Approaching Death Improving Care at the End of Life (1997) / Chapter Skim
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8 Educating Clinicians and Other Professionals
8 Educating Clinicians and Other Professionals
Pages 207-234
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From page 207... ...
47 Critics have taken the medical education community vigorously to task for failing to sufficiently educate health professionals about how to provide superior, or even competent, care for dying patients.) On a more personal level, many physicians can recount how poorly prepared they were as students and residents to encounter dying patients and their families and how profound have been the lessons they have learned from their patients (see, e.g., ABIM, 1996b)
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From page 208... ...
The rest of the chapter focuses on the undergraduate and graduate education of physicians, nurses, and social workers and also points to the importance of continuing education. The fundamental argument of the chapter is that health professions education can do better in 1.
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From page 209... ...
CORE COMPONENTS OF PROFESSIONAL PREPARATION FOR CARE AT THE END OF LIFE Different people will bring to their roles as health professionals differing intellectual talents, emotional strengths, physical capacities, and other personal qualities. lust as some individuals may not be well-suited to become surgeons or pediatric nurse specialists, others may not be well-suited to specialize in palliative care.
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From page 210... ...
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. PHYSICIAN EDUCATION General Despite the difficulties in bringing about curriculum reform and the many legitimate competing interests,2 the stakes here avoidable physical, 2The committee was, for example, aware of Renee Fox's observations about a series of reports on medical education.
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From page 212... ...
The discussion below does not probe the implications of financial and political pressures facing medical schools, residency programs, and academic health centers. These pressures include threats to cut or revamp funding for graduate medical education, proposals to restrict the number of residencies (and, possibly, the use of international medical graduates)
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From page 213... ...
Similarly, efforts to improve communication skills might reasonably consider communication with patients and families about incurable diagnoses, unexpected or expected death, referral to hospice, and similar matters to represent one end of a continuum of progressively more difficult responsibilities. The last two years of undergraduate medical education bring some special challenges.
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From page 214... ...
the principles and values taught in palliative care are also relevant to the care of many patients who are seriously or chronically ill but not thought to be dying. In addition, physicians in a managed care environment will likely see a broader range of patients and patient problems than in the past.
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From page 215... ...
that "program directors acknowledge that critically ill patients, having few or no therapeutic alternatives, can have a negative impact on House Staff and students. They urged an exposure to outpatient oncology, where treatment successes are more frequently found" (cited in MacDonald, 1995, p.
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From page 216... ...
In contrast, a 1996 review of curricula in Canadian medical schools found that all 16 schools provided specific required time for palliative care education (MacDonald, submitted for publication)
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From page 217... ...
of psychiatric residency programs found that 56 percent of responding program directors reported that their programs offered some didactic coverage of the topic; of the residents responding, 26 percent reported participation in such lectures. As yet unpublished research based on focus groups and surveys in a number of medical schools presents similar reports of educational gaps and student or resident discomfort, uncertainty, and avoidance (Rappaport et al., 1991; Block, 1997~.
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From page 218... ...
One challenge in improving graduate medical education is the large number and diversity of residency experiences. Today, for example, many residents may train in institutions without strong palliative care services and consultative resources.
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From page 219... ...
One argument offered by those who support the creation of a palliative care specialty is that students need role models who are skilled in all aspects of palliative care (Calman, 1988; MacDonald, 1993~. As discussed further below, experienced, multidisciplinary consulting teams provide such role models, in addition to the important clinical and other expertise and instruction they may contribute to the care of patients with difficult problems.
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From page 220... ...
Exposure to patient and clinician narratives, literature, and structured opportunities for personal reflection. lust as the use of clinical teaching cases adds clinical richness and individual complexity to medical education, the use of personal narratives and literature provides compelling insights into the personal significance and interpersonal experience of caring for dying patients and those close to them and the ways in which a loved one's dying can brine richness and meaning to others as well as loss and .
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From page 221... ...
Gomez describes the development of a model inpatient hospice and palliative care program that was intended both to improve care for dying patients and to serve as a training site for internal medicine residents, medical students, and nurses (Gomez, 1996~. The program was separated from acute care units and linked to a well-established community hospice, which provided residents the opportunity to follow 4Standardized patients are individuals who are specially trained to present consistent behavior and descriptions of symptoms.
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From page 222... ...
Appendix H includes outlines for two examples of medical educational curricula on palliative care. The first was developed by the Canadian Committee on Palliative Care Education.
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From page 223... ...
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.
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From page 224... ...
Palliative Care as a Specialty The criticisms of medical education and the options for improving it imply the commitment of significant energy and resources to establish objectives, correct deficiencies, design and implement innovative programs, and develop means for evaluating progress and improving programs on an ongoing basis. Given all the challenges facing medical schools, academic health centers, and universities, the sustained availability of such energy and resources can hardly be taken for granted in either the short- or the long-term.
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, and recognition by hospitals and other organizations that credential professionals (e.g., grant hospital privileges, offer health plan contracts) .6 The case for seeking specialty recognition for palliative care has been forcefully argued in the United Kingdom, Australia, and Canada.
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under siege from health care restructuring. Formal specialty status is not the only way to expand the core of palliative care experts.
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After its months of examination of the problems in care at the end of life, it concluded that the needs are so great that palliative care should become established, if not as a recognized medical specialty, then as a defined and accepted area of teaching, research, and patient care expertise. NURSING, SOCIAL WORK, AND OTHER PROFESSIONS Other professions, including nursing, social work, dentistry, pharmacy, physical therapy, nutrition, and pastoral counselling have not been as severely criticized as medicine for inattention to care at the end of life.
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From page 228... ...
Variation exists in the availability of courses, their content, the degree to which end-of-life issues are integrated into basic nursing coursework, and the preparation of the faculty. Some topics related to critical care, pain management, pediatrics, and other specialized areas
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From page 229... ...
To take advantage of such shifts and encourage them, it makes good strategic sense for nurses and nurse educators to promote collaborative educational and training experiences in medical schools, residency programs, and physician continuing education activities.
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From page 230... ...
Although they do not provide medical services, social workers in the health care arena need a sound understanding of the medical problems their patients are facing. Some professional organizations, social service agencies, universities, and other organizations sponsor a broad range of continuing education and multidisciplinary training opportunities for social workers.
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From page 231... ...
For social workers, like nurses, collaborative educational and training experiences in conjunction with meclical schools, residency programs, and physician continuing education activities may help all participants improve their competency in the psychosocial dimensions of care at the end of life and their ability to participate effectively in multidisciplinary patient care. Such specialized, multidisciplinary training is not widely available.
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From page 232... ...
General strategies for lifelong learning are changing as university-based and other video conference capacities expand and as the Internet and similar electronic media make resources for self-learning more sophisticated and far-reaching. Distance learning options in palliative care have already been developed in Australia (cited in Scott and MacDonald, 1997~.
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From page 233... ...
Clinicians in training are not systematically prepared to assess the clinical and psychosocial factors that indicate what extent of curative, life-prolonging, and palliative care is appropriate for a patient or how it is to be initiated and managed through the course of illness. Attention to skills in communication and shared decisionmaking (including listening skills)
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From page 234... ...
234 APPROACHING DEATH In order to promote and monitor the initiatives already under way to improve health professionals' education and to consider what additional steps may need to be taken, the committee encourages the Institute of Medicine to organize, within the next one to three years, a symposium on the education of health professionals in care at the end of life. The objective would be to assess progress and identify directions for further efforts to ensure that physicians, nurses, social workers, and others have the attitudes, knowledge, and skills to care well for those approaching death.
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