with others in the health professions, the university, and the community to develop an explicit statement on palliative care training for faculty, students, administrators, and others. The statement should

  • recognize that medical students and residents need education and training in the effective and humane care of patients approaching death;
  • define required and elective curriculum elements for such education and training including lectures, seminars, cases, clerkships, experiences, teaching methods, evaluation techniques, and personnel; and
  • specify the scientific, clinical, interpersonal, ethical, cultural, and organizational aspects of care to be covered; and
  • identify how the curriculum elements will contribute to student preparation for care of dying patients.

The last point underscores that the concern should not be narrowly with curriculum change but, more broadly, on evaluating the impact of educational strategies on practice and outcomes. As noted above, the committee understood that change is not cost-free and that educational resources need to be used wisely.

Incentives and Levers for Change

The incentives and levers for strengthening education in end-of-life care are varied. In addition to various forms of persuasive argument, a number of other, potentially more compelling means exist to secure change in medical education. Within the medical school curriculum, examination questions on symptom pathophysiology and management and other palliative care topics can focus student and faculty attention. Nationally, inclusion of such questions in licensure and board examinations would, in particular, signal the importance of the subject. The American Board of Hospice and Palliative Medicine has developed a certification examination in hospice and palliative medicine. For graduate medical education, residency program requirements and accreditation are potent means of directing attention to an issue.

For each specialty, residency review committees (RRCs) oversee the process of establishing and reviewing program requirements. The process for changing the requirements takes at least three years and more commonly lasts four or five years. As described by the ABIM, it "involves getting the language in, getting the word out to the many specialty RRCs and other professional societies and groups that are asked to comment, getting the impact statement completed to justify any new changes, and then getting the new requirements through the Accreditation Council for Graduate Medical Education for approval. From that point, the effective



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