A modified Delphi approach to enhance nurturing of professionalism in postgraduate medical education in Singapore

INTRODUCTION

Nurturing professional identities instils behavioural standards of physicians, in turn facilitating consistent professional attitudes, practice, and patient care. Identities are socioculturally constructed efforts, thus we must account for the social, cultural, and local healthcare factors that shape physicians' roles, responsibilities and expectations. This study aims to forward a program to nurture professionalism amongst physicians in Singapore.

METHODS

A 3-phased-evidenced-based-approach was used. First, a systematic scoping review (SSR) was conducted to identify professionalism elements. Second, a questionnaire was created drawing from the SS's findings. Third, a modified Delphi involving local experts identifying socioculturally appropriate elements to nurture professionalism was conducted.

RESULTS

The 124 included articles in the SSR revealed definitions, knowledge, skills, and approaches to nurturing professionalism. The modified Delphi identified professional traits, virtues, communication, ethical, self-care, teaching and assessment methods, and support mechanisms.

CONCLUSION

Results formed the basis to a holistic and longitudinal program focused on instilling professional traits and competencies over time through personalised and holistic support of physicians. Findings will be of interest to medical communities in the region and beyond.

The role of palliative medicine in ICU bed allocation in COVID-19: a joint position statement of the Singapore Hospice Council and the Chapter of Palliative Medicine Physicians

Facing the possibility of a surge of COVID-19-infected patients requiring ventilatory support in Intensive Care Units (ICU), the Singapore Hospice Council and the Chapter of Palliative Medicine Physicians forward its position on the guiding principles that ought to drive the allocation of ICU beds and its role in care of these patients and their families.

Mentoring relationships between senior physicians and junior doctors and/or medical students: A thematic review

INTRODUCTION

Mentoring relationships are pivotal to the outcome of the mentoring process. This thematic review seeks to study the key aspects of mentoring relationships between senior physicians and junior doctors and/or medical students to inform efforts to improve mentoring programs.

METHODS

Literature search was performed on publications across PubMed, ERIC, Cochrane Database of Systematic Reviews, OVID and ScienceDirect databases between 1 January 2000 and 31 December 2015 by three independent reviewers. The BEME guide and STORIES statement were used to develop a narrative from the articles selected.

RESULTS

Thematic analysis of 49 articles reveals five semantic themes of initiation process, developmental process, evaluation process, sustaining mentoring relationship, and obstacles to effective mentoring. The evolving and relational-dependent nature of mentoring pivots upon the compatibility of mentors and mentees and the quality of their interactions, which in turn depend on mentoring environments and awareness of mentor-, mentee-, organizational-related factors and changes in context and goals.

CONCLUSIONS

Embrace of a consistent mentoring approach to ensure effective oversight of the mentoring process must be balanced with sufficient flexibility to ensure a mentee-centered approach. Efforts must be made to optimize the key aspects of mentoring relationships in order to ensure successful mentoring processes and outcomes.

Effect of palliative doctor in medical oncology team on patient outcomes

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Background: Advanced cancer patients have a high symptom burden and not infrequently have unplanned hospital admissions. In our institution, PM services are provided via a separate consult team rather than an integrated palliative oncology team. Sometimes, PM doctors join the oncology team as integrated members for a few months each as part of their PM fellowship training program. This study aims to explore the effect of this PM doctor. Methods: Patients admitted under the lung and gastrointestinal (GI) oncology teams from June 2013 to June 2014 were studied as this cohort of patients had a higher symptom burden and were more likely to benefit from PM input. The following information for each month was obtained from the computer system: hospital length of stay, formal referrals for a PM consult, 30-day, 60-day and 90-day mortality, and place of death. 2-sample T test was used to compare outcomes when there was a PM doctor in the oncology team for at least half of the month versus when there was not. Results: See table below. The presence of a PM doctor reduced the monthly percentage of formal referrals for PM consults but did not have clinically significant effects on other outcomes. Conclusions: PM doctors were there to learn oncology rather than provide a PM service. However, a reduction of PM referrals suggests that they were still able to meet some of the PM needs of the patients admitted. A new model of PM service provision whereby a PM healthcare professional is integrated within the oncology team warrants further study. [Table: see text]

Is there an unmet need for palliative care in cancer patients admitted to hospital?

