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include (1) command of relevant scientific and clinical knowledge; (2) mastery of appropriate technical, communication, interpersonal, and other skills; (3) appreciation of ethical and professional principles of care; and (4) development of organizational skills to help patients and families navigate the health care system. These four components are covered in more detail in Box 8.1, which draws from a variety of sources including the components and competencies identified by a number of organizations, clinicians, and educators (see, generally, Doyle et al., 1993; MacDonald, 1994, 1995; ABIM, 1996a; Blank, 1996a; see Appendix G for the American Board of Internal Medicine statement of clinical competencies). Although the elements listed emphasize knowledge and skills, they also reflect a concern for the attitudes, values, and feelings that shape and infuse their application in practice. For example, to the extent that students and practitioners have unexamined anxieties about death, they may unconsciously distance themselves from those who are dying and fail their patients clinically and emotionally (Howells and Field, 1982; Vargo and Black, 1984; Field and Howells, 1985).
Some specific competencies lie particularly, but not necessarily exclusively, in the realm of certain professions. For example, pharmacological management of symptoms is largely the physician's domain, although nurses, especially advanced practice nurses, may have some discretion in this area. Mobilizing community resources in behalf of patients and families is a special responsibility of social workers. Nurses play a particularly central role in coordinating interdisciplinary palliative care and attending to patient comfort. More widely shared are interpersonal and ethical competencies in end-of-life care, and many of the nonpharmacological options for preventing and managing symptoms and distress draw on the skills and sensitivities of all members of the palliative care team and, indeed, all of those who come in contact with seriously ill and dying patients.
Despite the difficulties in bringing about curriculum reform and the many legitimate competing interests,2 the stakes here—avoidable physical,
The committee was, for example, aware of Renee Fox's observations about a series of reports on medical education. In her words, they have appeared at "periodic, closely spaced intervals … [and have] contained virtually the same rediscovered principles, the same concern over the degree to which these conceptions are being honored more in the breach than in practice, the same explanatory diagnoses [about] what accounts for these deficiencies, along with renewed dedication to remedying through essentially the same exhortations and reforms" (cited in Howell, 1992, p. 717).