Palliative and Supportive Care and Nephrology: Education and Training Opportunities for the Nephrologist

September 16, 2020

UPMC and the University of Pittsburgh for decades have had one of the most robust and far-reaching palliative care clinical, research, and training programs integrated into its hospitals and subspecialty programs. 

Jane Schell, MDAmar Bansal, MDThe Renal-Electrolyte Division at UPMC has two physicians who are both dually fellowship-trained in nephrology and palliative care. Jane O. Schell, MD, MHS, FNKF, is one of those physicians, along with her colleague Amar Bansal, MD, FASN.

For many years, Dr. Schell has been a leading voice and innovator in developing educational platforms and curricula for palliative care in nephrology and clinical program advancements to improve patient care and outcomes.

"Patients with kidney disease are one of the least likely groups to receive palliative care and hospice services at the end of life, but also one of the groups that can benefit the most. These patients have a tremendous need for the services and benefits that palliative and supportive care offers because of their high symptom burden and communication needs to address their disease course, prognosis, and treatment options. As a nephrologist and palliative care physician, my passion and focus in my practice, research, and education have been to help improve how clinicians talk to their patients about their disease and what their future may look like," says Dr. Schell.

Communication and difficult conversations are part of the DNA of treating an individual with kidney disease. However, training for doctors and clinicians during medical school, residency, or fellowship on how to most effectively handle these aspects of patient care is not optimal.

"Traditionally in nephrology, there is little communication training on how to have difficult conversations with patients and families about kidney disease, what treatment options are available or may be appropriate, prognosis and the factors that can affect it, or the use of conservative management when dialysis is either not desired or when patients may not meaningfully benefit from dialysis. Much of my research and educational work has been to address these gaps and better prepare trainees and my physician colleagues for the complexities and challenges of the communications inherent in our specialty," says Dr. Schell.

Palliative Care Educational Offerings for the Nephrologist: NephroTalk

One of the signature programs Dr. Schell worked to develop is NephroTalk. Initially developed by Dr. Schell during her palliative care fellowship training at Duke University, NephroTalk is a multi-day seminar for nephrology fellows developed based on the learner-centered principles and communication strategies of national communication nonprofit VitalTalk. VitalTalk is an evidence-based teaching method that equips clinicians to navigate difficult conversations with patients. It was co-developed by Robert M. Arnold, MD, FAAHPM, Distinguished Service Professor of Medicine, chief of the Section of Palliative Care and Medical Ethics at the University of Pittsburgh School of Medicine, and medical director of the UPMC Palliative and Supportive Institute.

How physicians communicate with patients is essential. Communicating about such weighty matters as life and death are fraught with complexities, challenges, and pitfalls that few are naturally equipped to navigate. Nevertheless, how one communicates about such issues can be taught.

NephroTalk has evolved over the years into a three-day annual training for all first-year nephrology fellows in the Renal-Electrolyte Division. It also is open to fellows from other programs, as well as advanced practice providers. Faculty includes Dr. Schell and colleagues from the Section of Palliative Care and Medical Ethics in the Department of Medicine at the University of Pittsburgh, and two instructors from outside institutions. 

“A major focus of NephroTalk is helping trainees ask about patient values and goals of care. Understanding these is one of the bedrock principles of the practice of palliative medicine. We teach it from a didactic perspective, but we also practice with simulated patients and conduct large group exercises where the fellows can practice asking about values and then considering how they would make a recommendation about treatment and communicate that to the patient,” says Dr. Schell.

Developing a Conservative Care Curriculum for Physicians

Stemming from her work developing and evolving NephroTalk, Dr. Schell received a grant from the American Society of Nephrology William and Sandra Bennett Clinical Scholars Program to develop a scalable and generalizable curriculum for fellows and physicians that teaches the topics of advance care planning and medical management without dialysis (conservative management.) 

What arose from these efforts is NephroTalk Conservative Care Curriculum. This four-part online course is intended for clinicians and fellows to focus on conservative management or medical management without dialysis. The training teaches participants how best to identify patients who may benefit from conservative care and how to discuss it with their patients or arrive at a recommendation that is patient-centered. Co-creators of the training program include Dr. Arnold, Robert Cohen, MD, from Beth Israel Deaconess Medical Center, and the online learning expert Marie Norman, PhD. 

"We decided to address conservative care because there is little guidance for clinicians to discuss this option with their patients. Most physicians are not comfortable providing conservative management stemming from a lack of training and appreciation for when it may be a viable option for patients," says Dr. Schell.

Another part of the NephroTalk Conservative Care Curriculum was developing a mechanism to grow and foster the community of educators who are more comfortable with palliative care topics such as conservative care. 

Dr. Schell and colleagues piloted the curriculum with 19 nephrology programs around the country with 172 fellows participating and providing feedback via pre- and post-seminar surveys.

"At each of the institutions, we identified educators who had the desire to champion our curriculum. We developed materials for them to use to conduct interactive sessions using communication skills we taught them to work through a simulated case," says Dr. Schell.
“We are excited and hopeful this will eventually lead to a cadre of educators who want to expand upon the work in the future.”

Learn More

To learn more about Dr. Schell's educational and clinical work or learn more about NephroTalk and the NephroTalk Conservative Care Curriculum and how you can participate in educational opportunities in palliative care in nephrology, contact Dr. Schell at schelljo@upmc.edu.

More About Dr. Schell

Dr. Schell joined the University of Pittsburgh and UPMC in 2012 as a clinician-educator within the Renal-Electrolyte Division and Section of Palliative Care and Medical Ethics. Focused on improving the experience of patients living with kidney disease, Dr. Schell has pursued this interest through educational curricula development and clinical care. She has developed a renal supportive care clinic for kidney disease patients with palliative care needs. 

Dr. Schell’s academic and educational work centers on communication and provider-patient relationship. Dr. Schell has received funding through the American Society of Nephrology to develop and evaluate curriculum for nephrology fellows within palliative care. She has developed an annual communication training for nephrology fellows called NephroTalk that teaches skills in dialysis decision-making and end of life. This training has been adapted and taught for national audiences as well as practicing nephrologists. 

Dr. Jane Schell receiving the Hastings AwardDuring her career, Dr. Schell has published peer-reviewed articles within the topic of palliative care and nephrology in high-impact journals. Dr. Schell is an active participant in national organizations within palliative care and education, including the American Society of Nephrology, the American Kidney Foundation, and the Coalition for the Supportive Care of Kidney Patients.

In 2018, Dr. Schell was awarded the Hastings Center Cunniff-Dixon Foundation Early Career Award for her dedication to improving the care of seriously ill patients with kidney disease. The prestigious national award is given annually to five palliative care doctors whose work enriches the relationship between doctors and their patients who are near the end of life.


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