Abstract
Dr. Warm, with no background in palliative care, attended the first training workshop in the fall of 1988. The training included six modules, five on curriculum integration and one on faculty development. Dr. Warm returned to Cincinnati after the conference and thought hard about the needs of faculty and residents, leading to the first palliative care Fast Facts and Concepts. In a 2002 interview, he said:
In retrospect, the element with the greatest impact was the Fast Facts newsletter. I had just gotten cable TV that year and the idea came from watching Headline News on CNN. As you probably know, they give the viewer the 40 words it takes to get the story out, and then at the bottom of the screen is a running strip of text with the same message, only in fewer words. It gave me the idea that people just want less, rather than more. The idea was that if I put a 1-page newsletter in residents' and faculty mailboxes, they'd pull it out, look at it, and by the time they figured out they didn't want it, they'd have already read it. This was before e-mail really took off, so I was literally stuffing mailboxes. Unannounced, unwanted, I put each issue of Fast Facts in everyone's mailbox.
My goal was to make it short and to the point. Each Fast Fact addressed just one question, for example, “Do you know what an advance directive is?” Then, I'd answer it in less than 1 page, in big print. Fast Facts took off like wildfire because it was so easy. Word got around the medical school, and soon different residency programs and health personnel across the medical center were requesting them. The assistant dean for medical education got a hold of it, and asked me to send it to everyone in my medical institution. I was asking some difficult questions, initially. And surprisingly, this 1-page sheet was spawning these great discussions and responses. 3
Eric and I talked about his work and I invited him to make a 5-minute presentation at the follow-up meeting of the 30 residency programs in 1989. As I listened to his presentation, the eureka moment went off in my head that his insight had the potential to transform palliative care physician education in a manner than no amount of Grand Rounds or CME courses could ever accomplish, because it was specifically designed to answer a targeted clinical problem or illustrate a palliative medicine aspect of a bedside teachable moment. I asked Eric if we could collaborate and enlarge the project to include the other faculty working on the residency curriculum project (Charles von Gunten M.D., Ph.D., Jim Hallenbeck, M.D., Bruce Ambuel, Ph.D., and Susan Block, M.D.); Eric readily agreed and the national Fast Facts project was launched.
Beyond the content, Eric's gumption was to provide it directly to faculty—without their asking—a truly inspired idea. One of the earliest findings from the residency project was the “confidence-competence gap,” aka, “arrogance–ignorance gap.” A key part of the project was to have residency faculty complete a self-assessment of palliative care competencies and a knowledge examination. Despite great self-confidence, their average level of knowledge was nearly identical to that of interns. A truism of education is that learners primarily seek out new learning only in the setting of educational tension; there must be a need to know. If one feels great self-confidence there is little tension to learn—thus the failure of Grand Rounds, CME courses, and the like to substantially change palliative care practice behavior. Eric turned this problem upside down with the insight that clinical faculty frequently encounter patients with palliative care problems (e.g., conflicts regarding resuscitation status) they are not always sure how to manage—their personal tension for learning—but for whatever reason, rarely seek out help. He imagined that if provided with educational content automatically, without the burden of asking, perhaps a dialog to new learning can occur; which is exactly what happened.
Before national distribution, I thought I should do my own test. I constructed an email distribution list of approximately 100 Medical of College of Wisconsin faculty from diverse departments; all were faculty who I knew regularly faced the problems of caring for seriously ill patients. Following Eric's insight, I did not ask if they wanted the information, it just came automatically to their inbox. As in Cincinnati, the response was overwhelmingly positive; numerous emails ensued, thanking me for the information along with a rise in hallway conversations discussing challenging patient issues. So much for the often repeated myth that physicians are not interested in learning about palliative care! In 10 years of biweekly distribution, only two MCW faculty asked to have their names removed from the distribution list.
The first national Fast Fact distribution list was the pool of residency programs enrolled in the residency curriculum project, many of whom incorporated Fast Facts into their palliative care curriculum. Soon Fast Facts became part of EPERC which provided an even larger distribution pathway. Over the years a formal peer review process was established, Fast Facts was uploaded in various formats for PDAs, and publication of selected Fast Facts was added as a JPM feature. In 2007 I turned the leadership and editing of Fast Facts over to Drew Rosielle, M.D., now at the University of Minnesota, and Fast Facts have continued to thrive under his fine direction. Throughout this time, the core principles of writing and editing Fast Facts have been maintained.
• Choose a focused, clinically relevant topic that clinicians care about. • Provide concise, up-to-date, referenced information limited to 1 page. • Make Fast Facts freely available to anyone and encourage redistribution.
Fast Facts are a bit like the “Veg-o-Matic” food processor, there are a million uses for them. Here are just a few examples that I've come across:
• Weekly Fast Fact distribution reading during hospice interdisciplinary team meetings. • Assignment for medical students/residents to read/report during daily clinical team meetings. • Assignment to write a new Fast Fact during a month-long hospice/palliative care rotation. • E-mail distribution to referring hospice physicians. • Compilation into a teaching resource guide for academic faculty development programs. • Core content for hospice and palliative medicine fellowship training and hospice and palliative medicine board preparation. • Printing a relevant Fast Fact to place on the medical chart after every palliative care consultation. • Core content for nurses preparing for hospice and palliative medicine board examination. • E-mail distribution to hospital physicians and advance practice nurses.
But all these educational activities are just surrogates for what Fast Facts were ultimately designed for-to change clinical practice behavior with a goal of improving patient care. Dr. Shapiro's unsolicited letter provides a wonderful example of how a “just-in-time” educational resource (Fast Facts) can lead to a positive “just-in-time” clinical outcome; what more could a medical educator ask for?