Amy M. Sullivan

The Status of Medical Education in End-of-life Care: A National Report

OBJECTIVE: To assess the status of medical education in end-of-life care and identify opportunities for improvement.DESIGN: Telephone survey.SETTING: U.S. academic medical centers.PARTICIPANTS: National probability sample of 1,455 students, 296 residents, and 287 faculty (response rates 62%, 56%, and 41%, respectively) affiliated with a random sample of 62 accredited U.S. medical schools.MEASUREMENTS AND MAIN RESULTS: Measurements assessed attitudes, quantity and quality of education, preparation to provide or teach care, and perceived value of care for dying patients. Ninety percent or more of respondents held positive views about physicians’ responsibility and ability to help dying patients. However, fewer than 18% of students and residents received formal end-of-life care education, 39% of students reported being unprepared to address patients’ fears, and nearly half felt unprepared to manage their feelings about patients’ deaths or help bereaved families. More than 40% of residents felt unprepared to teach end-of-life care. More than 40% of respondents reported that dying patients were not considered good teaching cases, and that meeting psychosocial needs of dying patients was not considered a core competency. Forty-nine percent of students had told patients about the existence of a life-threatening illness, but only half received feedback from residents or attendings; nearly all residents had talked with patients about wishes for end-of-life care, and 33% received no feedback.CONCLUSIONS: Students and residents in the United States feel unprepared to provide, and faculty and residents unprepared to teach, many key components of good care for the dying. Current educational practices and institutional culture in U.S. medical schools do not support adequate end-of-life care, and attention to both curricular and cultural change are needed to improve end-of-life care education.

It was haunting...: physicians' descriptions of emotionally powerful patient deaths.

Purpose To understand the emotional experiences of physicians who care for dying patients and to identify educational opportunities for improving patient care and physician well-being. Method Between 1999–2001, physicians at two quaternary care medical centers in Boston, Massachusetts, and Pittsburgh, Pennsylvania, participated in 90-minute, semistructured personal interviews on their most emotionally powerful patient death. Quantitative data was obtained through face-to-face surveys rated on ten-point scales that asked physicians about emotional characteristics of and emotional responses to the death. In the qualitative portion of the survey, physicians were asked to describe the details of the most emotionally powerful patient death, the types and sequence of their emotional reactions, their methods of coping, and subsequent changes in behavior. Results Physicians had powerful experiences with death during all stages of their careers. Experiences with patient death generally fit into one of three types: “good,” “overtreated,” or “shocking/unexpected.” Housestaff often described coping in isolation with the disturbing emotions generated in the care of dying patients. Physicians learned how to care for and cope with dying patients from their experiences with patients whose deaths were most emotionally powerful and reported changes in their clinical behavior and career paths as a result. Conclusions Physicians’ emotional reactions to patient death can affect patient care and the personal lives of physicians. Supervising physicians have an opportunity to improve both the care of dying patients and house-staff coping with these deaths by using the “teachable moments” that are present for trainees as they care for the dying.

Teaching and learning end-of-life care: evaluation of a faculty development program in palliative care.

Purpose To evaluate the effectiveness of the Program in Palliative Care Education and Practice (PCEP), an intensive faculty development program at Harvard Medical School. Method PCEP is a two-week program offered annually with two on-site sessions in Boston, MA, and an interim period distance-learning component. Training integrates palliative care clinical skill development, learning theory and teaching methods, and leadership and organizational change. Longitudinal surveys (preprogram, retrospective preprogram, and postprogram) of participants from 2000–03 assessed self-reported preparation in providing and teaching palliative care; teaching and patient care practices; and satisfaction with program. Results The response rate was 96% (n = 149) for Session I and 72% for both Session I and II (n = 113). Questionnaire responses demonstrated statistically significant improvements with large effect sizes (range 0.7–1.8) on nearly all measures. Preparation increased from 3.0 ± 1.1 to 4.2 ± 0.7 for providing end-of-life care (1 = not well prepared, 5 = very well prepared), and from 2.6 ± 1.0 to 4.3 ± 0.7 for teaching this topic. Respondents reported behavioral changes in patient care and teaching; e.g., after the program, 63% noted that, specifically as a result of attending the course, they encouraged learners to reflect on their emotional responses to dying patients, and 57% conducted experiential exercises (e.g., role-play). Eighty-two percent rated the experience as “transformative,” and many responses to open-ended items described powerful learning experiences. Participants rated the program highly (4.9 ± 0.1, 1 = lowest, 5 = highest rating). Conclusions Integrating clinical content with learning about educational methods is an efficient and effective approach to enhancing clinical faculty’s capacity to model and teach clinical care. This program offers an educational model that engages practitioners, stimulates changes in practice, and offers opportunities for reflection and professional revitalization.

