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The Palliative Medicine Residency Program at the University of Manitoba has been in existence since 1999. It is one of the first to have been accredited by the Conjoint Committee of the Canadian College of Family Physicians and the Royal College of Physicians and Surgeons of Canada. The program provides a one year educational experience in Palliative Care Medicine. Trainees completing the year will be able to work as a consultant in palliative medicine in either an academic centre or as a community physician. A series of rotations encompassing inpatient, outpatient and consultation experiences as well as exposure to oncology and rural palliative care make up the program. A scholarly project is a mandatory requirement and a research rotation and guidance is provided.

Training Program Details
1. Eight week supervised training period on the Tertiary Level Palliative Care Unit, located at St. Boniface General Hospital (SBGH). Supervision will be determined at the time of the rotation. This rotation will include:

• Inpatient care on a 15-bed academic unit in a tertiary care teaching hospital. This hospital is in the centre of the culturally French-speaking part of Winnipeg. There is a diverse exposure to different cultures, languages and spiritual beliefs.
• In-hospital consultations.
• Telephone consultations for other city hospitals, the community, and for rural sites
• Out-patient Pain & Symptom control clinic.

2. Eight weeks at the Riverview Health Centre Palliative Care Unit. This would involve:

• Inpatient care on a 30 bed unit in a community-based long-term care facility
• Telephone consultations for city hospitals, community, and for rural sites
• Out-patient consultations through the Regional Palliative Care Program

3. Four weeks with the medical oncology service at CancerCare Manitoba. The resident will participate in outpatient clinics associated with several Disease Site Group, as well as hospital consultation and academic rounds. The rotation will focus on issues related to learning principles of malignant disease, its diagnosis and treatment. This includes solid tumours as well as hematologic malignancies.

4. Four weeks with the radiation oncology service at CancerCare Manitoba. The resident will rotate through several of the Disease Site Groups, and learn some of the principles of therapeutic radiation as well as the use of radiation as a modality for treatment, especially as therapy for the palliation of symptoms.  If the resident has previously completed an oncology training program, these rotations could be spent with the University of Manitoba Family Medicine Program, focussing on issues of communication and interview skills. Alternatively, it may be used for research or elective time. Such alterations in the schedule would require the approval of the program director.

5. Eight weeks working with the Community Consults and Home Visit Team. This will include the assessment and management of the terminally ill in the home, as well as preparation of the patient and family for death at home. The resident will work in conjunction with an interdisciplinary care team. As well, the resident will provide consultative services to other community hospitals in conjunction with clinical nurse specialists providing supportive and palliative consultation. These services will include pain and symptom management, as well interventions to improve end-of-life care.

6. Four weeks in a rural setting under the supervision of Dr. Cornelius Woelk, a rural palliative medicine practitioner. This would involve inpatient and home palliative care, both primary and consultative.  The resident will be exposed to the unique aspects of the provision of palliative care in the rural setting. This may be substituted by another core ward rotation in palliative care if geographic/family difficulties are encountered.

7. Four weeks elective in an area of study of the resident’s choice. This may include interventional anaesthesiology, psychiatry, psychosocial oncology, bereavement counselling, or other areas related to the delivery of palliative care medicine. The Program Director/Committee prior to commencement of the rotation will approve this program and as well as the specific rotational objectives developed by the trainee.

8. Four weeks vacation which can be distributed throughout the training year.

9. The resident will undertake a scholarly project, which will be ongoing throughout the year of training. The resident will be able to use one rotation to help with the completion of this or other scholarly projects. This block can be used to learn further techniques in biostatistics or clinical trial design. Supervision can be under any of the palliative medicine physicians with research experience, or may be under a physician from another but related area (e.g., radiation or medical oncologist). The resident will also be encouraged to present any findings from the research project at local, national or international conferences.

10. The final four-week period is the Senior Rotation. The resident will act as an attending physician on the SBGH Palliative Care Unit. Patients will be admitted under him/her, and the resident will initially review consultations. The resident will take responsibility for teaching of other trainees on the unit at this time. Supervision will continue to be provided by the faculty.

11. The resident will participate in the CancerCare Manitoba (CCMB) Pain & Symptom Clinic or the WRHA Palliative Care Clinic as a horizontal exposure. These clinics have a multidisciplinary focus, with the participation of medicine, nursing, pharmacy, psychosocial oncology and nutrition (CCMB site). It is located at the St. Boniface Site of CancerCare Manitoba. Research and education are an integral part of the clinic. The resident will be expected to participate in this weekly clinic throughout the year.

12. The resident has the option of pursuing up to one clinic a week in the area of their certification (Family Medicine, Internal Medicine, Oncology, etc.). This must not interfere with their progress in the residency, and should be timed to cause the least disruption to their work on the individual rotations.

