VCUHS HEMATOLOGY/ONCOLOGY FELLOWSHIP CURRICULUM
Palliative Care Rotation
Description of Rotation or Educational Experience
The Hematology-Oncology fellowship palliative care rotation is designed to provide the fellow with the opportunity to
participate in the care and management of patients admitted to the hospital in the acute setting requiring palliative acute
symptom relief and/or end-of-life management and well as outpatients with cancer with chronic pain or palliative needs. The
fellow operates in the context of the interdisciplinary team of physicians, mid-level providers, nurses, chaplains, social
workers, and therapists trained in hospice and palliative care medicine. The fellow is exposed to the use of care sets
developed for palliative care and hospice management. This rotation provides a unique opportunity for exposure to routine
and advanced pain management techniques and organ-based and systemic symptom management techniques when diseasespecific therapy alone has been insufficient. The rotation also allows fellows to directly experience patient care in the
inpatient and home hospice settings. Additionally, the rotation focuses on training the fellow in the establishment and
communication of goals-of-care with the patient, the family, and an interdisciplinary team. All of this occurs under the
supervision of the specially trained attending physicians and mid-level providers in hospice and palliative care within the
Division of Hematology, Oncology, and Palliative Care.
To optimize this experience for Hematology-Oncology fellows, the rotation is divided into three parts. The first part focuses on
pain and symptom management. During this one-week period, fellows work with a member of the palliative care team
evaluating case studies and seeing consults focused on pain and symptom management. Fellows also participate in palliative
supportive care clinics during this week. The second part of the rotation focuses on inpatient care on the palliative care unit
and consults pertaining to oncology patients. During this two-week period, fellows are the primary provider for at least one to
two patients on the inpatient palliative care unit. Fellows are also the primary consultant for a variety of palliative care
consults with a focus on those pertaining to oncology patients. Fellows also accompany the palliative care chaplain on at least
two chaplain consults, which enables fellows to observe spiritual assessment and communication. The third part of the
rotation focuses on hospice care. During this one-week period, fellows attend an inpatient hospice unit visit and a home
hospice visit that they schedule through a local hospice agency. Throughout the 4 week rotation, fellows also participate in the
weekly palliative care Problem Based Learning Initiative (PBLI) conferences, and they complete required reading assignments
on palliative care and hospice. Fellows are also available to see general palliative care consults when not in clinic or on a
specific assignment.
Location:
VCUHS MCV Hospital Palliative Care Unit
VCUHS Dalton Oncology Palliative Care Clinic
VCUHS MCV Hospital inpatient nursing units
Hospice of Virginia inpatient unit and home hospice settings
Length of Experience:
4 week block – days only including weekend day coverage with one day in 7 off of all clinical duties. There is no in-house
overnight call on this rotation.
Educational Goals
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Gain experience and knowledge in the evaluation, grading and management of acute and chronic pain from
malignant and non-malignant etiologies
Gain experience and knowledge in the diagnosis and management of organ-based and systemic manifestations of
locally advanced or metastatic malignancy
Gain experience in working with an interdisciplinary palliative care team.
Gain experience and knowledge in effective establishment and communication of goals of care
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Gain experience in the management of the patient at the end-of-life and the resources available to the patient and
their families
Gain experience and knowledge of hospice care in both the inpatient and outpatient settings.
Gain experience in addressing psychological and spiritual concerns in patients enduring severe illness and at the end
of life.
Gain experience and knowledge of the legal and societal issues as they pertain to the end-of-life management.
Gain experience in and respect for the cultural differences in response to severe illness and death
Gain experience in recognizing one’s own reaction to grief and stress as a provider
Patient Care
Goal
Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health
problems and the promotion of health. Please refer to overview of the fellowship curriculum for competencies/objectives for
patient care.
Specifically, fellows will see patients in both the acute inpatient hospital and the outpatient clinic settings under the
supervision of the appropriate subspecialty faculty members. In addition, fellows will see patients in the inpatient hospice and
home hospice settings under the supervision of certified hospice nurses. Fellows will participate in the evaluation, counseling,
and management of acutely and chronically ill patients with both malignant and non-malignant medical conditions in need of
palliative and/or end-of-life care. This will provide the opportunity to learn the different approaches to the management of
these conditions. Fellows will additionally work within an interdisciplinary team of health professionals including midlevel
providers, pharmacists, nurses, physical therapies, occupational therapists, social workers, care coordinators, and pastoral
care. This will provide the fellow experience and feedback in effectively working within an interdisciplinary team of health
professionals.
Competencies
Fellows are expected to:
 Gather appropriate clinical information
 Synthesize information into a care plan
 Partner with patients/families in the implementation of the plan and goals of care
 Coordinate care plans with the interdisciplinary team of health professionals and the home health agencies
Objectives
Fellows are expected to:
 Develop skills in history/physical examination of the patient
 Integrate clinical data in the formation of a comprehensive care plan
 Document the encounter in the medical record in sufficient detail to communicate to other physicians and meet
billing requirements
 Provide compassionate, appropriate, and comprehensive patient care
Medical Knowledge
Goal
Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral
sciences, as well as the application of this knowledge to patient care.
