Making the Grade as a Health Care Profession

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Making the Grade as a Health Care Profession

• Durham 2006

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Every profession is a conspiracy against the
laity

• George Bernard Shaw

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GP reactions to a new hospice
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Whats all the fuss about?

• Christian Bioethics 2003
• The deChristianization of Christian hospital
  chaplaincy some bioethics reflections on
  professionalization, ecumenization and
  secularization. (1)

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Part 1

• The history of palliative care
• Personal experience of an evolving specialty
• Pros and cons of increasing professionalism
• Medical professionalism

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Part 2

• Proving our worth

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What is palliative care?
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My Story
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Quote from Palliative Medicine Journal
many doctors and nurses .are making a life
career in Palliative Care, yet we have neither
professional recognition as a specialty nor
any nationally recognised training programme for
either profession (2)
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Joint committee for higher medical training
(JCHMT)1987
.. gave approval in principle to the introduction
of a training programme in Palliative Medicine
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The Hospice movement put death on the agenda but
Palliative Care has the ability to relegate to
the sidelines (3) Hospice matron
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much of the distress of death is caused by poor
communication and badly planned clinical care in
the early stages of disease. (4) Hospice
Medical Director
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If we carry this search for efficiency too far,
we may save a few pounds, while we lose the
hospice soul (5)
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Pros Cons

• Training
• Integration into NHS
• Teaching
• Probity
• Audit and Research
• a Voice

• More bureaucracy
• The quality battle
• Loss of individualised care
• Proving ones worth

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Specialist versus Generalist

• Palliative Care approach
• Specialist Palliative Care

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Medical ProfessionalismIn need of resuscitation?
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Doctors in SocietyMedical professionalism in a
changing world

• Report of a Working party of the Royal College of
  Physicians
• December 2005

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but medicine is more than the sum of our
knowledge about disease. Medicine concerns the
experiences, feelings and interpretations of
human beings in often extraordinary moments of
fear, anxiety and doubt. In this extremely
vulnerable position it is medical professionalism
that underpins the trust the public has in
doctors
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Committed to

• Integrity
• Compassion
• Altruism
• Continuous improvement
• Excellence
• Working in partnership with members of the wider
  healthcare team

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Recommendations

• Leadership
• Teamwork
• Education
• Appraisal
• Careers
• Research

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In an age when deference is dead and league
tables are the norm, doctors must be clearer
about what they do and why they do it
A doctors corporate responsibility, shared as
it is with managers and others, is a frequently
neglected aspect of modern practice.
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Quote from a trainee doctor
Medical professionalism is not optional. It is
an essential part of being a doctor, no matter
how many challenges face us.
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(No Transcript)
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Research and Evaluation

• Do we need (or want) to prove that Palliative
  Care is of benefit to patients and
  cost-effective?
• How do we do it ?

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Dilemmas and Directions the future of Specialist
Palliative Care National Council for Hospice and
Specialist Palliative Care Services 1997

• .there will be increasing expectations that
  palliative care is evidence-based and
  cost-effective. The time may come when also ask
  whether a hospice ..is providing value for money.

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(No Transcript)
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The need and appropriateness of measurement and
research in chaplaincy its criticalness for
patient care and chaplain department survival
post 1987
Journal of Health Care Chaplaincy 1987
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Difficulties in Research

• Interventions are complex
• Different individuals receive different care
• Problems of randomisation
• Clinical condition is changing
• Life expectancy is short
• Outcomes are multi-dimensional

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The plural of anecdote is not evidence
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Making the grade
The Grading of Recommendations, Assessment,
Development and Evaluation working group was
formed in 2000
In 2006 an editorial was published entitled
An emerging consensus on grading recommendations ?
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Making the GradePalliative Medicine 2004
the production of good quality evidence is a
matter of justice
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Certainty
Systematic review
Prospective RCT
Contributory knowledge and historical comparison
Organised observation
Pattern recognition
anecdote
Ignorance
Dudley 1983
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THAG Audit

• Survey of hospice inpatients
• Includes symptom management
• Information and communication
• Input from different professionals

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Question re chaplains input

• 1st Survey
• 8/10 patients had seen chaplain and found it
  helpful

• 2nd Survey
• 6/10 had seen chaplain and found it helpful.
• 2 out of the other 4 patients would have liked to
  see a chaplain

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Questions posed to chaplains by palliative care
patients
Strang and Strang 2002
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Certainty
Systematic review
Prospective RCT
Contributory knowledge and historical comparison
Organised observation
Pattern recognition
anecdote
Ignorance
Dudley 1983
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Are we value for money?
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Quality-adjusted life
years
months
QALYs
QALMs
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Possible money savers!

• Day Care keeping patients out of hospital
• Chaplains input reducing the drug bill
• Chaplaincy input reducing sickness levels

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(No Transcript)
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The absence of evidence is not evidence of absence
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A New Approach to Eliciting Patients Preferences
for Palliative Day Care the Choice Experiment
Method Douglas H-R et al
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Example of a choice set
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Patients Preferences

• Access to complementary therapy
• was 3 X as important as seeing the doctor each
  visit
• and 2 X as important as staying all day

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Evidence based Palliative Care

• There is some evidence and there needs to be
  more
• (BMJ Aug 1999)

Wisdom and compassion are needed when evidence
is lacking (BMJ Dec 1999)
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(No Transcript)
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Do Palliative Care and Chaplaincy have anything
in common?

• What does an orthopaedic surgeon do?

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Tips for being recognised as a health care
profession

• Change your title

Specialist Spiritual Care Support Facilitator
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How will you know if youve made the grade as a
health care profession?

• Ombudsman inquiry

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Father Ted Responsible for Destruction of NHS

• Health Secretary blames
• hospital closures on ½ million trendy rev
  payout.
• Ministers today denounced rising chaplains
  salaries.. ..