1. The doctor as a practitioner Consultation skills Communication skills Procedural skills Physical examination skills Clinical Reasoning & Patient Management skills including prescribing And Information management Team working and leadership Skills

2. Elderly care and Multi-morbidity End of Life Care Janet Lefroy, Ranjan Sanyal, Claire Hookey

3. Required competencies Tomorrow’s doctors must be able to: ‘formulate a plan for treatment, management and discharge, according to established principles and best evidence, in partnership with the patient, their carers, and other health professionals as appropriate. Respond to patients’ concerns and preferences, obtain informed consent, and respect the rights of patients to reach decisions with their doctor about their treatment and care and to refuse or limit treatment’ ‘contribute to the care of patients and their families at the end-of-life, including management of symptoms, practical issues of law and certification, and effective communication and team-working’ Keele University School of Medicine

4. Required competencies Tomorrow’s doctors must be able to: ‘formulate a plan for treatment, management and discharge, according to established principles and best evidence, in partnership with the patient, their carers, and other health professionals as appropriate. Respond to patients’ concerns and preferences, obtain informed consent, and respect the rights of patients to reach decisions with their doctor about their treatment and care and to refuse or limit treatment’ ‘contribute to the care of patients and their families at the end-of-life, including management of symptoms, practical issues of law and certification, and effective communication and team-working’ Keele University School of Medicine

5. Opportunities for students to learn in clinical practice in GP and hospital Appropriate Individualised healthcare Constructive workplace- based learning Established principles & Best evidence

6. Elderly care and Multi-morbidity Challenges Multimorbidity doesn’t fit well with learning focusing on index conditions What is good care? - disease-specific management guidelines don’t fit multi-morbid patient priorities What is good care? - risk avoidance is sometimes modelled where risk management might be better What is good care? – are we able to do it (and to involve our students in it)? Keele University School of Medicine

7. Current Curriculum Year 1 PBL cases, group work and lectures on ageing, Placement interview about patient experience of ageing Year 2 Body system-based history and examination, case presentation Placement practice SSCs with community providers of care (some for older people)

8. Year 3 ‘The older patient’ block: CBL cases falls, confusion, stroke, dementia, Parkinson’s Clinical practice exposure to elderly care Longitudinal patients are often elderly Communication skills consulting with patients with diminished capacity, talking with relatives. Year 4 Clinical practice exposure to elderly care, focus on management Keele University School of Medicine

9. Y5 Elderly Care and Multi-morbidity Clinical care in medicine, surgery, acute and critical care, GP IPE Care Pathways and Discharge Planning Reflective case study about a patient discharged from hospital with a care package

10. Reflective Summary Hospital Discharge Reflective Summary Template 1. The Case: Why did you select this particular person for the study? A brief statement of the relevant clinical information about this person. What is the patient’s perspective about their condition, what information have they received from health care professionals (or other sources) about it? What is their opinion as to the treatment/ care they have received? How did they experience any transitions between primary and secondary care for example 3. Background: Brief explanation of disease (if appropriate).How might this persons’ care or medical needs change over the next few weeks? How can we as health professionals anticipate or meet these needs as they arise? 4. Critical Assessment of Care: Give examples of good practice identified by this case study. In particular look at how teams have worked together well or communicated well. What changes could have been made in the care of this patient? How does this fit in with your other experiences. 5. Recommendations for Change: What changes would you make as a result of this case study? There may not be any but think about what limitations they might be at times in delivering the best possible care 6.Reference list: Citing the evidence base used for discussions 7. Additional comments: After discussion with peers and at study day, what other issues arose? How did this change what you thought? Each case study will be 1000 (+/- 10% words (excluding references) in length.

11. Questions for the new curriculum Can we give our students (and their clinical tutors in hospital and GP) a set of guiding principles and best evidence to help navigate the choices and trade-offs in multimorbidity? Can we get students more actively involved in applying these? What is legitimate participation in year 1 - 5? Is there a teaching and learning method for teasing learning out of multimorbidity? In discussions with students, should we ‘mind the gap’ between ideal and actual care?

12. Guidelines? Patient-centred care Integrated care

13. NICE guidelines

14. A model for learning about multimorbidity positive and holistic patient care in a range of situations where cure is not an option Needs- based CARE Needs- based LEARNING Sarah Yardley et al., “Modelling Successful Primary Care for Multimorbidity: A Realist Synthesis of Successes and Failures in Concurrent Learning and Healthcare Delivery,” BMC Family Practice 16, no. 1 (2015): 23, doi:10.1186/s12875-015-0234-9.

