Clinical Rotations

Blocks

Inpatient block

The consult service sees patients in various inpatient settings at Dartmouth Hitchcock Medical Center, including medical, oncology, cardiology, pediatric, surgical floor and critical care units. Daily Inter-Disciplinary Team (IDT) meetings are held with:

  • Bereavement
  • Between one and six learners on rotation
  • Chaplaincy
  • Creative arts
  • Healing arts
  • Nursing, including advanced practice nurse faculty and fellows, and inpatient and outpatient nurse clinicians.
  • Pharmacy
  • Physicians, including faculty and fellows
  • Social work
  • Volunteer coordinators and services at the Byrne Center and Dartmouth Hitchcock Medical Center

IDT meetings are held at Dartmouth Hitchcock Medical Center to comprehensively review each patient and family being followed by the palliative care team.

Fellows take weekend call about one weekend per month, either at the Byrne Center or at Dartmouth Hitchcock Medical Center. Fellows transition from direct supervision to indirect supervision on weekends as the year progresses. Additionally, fellows will cover night home pager call for about one night per week to gain experience in responding to palliative care emergencies.

As the year progresses, fellows will receive mentoring and take an active role in serving as a teaching mentor for other learners who are rotating with palliative care.

Jack Byrne Center for Palliative & Hospice Care block

Fellows work in this stand-alone hospice and palliative care unit which serves as an extension of Dartmouth Hitchcock Medical Center to collaboratively manage complex end-of-life care in an interdisciplinary fashion. Patients come from Dartmouth Hitchcock Medical Center, when the focus of care is on comfort, and fellows work in conjunction with local home hospice agencies to both admit from and discharge patients. The fellow will gain experience with terminal agitation, pain crises, and existential crises as well as better understand how the system of respite and General Inpatient Admission (GIP) hospice admissions works.

Daily Inter-Disciplinary Team (IDT) meetings are held with:

  • Bereavement
  • Between one and three learners on rotation
  • Chaplaincy
  • Creative arts
  • Healing arts
  • Licensed Nursing Assistants (LNAs)
  • Nursing, including advanced practice nurse faculty and fellows, JBC nurse clinician, bedside nursing, nurse educator, and nurse manager
  • Pharmacy
  • Physicians, including faculty and fellows
  • Social work
  • Volunteer coordinators and services at the Byrne Center and Dartmouth Hitchcock Medical Center

IDT meetings comprehensively review each patient and family.

As the year progresses, fellows will receive mentoring and take an active role in serving as a teaching mentor for other learners who are rotating with at the JBC.

Hospice block

The hospice rotation includes 2 to 4 week blocks of time split between Bayada Home Hospice (Norwich, VT) and Visiting Nurse and Hospice for New Hampshire and Vermont (White River Junction, VT). Fellows act as part of the hospice team, learn about the interdisciplinary support offered, and learn about being a medical director or hospice clinician. Experiencing 2 different hospices allows for a fellow to more deeply understand the hospice system and the variability inherent in that system. Fellows focus on caring for GIP or respite hospice patients being cared for at the Jack Byrne Center to meet their Accreditation Council for Graduate Medical Education (ACGME) requirements.

Nurse Practitioner fellows additionally focus on gaining an understanding of the nurse practitioner role in a hospice agency and as a clinician of record.

Long-term care rotation

Fellows are required to spend 4 weeks, or 100 hours, seeing patients with serious illness who reside in a long-term care facility (LTCF). The fellowship uses two interdisciplinary LTCF teams – led by Dr. Dacey and Kendal-at-Hanover and Dr. Fernandez of Dartmouth Hitchcock Medical Center GIM Geriatrics service. The fellow spends a two-week block with each team.

Kendal-at-Hanover is a Continuing Care Retirement Community (CCRC) with a spectrum of independent to assisted living residences, a secure dementia assisted living unit, and a skilled nursing unit. The Dartmouth Hitchcock Medical Center Geriatrics Team provides medical direction and patient care at four Skilled Nursing Facilities (SNFs) all of which have wide socioeconomic diversity among the patient population. Both sites offer significant opportunities in goals of care discussions, advance care planning and end of life care as well as providing experience in routine geriatric evaluation and management.

The Fellow participates in evaluation and management of patients. Patients range from fully independent to those with various stages of progressive dementia, and late-stage cardiac, pulmonary, and cancer diagnoses. Fellows will have the opportunity to see patients whose goals range from full aggressive interventions to those wanting to focus solely on comfort. Fellows will take night call during their Geriatrics Team time in order to gain experience with clinical triage based on goals of care and principles of geriatric care. Backup supervision will be provided by the Geriatrics team for teaching and confirming appropriate clinical plans.

Spirituality block

Fellows will spend 2 weeks of time with the chaplaincy department and experience the Clinical Pastoral Education (CPE) program run through this department. This experience will include being involved with CPE education, self-reflection and one-on-one reflection with Chaplaincy staff, CPE clinical review and rounding, learning spiritual screening and assessment tools, and observing verbatims by CPE interns.

Pain clinic block

The Pain Clinic rotation is a one-week experience. Fellows take part in the evaluation of patients with chronic pain issues, and gain knowledge and experience in non-opioid management for treatment of pain.

Pediatrics block

Fellows will rotate at the Children’s Hospital at Dartmouth working with the Complex Care Team seeing pediatric patients with multiple medical issues to learn the principles of pediatric palliative care. In addition, some patients will be seen in their homes or at Cedar Crest, a long-term care facility for children with medical needs.

White River Junction VA block

Clinical exposure to holistic care for patients and their families with advanced serious illness and receiving care through a federally funded VA system. At the VA, fellows will see a mix of inpatient and outpatient palliative medicine consultations. Attention is directed towards pain and symptom management, psychosocial-spiritual issues, and core communication skills in this population with special attention to the unique needs of the Veteran population. Learners are part of daily interdisciplinary team meetings, team and learner-specific educational sessions, and rounding with an attending or interdisciplinary team members.

Social work block

Fellows will spend time with HPM social workers that practice in the outpatient, JBC, and inpatient contexts. This occurs early in the fellowship and allows HPM fellows to gain familiarity with the discipline of social work, form coaching relationships with these interprofessional faculty members, and learn explicitly about counseling skills.