Resources and Locations Involved in Training
The resident will train in a variety of different learning environments including tertiary palliative care and community palliative care units. There will be an opportunity to acquire skills in a hospice or home setting as part of the Home Visit Team. In addition, the resident will undertake rotations as part of the Palliative Medicine Consultation Team at the SBGH or HSC to broaden his/her understanding of the consultative and cultural dimensions of palliative care. There will be interdisciplinary faculty guiding the resident, including Family Medicine, Medical Oncology, Radiation Oncology, Nursing, Social Work, Pastoral Care, Psychiatry and Psychosocial Oncology. Opportunities will exist for the resident to interact with anesthetists, surgeons, and neurologists, through the elective rotation.

Appropriate resources will be provided for administrative support in terms of space, access to libraries and computers with internet access. During the rotations at SBGH, residents will have access to complete diagnostic radiology facilities, including diagnostic ultrasound, CT scanning and MR imaging. Access to surgery and its specialties, as well as anesthesia is also available at St. Boniface.

Palliative Care Unit - St. Boniface General Hospital
First palliative care unit established in Canada, and presently sited within a tertiary care, university - teaching hospital. The Unit has been completely redesigned as of May 2000. This Unit provides inpatient, as well as community and tertiary palliative care services with a full complement of physicians, including an oncologist, family physicians and other members of the health care team. There are full diagnostic facilities, including radiology, laboratory support, surgery and its specialities, psychiatry, and medical & radiation oncology. The 15-bed unit has facilities for outpatient assessment, conferencing capabilities, and library resources both on the unit, as well as in the St. Boniface Research Centre (affiliated with the University of Manitoba). There is also access to computers, which have Internet capability. A separate teaching room is available for lectures and ongoing personal study.

Riverview Health Centre
A 30-bed community palliative care unit based in a community hospital. The resident will work directly with the physicians and providing supportive and palliative care to generally long-term care patients as a multidisciplinary team. Diagnostic radiology as well as laboratory support is located within this facility.

CancerCare Manitoba
This institution is the referral centre for cancer in the Province of Manitoba. The rotations in medical and radiation oncology will take place under the direction and supervision of specialists associated with this institution. CancerCare Manitoba is located at each tertiary teaching hospital in Winnipeg (HSC and SBGH). Each site is supported with space as well as administrative personnel. Library and computer access is available at both sites. The ability to interact with members of the Department of Psychosocial Oncology is also available at both sites.

Boundary Trails Hospital
The resident will be centred here for the rural rotation. The supervising physician has completed a clinical fellowship in Palliative Care Medicine. It is from this location that the resident will visit communities in the region with the supervisor. In addition, visits to personal care institutions and family homes will also be part of this rotation.
The Boundary Trails Hospital is a community-based hospital that contains diagnostic radiology as well as laboratory support services. It contains in-patient, out-patient as well as surgical facilities.

Health Sciences Centre
This University-associated tertiary level facility is the largest hospital in Manitoba. Like the St. Boniface site, it has a full complement of diagnostic radiology, laboratory support, surgery and its specialities, as well as the main children’s referral centre in the province. The resident will have access to the University Medical Library, as well as the main undergraduate medical teaching centre. This centre will be used for patient consultations in symptom management and palliative medicine.

Grace Hospice
This new (January 2004) 12-bed unit is designed to accommodate patients and their families in a home-like setting, with the supports of nursing staff, support staff, and medical follow-up. Patients residing in the Hospice have advanced disease in a generally stable condition, but their care needs prevent them from being at home. All patients are registered with the Regional Palliative Care Program, and may require input from the Clinical Nurse Specialist (CNS) or the community/home visit physician. The Patient Exposure

The WRHA Palliative Care Program administers the major units at St. Boniface General Hospital and Riverview Health Centre, as well as having input into admissions to the Grace Hospice and Jocelyn House (a 4 bed free standing hospice). The program has approximately 1300 terminally ill patient deaths per year. This group includes approximately 60-70% of the total cancer deaths in Winnipeg. In addition, there are significant proportions of terminally ill patients with non-malignant conditions that are seen throughout the program sites. These include patients having diseases such as end-stage renal failure, cardiac failure, neurologic conditions, and catastrophic brain injury, either through trauma or stroke. As well, patients requiring terminal care may be transferred from the Intensive Care Unit or Emergency Room.  The patient population seen at these two units encompass a wide variety of cultures.

St. Boniface Hospital has a special commitment to the French Canadian population of both Winnipeg, as well as Manitoba. Winnipeg has a large urban Aboriginal population, and they have significant representation in the patient population that both of these units serve. In addition, patients from many cultural backgrounds are seen in the two units. This includes patients whose first language is not English, who may have different cultural or ethnic backgrounds, and a wide variety of religious or spiritual associations.

Boundary Trails Hospital is located in Southern Manitoba, and in the centre of a large Mennonite community. As well, there is exposure to people of the Hutterite community. These are people of Eastern European and Germanic descent, whose culture and language are quite different from that of typical North Americans.

As CancerCare Manitoba is the main referral centre for the treatment of malignant, as well as hematologic diseases in the province, exposure to the diverse cultural minorities of the province will also take place. This may also include exposure to patients from Northern Manitoba or Nunavut including Dene and Inuit backgrounds.