Competencies
Fellows are expected to demonstrate skills in:
 Acquisition of knowledge
 Analysis of information
 Application of knowledge
Objectives
All fellows are expected to:
 Demonstrate the ability to perform a comprehensive and accurate physical examination; demonstrate the ability to
arrive at an appropriate differential diagnosis; outline a logical plan for specific and targeted investigations pertaining
to the patient’s complaints; and formulate a plan for management and follow-up treatment of the patient
 Demonstrate their knowledge by presenting the results of a consultation orally and in writing and by defending the
clinical assessment, differential diagnosis, and diagnostic and management plans
Rotation-Specific Objectives
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Assess and quantify a patient’s pain using a variety of pain assessment tools
Discuss the indications and use of a variety of medications and delivery methods used in delivery of analgesia in both
the acute and chronic pain setting.
Discuss the indications and use of a variety of non-pharmacologic methods used in the management of both acute
and chronic pain.
Calculate initial PCA dosing parameters, interrogate a PCA pump and make dose adjustments based on serial
assessments of the patient’s pain.
Convert among a variety of analgesics including the ability to account for a variety of routes of delivery including but
not limited to oral, intravenous, subcutaneous, and epidural routes
Discuss the pharmacologic properties of the various analgesics
Discuss the palliative management of malignancy-related dyspnea, nausea/emesis, and anorexia/cachexia.
Assess a patient’s functional performance using a variety of assessment tools
Recognize the stages of normal grieving and coping.
Recognize, diagnose, and manage psychological and spiritual conditions and the role that they might play in the
management of the patient’s other medical conditions.
Recognize the need for referral and demonstrate a knowledge of the resources available in the management of
psychological and spiritual conditions
Demonstrate a knowledge of and application of palliative care algorithms for the management of end-of-life
conditions including but not limited to anxiety, agitation, psychological and spiritual angst, dyspnea, and pain.
Practice- Based Learning and Improvement
Goal
Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. The fellow is
expected to present primary scientific and medical evidence to support their conclusions and care plans in the diagnosis,
prognosis, management, and monitoring of the patients on the service. The fellow is expected to recognize their areas of
deficiency. Depending upon the acuity of the care situation, the fellow is expected to be able to effectively utilize their
resources to arrive at necessary information and to apply the information to their patient care. Moreover, the fellow is
expected to recognize conditions and circumstances requiring escalation.
Please refer to overview of the fellowship curriculum for competencies/objectives for practice based learning and
improvement.
Systems Based Practice
Goal
Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the
ability to call effectively on other resources in the system to provide optimal health care. Fellows will work within an
interdisciplinary team of health professionals including midlevel providers, pharmacists, nurses, physical therapists,
occupational therapists, social workers, care coordinator, and pastoral care. This will provide the fellow experience and
feedback in effectively working within an interdisciplinary team of health professionals. Additionally, working within the
context of a broader health system includes the importance and necessity to recognize conditions and circumstances requiring
consultation and/or escalation for the effective and safe delivery of patient-centered medical care.
Please refer to overview of the fellowship curriculum for competencies/objectives for systems based practice.
Professionalism
Goal
Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
The fellow is expected to model professional and courteous behavior in the treatment of the patient and in working with the
entire health care team. The fellow is expected to complete documentation of their patient care, of their communications with
the patient and health care providers, and of their procedures in a timely fashion within the medical record. The fellow is also
expected to recognize the critical importance of their own education and the importance of life-long learning as part of their
professional responsibility. As such, it is the obligation of the fellow to themselves, their profession, and their patients to
attend and complete in a timely fashion all of fellowship training program’s expected educational activities.
Please refer to overview of the fellowship curriculum for competencies/objectives for professionalism.
Interpersonal and Communication Skills
Goal
Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and
teaming with patients, their families, and professional associates.
Please refer to overview of the fellowship curriculum for competencies/objectives for interpersonal and communication
skills.
Teaching Methods
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Patient care/clinical experience
Modeling of observed behaviors of attending physicians and other members of the interdisciplinary team
Case-based interactive discussions
Didactic sessions
Performance feedback
Self-directed learning
Assessment of Fellow Performance
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End-of-rotation evaluation of the fellow by the supervising attending physicians
Mini-CEX by the supervising attending physicians and/or the nurse practitioner faculty of a counseling and
communication encounter
Semi-annual self-assessment by the fellow
Assessment of Rotation
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End-of-rotation evaluation of the supervising attending physicians by the fellow
Annual program review
Discussions with fellows during biannual review
Review in-service and ABIM exam results
Level of Supervision
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Indirect supervision with faculty immediately available
Direct supervision by the faculty of select patient, family and professional health staff encounters to assess medical
knowledge as conveyed in the provided counseling and care coordination, system-based practice, professionalism,
and interpersonal communication skills
Educational Resources
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VCUHS Hospital Palliative Care Unit patient care set algorithms and procedures manual
UNIPAC Self-Study Program (4th Edition)
EPERC
Bonica Management of Pain (4th Edition)
Bruera Oxford American Handbook of Hospice and Palliative Care
Bruera Textbook of Palliative Medicine and Supportive Care
Devita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology (9th Edition)
UpToDate
ASCO University
ASCO Practice and Guidelines
ASCO-SEP
ASH-SEP