The ESPS provides a number of unique opportunities to practice clinical skills that are not readily available in clinical teaching settings or traditional SP. It is important to draw your attention to them in advance so you can maximize the benefits from the experience. The sessions will be taped and available for your review and critique by clinical faculty. You should also record your notes in the chart so that you can practice documentation of treatment preferences as well as more technical medical decisions for your own reference at subsequent visits.
Communication Skills. While particularly critical in palliative medicine, effective communication skills are important in all aspects of clinical medicine. Acquisition of historical data, formulation of a coherent plan, and assuring patient understanding of that plan are all important elements of competent medical care. In addition, life limiting illness presents new challenges to the physician's communication skills. Prominent among these is the ability to break bad news. The most experienced, competent, compassionate clinicians still find this task difficult. When done well however, it is among the most rewarding in medicine.
Because the ESPS is spread over multiple visits, and several month's time, the physician will have the natural experience of reviewing patient understanding from prior sessions, and the opportunity to pick the best time to broach specific issues. Of course, just as in real life, the ESPS might provide the false comfort that difficult issues can be put off for discussion at a later time.
Doctor-Patient Relationship. Closely related to communication skills is the development of a doctor-patient relationship. It is rare that such relationships solidify in contemporary inpatient hospital teaching services. Inpatients today are sicker, more cognitively impaired, and in the hospital for shorter periods of time than in the past. It is difficult for medical trainees to establish relationships in that setting. Ambulatory continuity clinic training provides a better opportunity for cultivating a doctor-patient relationship, but relatively few of those patients have life threatening illness, leaving the trainee to "practice" developing the relationship under those circumstances, on real patients. The ESPS permits the physician to explore different practice styles with seriously ill patients in a realistic environment that is then videotaped and reviewed.
Biopsychosocial Medicine. Primary care training emphasizes the importance of social and psychological factors in illness and the suffering that accompanies it. In addition to physical pain, competent physicians must explore emotional factors, social supports, independence in activities of daily living, as well as spiritual and existential sources of suffering. The repeat visits of the ESPS permits the physician to discuss these factors as a part of medical care, and development of a full, rich doctor-patient relationship.
Advance Directives. Too often, meaningful advance care planning never occurs, even among the most seriously ill patients. When discussions do occur, the may be too brief, and dominated by patient misconceptions, slogans and little or no medical input. Authentic patient directives reflect that person's values, attitudes, and goals of medical care, as well as prior experiences with friends or loved ones. It is a difficult task to guide the patient from core values and prior experiences, through clarification of goals of treatment, to the application of specific treatment decisions (incorporating the medical realities as framed by the physician). What often occurs instead is a superficial listing of requested or refused treatment modalities, completely taken out of the context.
Because the ESPS is spread over several visits, the physician gets to know the patient and establishes a rapport that facilitates meaningful discussion. The timing of advance directive discussion can occur naturally, moving from general issues (e.g. Health Care Proxy) when healthy, to more specific issues (e.g. CPR) when illness progresses.
Discussion of Life-Sustaining Therapies. Advance directives are those statements that are made in advance of decision making incapacity. These often involve decisions about life sustaining treatment (LST), but such treatment decisions continue to be made during the course of the patient's illness while still possessing capacity. The longitudinal framework of the ESPS permits realistic discussion of these decisions over time, gaining in importance as the disease escalates.
Medical Decision Making. Complex medical decision making is commonplace in real life and take place in an environment of uncertainty. The model of shared decision making integrates patient values and attitudes into a decision making framework based upon medical science. That science however often involves probabilities and statistical certainty. Thus, a patient must not only weigh how much burden or risk is justified for a certain outcome, s/he must consider the likelihood of that outcome occurring . Furthermore, the outcomes one strives for (or the risks/burdens one avoids) are moving targets. What seems very probable at one time, becomes a long shot at a later time. The ESPS is well suited to practice this evolving medical decision making algorithm.
Evidence Based Medicine. The medical "facts" described above, beyond being only statistical probabilities, are also constantly changing. Thus, the ESPS provides an ideal opportunity to practice evidence based medicine (EBM). Unfortunately, medical recommendations to patients are not always based upon sound evidence. When patients have life limiting illnesses with fading chance of cure, this is all the more true. Long shot treatments are recommended by physicians who are uncomfortable with "giving up" and see palliative care as failure. It is the responsibility of the physician to sort through such recommendations and clarify them for the patient. While one usually associates EBM with randomized placebo controlled clinical trials, there are other kinds of evidence that can be scrutinized as well. These data need to be researched, summarized and described to the patient in lay terms.
The multiple visit structure of the ESPS provides a real life opportunity to review medical texts and journals between visits. Physicians in clinical practice must often review current best practice between patient visits in order to provide competent recommendations. For example, if the primary care physician, know a patient with a specific malignancy will be seeing his oncologist before the next primary care visit, the physician could easily review the standard therapy in oncology texts and a few recent review articles. Having that information at one's fingertips during the next visit places the physician in a strong position to help the patient interpret the claims made by the oncologist.
Competent Palliative Medicine. It should come as no surprise that an ESPS on a palliative medicine elective will involve palliative care. This will naturally occur late in the scenario, and hence, later in the rotation. The physician will therefore be more knowledgeable about high quality palliative medicine principles and will be able to apply this knowledge to the care of the patient. As with other treatment decisions however, the time between visits can be put to good use by filling in gaps in the physician's knowledge base.