Scheduled Teaching Sessions and Other Scholarly Activities
The resident will be expected to attend weekly Case Conference on ward-based rotations.

The resident will also be expected to attend Academic Day, which takes place weekly on Thursday mornings (0830-1130). Journal Club as presented by the Attendings and residents will alternate with seminars presented by the resident to the attending physicians and fellow residents. These will be dealing with topics from the palliative medicine curriculum chosen. The resident will be expected to present at this venue on a regular basis, depending upon the number of residents in the program in any given year. Teaching rounds by the Attendings will be given to the resident(s), as well as other rotating trainees on a weekly basis. It will be expected that the residents will also participate in the education of the rotating trainees through teaching of selected topics. Attendance at Academic Day is mandatory.

Attendance at Palliative Care Rounds (first Thursdays of the month at noon) will also be expected of the resident. The resident will be required to present at least once during the year at these rounds, which have an interdisciplinary focus, and cover a wide variety of topics related to palliative care. Special rounds with guest speakers that may have a direct or indirect connection to palliative care may also take place throughout the year, and resident attendance will be encouraged.

Attendance at Grand Rounds in Internal Medicine, Family Medicine, Medical Oncology, Radiation Oncology, as well as relevant topics in Psychiatry will be strongly encouraged. Ethics Rounds are jointly held at both hospitals, Health Sciences Centre and St. Boniface Hospital, and will also be open for attendance. Specific Continuing Medical Education opportunities may also arise in which the resident will be encouraged to attend. In addition, teaching of undergraduate medical students and other postgraduate trainees by the faculty with a focus on palliative care topics will also take place throughout the year. The resident will be encouraged to participate in this teaching.

Attendance of at least one local, national or international palliative care conference such as the biennial International Conference on the Care of the Terminally Ill (held in Montreal) will be encouraged.

Scholarly Project/Research
The resident will complete a least one scholarly research project during the study year. This project may take one of several forms, including case reviews, chart audits, clinical trials or qualitative investigations. Participation in ongoing clinical trials within the section will be encouraged. An example would be a pilot study to test an opioid protocol for movement/incidental pain. Should the resident have an idea or a topic they would like to develop, they can meet with the Palliative Medicine Residency Director who will help facilitate their involvement in research and find a suitable supervisor. It is expected that the resident will acquire some knowledge of areas of research within Palliative Care through our Journal Club, Academic Day, and Palliative Care Rounds. In completing the research project, the resident will be given the guidance and support from established members in the Palliative Care faculty, as well as methodological and biostatistical support from other members of the Department of Family Medicine. It is anticipated that the resident will prepare the final results of the project for presentation at local and/or national meetings and also for submission for publication. A resident fund to help offset costs for conference attendance and travel will be available.

Evaluation
The resident will be evaluated by the attending physicians supervising each rotation, using a standard evaluation form based on objectives of the individual rotations. The resident will be asked to assess patients under direct supervision. Also, the resident will be expected to clinically summarise the case(s), and will be able to present to the interdisciplinary team. Clinical decisions will be discussed with the attending physicians, as well as other members of the team.
Technical skills, in particular paracentesis and thoracocentesis will be done under the direct supervision with the attending physicians of the individual rotations. This will likely occur in the in-patient units at St. Boniface and Riverview, as well as in the outpatient or home setting. Feedback regarding these technical skills can be given shortly after completion of the task.

The resident will undergo a formal in-house summative examination. The resident will examine a patient and will formulate a consultative plan. This plan will then be dictated in the form of a consultation letter, which will be prepared that day. After a reasonable amount of time (2-3 hours), the resident will meet with two supervising physicians to review the case by the bedside, as well as a review of the consultative letter. After this, the resident will be presented with standard case problems and will be asked questions related to management and disposition of the patient. The resident will be graded on their performance in both the patient case as well as the oral scenarios. As well, the written letter will be reviewed and will contribute to the resident’s final status. This will generally occur prior to the senior rotation.

Selection of Residents
The number of residents in the program will vary according to Manitoba Associated Teaching Hospitals (MATH) funding availability. At present, funding exists for two positions. These residents may be from either the Family Medicine stream or the Royal College stream. Consideration can be given to part-time positions, which can be designed to meet the trainees’ needs and the program requirements.

Residents will be selected from applicants that meet the minimum requirements. This means that they will have completed a postgraduate certification program as set out by the Royal College of Physicians and Surgeons or by the Canadian College of Family Physicians. They must have completed the certification examinations or be eligible to sit these examinations on the completion of the palliative medicine program. A letter of intent accompanying a current curriculum vitae is required. As well, the candidates will be interviewed by at least two members of the residency program committee, and external references (up to three) will be contacted. The Residency Program Committee will approve selection of the successful candidate.

The deadline for acceptance of applications will be November 15th yearly, with the offer of a position before the end of the calendar year.