15. Suggestions Develop a (Keele) guide for students encountering multimorbidity on placement – Years 1 - 3 making sense of the information they gather (Reporter and Interpreter) – Years 4 - 5 things to consider in management of multimorbidity (Manager and Educator) Guide introduced in Y3 elderly care block (some elements previously covered in skills sessions) used in consolidation block Guide used explicitly in Y4 GP block giving students hands-on opportunities to learn to manage multimorbidity (extend by 2 weeks?) Repetitive practice in Y5 GP placement Guide applicable to all other placements where there is multimorbidity so all clinical tutors will need to understand it

16. Guide to making sense of the information they gather Creating a current problem list Establishing an accurate PMH Understanding the patient’s perspective Medication list to include what each item is for Interpretation of test results Case presentation in multimorbidity

17. Guide to learning management of multi-morbidity Collaborative working Holistic goals negotiated (needs-based care) – Knowledge of diseases – Knowledge of impact – Identify (competing) priorities – Trade-off risks and benefits

18. End of Life Care Approximately 50% of people die in hospital. An estimated 12% of all hospital inpatients have ‘advanced and incurable disease’ (prognosis <3 months) Up to 86% of deaths follow a period of illness and/or frailty and can be predicted The APM estimate that an FY1 doctor will care for around 40 patients who die and an additional 120 patients in the final months of life.

20. End of Life Care Challenges What is good care? – are we able to do it (and to involve our students in it)? Integration of palliative care in the curriculum can mean it is lost by faculty/ unrecognised by students Students are not exposed to dying patients Keele University School of Medicine

21. Current Curriculum Year 1 PBL cases, group work and lectures on cancer, palliative care, end-of-life care, and a ‘good death’ Year 2 PBL cases group work and lectures on sudden death, patient perspectives on dying and issues in patient care, coroner’s role

22. Year 3 ‘The older patient’ block: Clinical practice exposure to elderly care, possibly end-of-life issues Communication skills breaking bad news Year 4 Clinical practice possible exposure to end- of-life issues, withdrawal of treatment, breaking bad news Keele University School of Medicine

23. Y5 End of Life Care integrated curriculum: Involvement with a patient at end of life in GP Study Day – Communication skills – Prescribing skills – DNACPR team discussions – Death certification and coroner notification Reflective Summary Keele University School of Medicine

24. Reflective Summary End of Life Care Reflective Summary Template The Case: Why did you select this particular person for the study? Brief description of the transitions in the course of their disease. If they have already died give an account including their carers’ transitions afterwards. Otherwise consider how this person’s care or medical needs might change in the future anticipating the end of their life. Describe the patient’s perspective of their condition, what information have they and their carers received from health care professionals (or other sources) about it? What is their opinion as to the treatment or care they have received? Critical Assessment of Care: Give examples of good Practice identified by this case study. In particular look at how teams have worked together or communicated well. What patient care changes could have been made? How does this fit in with your other experiences? You might also consider your experiences of hospital care at the End of Life. What changes would you make as a result of this case study? There may not be any but think about what limitations there might be at times in delivering the best possible care. Study day: After discussion with peers and learning at the study day, what other issues arose? How did this change what you thought?

25. The doctor as a practitioner Consultation skills Communication skills Procedural skills Physical examination skills Clinical Reasoning & Patient Management skills including prescribing And Information management Team working and leadership Skills

26. Questions for the new curriculum Can we give our students more palliative and end of life care experience? What is legitimate participation in year 1 - 5?

27. NICE guidelines

29. Palliative Care ideas from other schools A hospice day (or more than 1 day) Teaching from those who are dying/bereaved Reflecting on care of the dying in hospital as well as in the community Keele University School of Medicine

30. Suggestions for developing the curriculum Explicitly expect students to have observed/been involved in the care of dying patients through their clinical years – ?Set a number per year – Expect short reflection on one per year Consider multi-professional teaching on end of life care Opportunity to reflect on management of dying patients with a palliative care specialist

31. Currently, only a small proportion of students spend any time in a hospice. Should all students have the ability to spend some time there? Can they contribute to patient care? – If so, when in the course? – Aims and content would depend on when it takes place.