Publications
APS Bulletin • Volume 18, Number 1, 2008
Training Issues and Advancement
Robert P. Yezierski, PhD, Department Editor
An Educational Model to Enhance Team Attitudes and Functioning Among Pain Medicine Fellows
Diane Novy, PhD, Basem Hamid, MD, Larry Driver, MD, Lakshmi Koyyalagunta, MD, Joseph Ting, DO, Irfan Lalani, MD, Madhuri Are, MD, Philip Phan, MD, Allen W. Burton, MD, David L. Brown, MD
Department editor’s note: In an effort to enhance the effectiveness of pain medicine specialists, new multidisciplinary training strategies are needed to meet the challenges the next generation of pain specialists will face. This second article on fellowship training describes how new Accreditation Council for Graduate Medical Education (ACGME) requirements are being used to develop a multidisciplinary patient-oriented education model for pain medicine fellows.
In recognition of the fact that unsatisfactory resolution of patients’ complex pain medicine issues can adversely affect outcomes, ACGME recently revised its core curriculum requirements for pain medicine fellowship programs. The new requirements place greater emphasis on training physicians to appreciate other specialists’ roles in meeting pain management challenges. It is essential to develop positive team attitudes among individuals with diverse backgrounds who must focus on helping people in pain in clinical environments. To date, there has been no educational model or data on how improved team attitudes, efficiency, and multidisciplinary functioning affect patient care. The goal of the educational model being developed by pain medicine faculty at the University of Texas M. D. Anderson Cancer Center (MDACC) in Houston is to establish positive, team-oriented attitudes and functioning among fellows completing a year-long fellowship. A follow-up article will present data on the effectiveness of this model based on results of a team attitude and functioning assessment battery administered to five MDACC pain medicine fellows at the outset, midpoint, and end of their 2007–2008 fellowship period.
Rationale for Team Training in Pain Medicine
A team approach to health care that involves a variety of professionals often is essential when patients’ needs are multiple and complex (Heinemann, Schmitt, Farrell, & Brallier, 1999). The field of pain medicine has a long history of using multidisciplinary teams. Recognizing the importance of a diverse approach to pain medicine education, ACGME mandated new pain fellowship requirements that went into effect for the 2007-2008 academic year (Benzon, Rathmell, & Huntoon, 2007). Specifically, principal elements of pain medicine must be taught from the perspectives of anesthesiology, neurology, physical medicine and rehabilitation, and psychiatry, and ACGME now requires interaction with other members of a multidisciplinary team.
Growing interest in multidisciplinary, clinically based education for various practice settings (palliative care, geriatrics, rehabilitation medicine, and operating rooms) has focused attention on the importance of evaluating training outcomes beyond the core competencies needed in each discipline. As researchers, we hypothesize that attitudes about the concept of healthcare teams may have a major influence on a professional’s participation in team environments, the quality of team functioning, and patient care quality. In addition to task-oriented goals that pertain to assessing patients, identifying their medical needs, developing and implementing individualized care plans, monitoring outcomes, and adjusting care plans to optimize outcomes, programmatic goals (goals that focus on interpersonal relationships among team members and strategies to improve team performance over time) also are important. An educational model and educational resources for team training in pain medicine are not currently available.
Pain medicine at MDACC has three overlapping sections (acute cancer pain, chronic cancer pain, and basic science research), and each section is part of MDACC’s Department of Anesthesiology and Pain Medicine. We developed our team training educational model for pain medicine fellows in the chronic cancer pain section. Before developing this model, chronic cancer pain faculty and staff (nine physicians, three physician assistants, one psychologist, two nurse practitioners, six nurses, two medical assistants, three patient service coordinators, and five administrative staff) participated in two (4 months apart) day-long training and interactive sessions on improving our abilities to function as a team. An outside consultant with expertise in team functioning led the sessions.
After faculty and staff training, we designed a pain medicine team attitudes and functioning education curriculum for our fellows based on the Geriatric Interdisciplinary Team Training Model (Siegler, Hyer, Fulmer, & Mezey, 1998). This model uses a problem-based strategy to illustrate the breadth of knowledge needed to work with patients with complex and multiple problems, the need for team members to adjust their practice style, and the patient’s role as a team member.