End-of-life care in the curriculum: a national study of medical education deans.

Purpose. To describe attitudes and practices of end-of-life care teaching in the undergraduate medical curriculum in the United States as reported by administrative leadership and identify opportunities for improvement. Method. A telephone survey of associate deans for medical education or curricular affairs at a random sample of 62 accredited U.S. medical schools was conducted in 2002. Results. Fifty-one deans participated (82% response rate). Most (84%) described end-of-life care education as “very important” and supported incorporating more end-of-life care teaching into the undergraduate curriculum. Sixty-seven percent reported that insufficient time is currently given to palliative care in their curriculum. Although a majority opposed required courses (59%) or clerkships (70%) that focused on end-of-life care, they did unanimously endorse integrating teaching end-of-life care into existing courses or clerkships. Key barriers to incorporating more end-of-life care into the curriculum included lack of time in the curriculum, lack of faculty expertise, and absence of a faculty leader. Conclusion. Associate deans for medical education or curricular affairs in the United States support integrating end-of-life care content into existing courses and clerkships throughout the undergraduate medical curriculum. Successful integration will require institutional investment in faculty development, including both the development of faculty leaders to drive change efforts, and the education of all faculty who teach students and exert influence as role models and mentors. The strong support for end-of-life care education expressed by academic leaders in this study, combined with the high level of interest expressed in the authors’ 2001 national survey of students, provide evidence of the potential for meaningful change in the undergraduate medical curriculum.

Hematology/oncology fellows' training in palliative care: results of a national survey.

Palliative care is recognized as integral to the practice of oncology, yet many oncologists report inadequate training in critical palliative care domains, such as symptom management, psychosocial care, and communication skills. The authors of this report sought to assess the quantity and quality of palliative care education within oncology fellowships.

Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents.

Purpose Given the shortage of palliative care specialists in the United States, to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts. Method Proposed competencies were derived from existing hospice and palliative medicine fellowship competencies and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a Web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains. Results The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate = 72%, 71/98). Using predefined cutoff criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains. Conclusions This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community.

Variation in predictors of primary care career choice by year and stage of training

CONTEXT: It is not known whether factors associated with primary care career choice affect trainees differently at different times or stages of medical education.OBJECTIVE: To examine how role models, encouragement, and personal characteristics affect career choice at different stages (medical school vs residency) and periods (1994 vs 1997) of training.DESIGN: A split-panel design with 2 cross-sectional telephone surveys and a panel survey in 1994 and 1997.PARTICIPANTS: A national probability sample of fourth-year students (307 in 1994, 219 in 1997), 645 second-year residents in 1994, and 494 third-year residents in 1997. Of the fourth-year students interviewed in 1994, 241 (78.5%) were reinterviewed as third-year residents in 1997.MAIN OUTCOME MEASURE: Primary care (general internal medicine, general pediatrics, or family medicine) career choice.RESULTS: Having a primary care role model was a stronger predictor of primary care career choice for residents (odds ratio [OR], 18.0; 95% confidence interval [95% CI], 11.2 to 28.8 in 1994; OR, 43.7; 95% CI, 24.4 to 78.3 in 1997) than for students (OR, 6.5; 95% CI, 4.3 to 10.2; no variation by year). Likewise, peer encouragement was more predictive for residents (OR, 5.4; 95% CI, 3.3 to 8.9 in 1994; OR, 16.6; 95% CI; 9.7 to 28.4 in 1997) than for students (OR, 2.1; 95% CI, 1.3 to 3.2; no variation by year). Orientation to the emotional aspects of care was consistently associated with primary care career choice across stages and years of training.CONCLUSIONS: The effect of peer encouragement and role models on career choice differed for students and residents and, in the case of residents, by year of training, suggesting that interventions to increase the primary care workforce should be tailored to stage of training.

