is tri-fold: to see how his/her year is progressing in attaining the various competencies, plan ways to address ways of attaining different competencies and experiences as required by his/her personal goals, and support him/her.
The resident will meet regularly with the Program Director, Dr. Golda Tradounsky, to discuss his/her experiences and progress, as well as how well the program is meeting his/her expectations and goals.
Apply/Contact Us
For information regarding the program
golda.tradounsky [at] mcgill.ca (Dr. Golda Tradounsky)
Director Palliative Care Fellowship
For information regarding the application process
karen.french [at] mcgill.ca (Karen French)
Student Affairs Coordinator
514-934-1934 ext. 43879
Applicants can apply via CaRMS: https://www.carms.ca/match/family-medicine-enhanced-skills-match/
Please refer to the CaRMS website for details pertaining to the application period.