October 29, 2003
DFCI study shows medical schools lack end-of-life training
Susan Block, MD
A new study has revealed a substantial gap between American medical students' interest in caring for dying patients and their preparation to do so.
The study, published by Dana-Farber researchers in the September issue of the Journal of General Internal Medicine, suggests that increasing students' opportunities to learn about end-of-life care will require not only curriculum changes, but a re-examination of some of the unspoken rules that govern medical education.
"The tremendous growth of hospice and palliative care in recent years has generated many initiatives to improve the training of students in caring for patients near the end of life," says lead author Amy Sullivan, EdD, of Medical Oncology. "But these programs won't produce real change unless they also address the 'hidden' curriculum of medical schools — the values, attitudes, and beliefs that constitute the basic culture of medicine. Our findings show that the medical school curriculum and culture currently do not adequately support good end-of-life care."
The new study is the first to examine the status of medical education in end-of-life care at the national level. It consisted of a survey in which fourth-year medical students were asked to describe their attitudes about caring for patients in these situations and to compare the quality and quantity of instruction in end-of-life care with that provided in other subject areas. To plumb the cultural forces at work in medical schools, the survey asked students about faculty and medical residents' attitudes toward end-of-life care and asked residents and faculty about their attitudes, clinical practices, and how prepared they felt to teach the topic.
A randomly selected group of 1,455 students, 296 residents, and 287 faculty members at 62 accredited U.S. medical schools participated in the study, which involved a 20-minute telephone survey.
While 90 percent of the respondents thought favorably of physicians' responsibility and ability to help dying patients, fewer than 18 percent of students and residents had received formal end-of-life education. Forty-three percent of students felt unprepared to address patients' fears, and nearly half were not ready to manage their own feelings about patients' deaths or help bereaved families. That same sense of uncertainty was expressed by residents, more than 40 percent of whom felt unprepared to teach end-of-life care.
The responses indicate that medical school and hospital residency cultures do not place enough emphasis on physicians' ability to care for dying patients, the authors observe. More than 40 percent of respondents reported that meeting the emotional needs of dying patients was not considered a vital part of being a physician. Nearly 60 percent of the students had told patients about the existence of a life-threatening illness, but only half of these students had received feedback on their performance from residents or attending physicians. Nearly all the residents had talked with patients about wishes for end-of-life care, but a third of them had received no feedback from their instructors.
"Students don't have adequate opportunities to learn from caring for dying patients, and they receive mixed messages about the importance of this care," Sullivan says. "In addition, students and residents lack exposure to role models with expertise in hospice and palliative care, which would provide them with a vision of what can be accomplished at the end of life."
Tending to dying patients at the end of life requires a complex set of clinical skills, Sullivan continues, including the ability to assess and treat pain and other physical distress, as well as address the emotional needs of patients and families. "In a professional culture that emphasizes cure, acute care, and high technology, teaching about care for patients' and families' psychosocial needs and learning about how to have these difficult discussions with patients are not among the educational priorities."
The good news is that, knowing which elements of the 'hidden' curriculum contribute to the problem, medical school and residency program administrators are now in a position to correct them, says the study's senior author, Susan Block, MD, chief of Psychosocial Oncology and Palliative Care in the Department of Medical Oncology. "All of the skills needed for quality care at the end of life — communication, psychosocial care, ethical decision-making, and pain and symptom management — are essential to good medical practice with any patient population," she says. "So preparing physicians in these competencies is likely to be of benefit in almost any clinical practice.
"Medical schools can send consistent messages about the importance of these skills by providing more course offerings in this area, giving students the opportunity to attend clinical rotations in hospice and palliative care, testing students and providing feedback on their competencies, and enhancing their faculty's abilities to teach end-of-life care," Block adds. "We know that students are interested in gaining these skills. It is now up to faculty and leaders to create a climate that will support good care for patients at the end of life."