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Background: Cancer patients who are admitted to hospital often have symptom problems and progressive functional decline, and may benefit from palliative care (PC) input. The aim of this study was to determine the profile of patients admitted under Lung and Gastrointestinal (GI) oncology teams (as their cohorts of admitted patients probably have more symptom problems) and whether they are being referred for PC input. Methods: Patients admitted from 1 March 2015 to 31 March 2015 were included. The following were recorded: primary site of tumor and whether it was metastatic, whether the admission was planned or unplanned, referral for PC input, outcome of admission and unplanned readmission within 7 days and 30 days. Results: See table below. Conclusions: Although 84% of patient admissions had metastatic cancer and 82% were unplanned admissions, only 21% were referred for PC input. This represents a missed opportunity for PC input, which has been shown to improve outcomes in patients with advanced cancer. However, if all advanced cancer patients who had an unplanned hospital admission were referred for PC, there would be a large increase from the current workload of the PC team. Hence, there is a need to pilot a novel model of PC provision, perhaps one in which a PC healthcare professional joins the oncology team to provide integrated palliative oncology care. [Table: see text]

Effect of a spiritual care training program on patient quality of life and spiritual well-being

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Background: Spiritual care (SC) is a vital part of palliative care (PC) but its provision is still not routine. We studied the effect of a SC training program for staff on patient quality of life (QOL) and spiritual wellbeing (SPS), as measured by the Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being (FACIT-Sp). Methods: This study was conducted at two sites: a PC consultative service in an acute hospital and a home PC service. The program comprised a 30 min training session for nurses and doctors on using the FICA tool for spiritual assessment and subsequent referral to a medical social worker (MSW) if needed, and a 60min training session with the MSWs on how to manage spiritual problems. A prospective cluster-controlled trial was done across 7 clusters. FACIT-Sp comprises 27 items for QOL (FACT-G) in the 4 domains and 12 items for SPS. This was administered at T1: upon referral to the palliative care service and T2: after 3 clinical visits by the PC team (doctor, nurse or MSW visits). Results: QOL data from 142 participants (69 intervention and 73 control) were analyzed. There appeared to be some benefit of the program on all domains of QOL as well as SPS, although only the FACT-G score achieved statistical significance. After further statistical adjustment for scores at T1 (to account for any regression to the mean), FACT-G score remained practically significant (p value 0.076). Conclusions: A brief SC training program for staff (30 min for nurses and doctors, 60 min for MSWs) appeared to result in some improved QOL and SPS for patients. However, a larger sample size will be needed to estimate the degree of benefit more accurately. [Table: see text]

Improvements in End-of-Life Care with a Protocol-based Pathway for Cancer Patients Dying in a Singapore Hospital

Introduction: More than half of all deaths in Singapore occur in hospitals. Little is known about the quality of care received by dying patients in hospitals. The Liverpool Care Pathway (LCP) provides a framework of providing good end-of-life care for dying patients and has been used with success in the United Kingdom (UK). In this study, we investigate whether adoption of a modified LCP in a Singapore hospital translated to better end-of-life care for cancer patients. Materials and Methods: The LCP was adapted and implemented as a pilot project on an oncology ward in Singapore General Hospital. A baseline review of 30 consecutive death records was performed, followed by a 4-month pilot and post-implementation audit of 30 consecutive patients on the adapted LCP. Results: Five types of end-of-life symptoms were analysed. There was only 1 uncontrolled symptom at death in the post-implementation group compared to 24 uncontrolled symptoms in the retrospective audit group. The prescription of breakthrough medications for symptom control increased from 21% in the retrospective audit group to 79% in the post-implementation group. Inappropriate monitoring was discontinued in 25 patients in the post-implementation group compared to none in the retrospective audit group. The documentation of resuscitation status and religion of the patient was improved, achieving full documentation in the post-implementation group. Conclusion: This study shows promising results for improving end-of-life care in cancer patients with a protocol-based pathway in a Singapore hospital. Extension of this care pathway to other settings should be explored to maximise its benefits to patients dying from all causes in hospital. Key words: End-of-life care, Liverpool Care Pathway, Symptom control

Improvements in end-of-life care with a protocol-based pathway for cancer patients dying in a Singapore hospital

INTRODUCTION

More than half of all deaths in Singapore occur in hospitals. Little is known about the quality of care received by dying patients in hospitals. The Liverpool Care Pathway (LCP) provides a framework of providing good end-of-life care for dying patients and has been used with success in the United Kingdom (UK). In this study, we investigate whether adoption of a modified LCP in a Singapore hospital translated to better end-of-life care for cancer patients.

MATERIALS AND METHODS

The LCP was adapted and implemented as a pilot project on an oncology ward in Singapore General Hospital. A baseline review of 30 consecutive death records was performed, followed by a 4-month pilot and post-implementation audit of 30 consecutive patients on the adapted LCP.

RESULTS

Five types of end-of-life symptoms were analysed. There was only 1 uncontrolled symptom at death in the post-implementation group compared to 24 uncontrolled symptoms in the retrospective audit group. The prescription of breakthrough medications for symptom control increased from 21% in the retrospective audit group to 79% in the post-implementation group. Inappropriate monitoring was discontinued in 25 patients in the post-implementation group compared to none in the retrospective audit group. The documentation of resuscitation status and religion of the patient was improved, achieving full documentation in the post-implementation group.

CONCLUSION

This study shows promising results for improving end-of-life care in cancer patients with a protocol-based pathway in a Singapore hospital. Extension of this care pathway to other settings should be explored to maximise its benefits to patients dying from all causes in hospital.