Creating enduring change

BACKGROUND: Improved educational and evaluation methods are needed in continuing professional development programs.OBJECTIVE: To evaluate the long-term impact of a faculty development program in palliative care education and practice.DESIGN: Longitudinal self-report surveys administered from April 2000 to April 2005.PARTICIPANTS: Physician and nurse educators from North America and Europe. All program graduates (n=156) were invited to participate.INTERVENTION: Two-week program offered annually (2000 to 2003) with 2 on-site sessions and 6-month distance-learning period. Learner-centered training addressed teaching methods, clinical skill development, and organizational and professional development.MEASURES: Self-administered survey items assessing behaviors and attitudes related to palliative care teaching, clinical care, and organizational and professional development at pre-, postprogram, and long-term (6, 12, or 18 months) follow-up.RESULTS: Response rates: 96% (n=149) preprogram, 73% (n=114) follow-up. Participants reported increases in: time spent in palliative care practice (38% preprogram, 47% follow-up,P<.01); use of learner-centered teaching approaches (sum of 8 approaches used “a lot”: preprogram 0.7 ± 1.1, follow-up 3.1 ± 2.0,P<.0001); and palliative care topics taught (sum of 11 topics taught “a lot”: preprogram 1.6 ± 2.0, follow-up 4.9 ± 2.9,P<.0001). Reported clinical practices in psychosocial dimensions of care improved (e.g., assessed psychosocial needs of patient who most recently died: 68% preprogram, 85% follow-up,P=.01). Nearly all (90%) reported launching palliative care initiatives, and attributed their success to program participation. Respondents reported major improvements in confidence, commitment to palliative care, and enthusiasm for teaching. Eighty-two percent reported the experience as “transformative.”CONCLUSIONS: This evidence of enduring change provides support for the potential of this educational model to have measurable impact on practices and professional development of physician and nurse educators.

Facing the Challenges of Hematopoietic Stem Cell Transplantation With Mindfulness Meditation: A Pilot Study

The hematopoietic stem cell transplant (HSCT) experience is emotionally and physically stressful for cancer patients who undergo this procedure. Mindfulness-based interventions have been studied in patients with various diagnoses, including cancer, although minimal work has applied this intervention to hospitalized patients. Use of mindfulness meditation has potential to provide HSCT patients with coping skills to deal with unpleasant symptoms and an uncertain future. This exploratory study examined feasibility, physiological arousal, and psychological and physical symptoms in HSCT patients participating in a mindfulness meditation intervention that begins before and continues throughout hospitalization and involves one-on-one guided sessions and daily practice using a 17-minute meditation CD. Of the 20 participants, 78.9% completed the intervention. Statistically significant decreases in heart and respiratory rates and improvements in symptoms immediately before and after each session were found. These findings demonstrate feasibility and preliminary support of a mindfulness meditation intervention with symptomatic, hospitalized cancer patients.

A randomized pilot study of the use of concept maps to enhance problem-based learning among first-year medical students

Background: Medical student education is challenging, and concept maps (CMs) can help students link new and existing knowledge, promote critical thinking and identify knowledge gaps. Aims: To study the feasibility, acceptability, and effectiveness of CMs in problem-based learning (PBL) tutorials. Method: Students and tutors were randomized to tutorials that used or did not use CMs. A mixed-methods approach generated qualitative and quantitative results of participants’ perspectives on and the effects of CMs in PBL tutorials. Results: Student survey response rate was 71% (122/172). Most students (82.6%) planned to use CMs in the future at least occasionally, and students in CM tutorials endorsed increased likelihood of using CMs in the future (p = 0.02) versus students in non-CM tutorials. Qualitative analyses identified consistent associations between CMs and recurrent themes: integration of physiological mechanisms, challenging students’ knowledge of the material, and identification of knowledge gaps. Quantitative assessment of final exam scores revealed a statistically significant increase in the students’ scores in CM tutorials versus students in non-CM tutorials with an a priori α of <0.10. Conclusions: CMs are well accepted by students and faculty, feasible to incorporate into PBL tutorials, and may result in improved exam performance and student learning of physiologic concepts.