The formal structure of our fellowship program incorporates not only the ACGME program requirements but also an advanced interventional track with additional exposure to the range of interventional pain modalities and a didactic curriculum on interventional pain medicine (Benzon et al., 2007) and a team training component. The formal structure of MDACC’s pain medicine fellowship is illustrated in Table 1.
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Team Training Component Program Content
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Team Training Goals
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The team training component includes lectures and topics discussed in journal clubs and daily case conference rounds. Specifically, our faculty and staff provide one-on-one guidance on how to function as an effective multidisciplinary team member to the fellows in each of the fully integrated medical disciplines and in consultation with other disciplines (primarily palliative care, integrative medicine, internal medicine, physical and occupational therapies, neuro-oncology, chaplaincy, and pharmacy). There also is a forum in which fellows can interact with each other and with faculty and staff from different disciplines to introduce discipline-specific and discipline-shared issues.
Much of the content of our formal didactic series focuses on pain conditions, treatments, and interventions. In addition to those established topics, we also devote 1 hour monthly to a team training lecture (see sidebar, Team Training Component Program Content). We also discuss team topics in journal club articles and in daily case conference rounds. A recent journal club reviewed the ways our team could work together to assess suicide risk and provide preventive treatment. The important contributions from patients’ family members, psychologists, social workers, and chaplains were highlighted.
The primary goal of pain medicine fellowship programs is for fellows to become competent pain medicine physicians who can manage straightforward and complex pain syndromes for ambulatory and hospitalized patients. Fellows are expected to manage pain syndromes when they are complicated by other symptoms, complex medical illness, and psychological distress. A multidisciplinary team approach can bolster pain management effectiveness in these complex situations. To meet this educational need, MDACC’s newly developed teamwork didactic training component has critical additional goals (see sidebar, Team Training Goals).
Pain medicine specialists must be able to effectively treat patients with various pain conditions. These specialists must be well-versed in the related skills of anesthesiology, neurology, physical medicine and rehabilitation, and psychiatry as they relate to pain medicine. They also should be able to function effectively on their patients’ behalf with other healthcare providers. To achieve these goals, fellows work closely with attending physicians from different medical specialties and with staff from diverse professional backgrounds. There is ample opportunity for attending faculty to model effective teamwork. Fellows also receive guidance on interpersonal skills that strengthen team functioning.
In a subsequent article, MDACC faculty will report on the effectiveness of our team training educational model. Our five pain medicine fellows complete assessment batteries at three time points (pre-team training in August 2007; midpoint in January 2008, and post-team training in June 2008). The battery includes the Quality of Care/Process Subscale from the Attitudes Toward Health Care Teams Scale. This is a 16-item scale that uses a six-answer choice format and questions that elicit information on perceived comfort and skill to function on an interdisciplinary team and readiness to engage in shared learning with other fellows from different specialties. Other questions were adapted from Parsell and Bligh’s 1998 assessment of readiness for interprofessional learning (Parsell & Bligh, 1998). Descriptive statistics are used to report findings during the pre-, mid-, and post-1-year fellowship period. At pre-, mid-, and post-intervention time points, our fellows participate in a case study in which each of them must develop a treatment plan. The treatment plan is graded, and any change in treatment plan quality is assessed with qualitative data analyses over the course of the fellowship year.
In summary, MDACC’s emphasis on team training stems directly from faculty and staff’s ongoing efforts to function effectively as a team as we care for our patients.
References
Benzon, H. T., Rathmell, J. P., & Huntoon, M. A. (2007). New Accreditation Council for Graduate Medical Education requirements for fellowship training in pain medicine. APS Bulletin, 17, 3, 5.
Heinemann, G. D., Schmitt, M. H., Farrell, M. P., & Brallier, S. A. (1999). Development of an Attitudes Toward Health Care Teams Scale. Evaluation and the Health Professions, 22, 123–142.
Parsell, G., & Bligh, J. (1998). Educational principles underpinning successful shared learning. Medical Teacher, 20, 522–529.
Siegler, E. L., Hyer, K., Fulmer, T., & Mezey, M. (Eds.). (1998). Geriatric Interdisciplinary Team Training. New York: Springer Publishing Company.
Diane Novy, PhD, a professor in the Department of Anesthesiology and Pain Medicine, and her colleagues are developing this educational model at the University of Texas M. D. Anderson Cancer Center in Houston, TX.