BETHESDA, MdStudies in end-of-life care must be introduced into the standard medical school curriculum, David E. Weissman, MD, of the Medical College of Wisconsin, said at the First International Conference on Research in Palliative Care, sponsored by the National Institutes of Health (NIH) and the US Cancer Pain Relief Committee. They dont know what they dont know, Dr. Weissman said in his presentation on the need to change palliative care practice in academic medical centers.
IOM Report on End-of-Life Care
A 1997 Institute of Medicine report made seven recommendations intended to contribute to the achievement of a compassionate care system that dying people and those close to them can rely on for respectful and effective care. Among the recommendations were several aimed at improving end-of-life care at academic centers:
Recent trends in physician education that can be applied to education in palliative care include interactive rather than passive learning, evaluation of skills, and increasing utilization of ambulatory outpatient settings for training, he said.
Not a Recognized Specialty
A major factor holding back the development of palliative care education programs and research is that palliative medicine is generally not recognized as a separate specialty or discipline, he said.
Other barriers to the inclusion of palliative care in the medical school curriculum include the lack of a national commitment to palliative care, the impression that palliative care is a soft science more rooted in the humanities than in the natural sciences, and a failure of academic leaders to recognize the problem of inadequate training and preparation in end-of-life issues.
Furthermore, physicians-in-training lack role models in palliative care, and the discipline lacks tools for the evaluation of the skills needed to manage end-of-life patients.
Physicians face still further barriers when they attempt to establish palliative care programs in their institutions. The introduction of such programs usually must involve a change in the institutions cultural and hierarchical environment. Yet, there is generally a paucity of role models among senior staff who could be instrumental in effecting such change. In addition, the complex hierarchical organization of most academic centers may make it difficult to implement changes.
Another problem that may draw physicians away from palliative care is the fact that promotion incentives in academic medicine rely on peer-reviewed research and grant awards as opposed to active clinical patient care. This, along with a lack of clinical standards for palliative care, points to the need to develop guidelines for palliative care medicine and research tools for assessing palliative care outcomes.
Further, he said, in academic medicine, there is often a bias toward aggressive disease treatment to the exclusion of palliative or symptomatic management.
An important step toward facilitating the development of palliative care programs and research in academic medicine is the implementation of faculty development programs to provide role models regarding palliative care for physicians-in-training.
Training the Faculty
Faculty development must include programs to improve the working knowledge and skills of the faculty, Dr. Weissman stressed, as well as programs to train faculty to become better educators in end-of-life care.
The training should include information on the assessment of attitudes about end of life; the ability to transfer factual knowledge to practice; skills development (including communication skills and training in pain management); and methods to evaluate the skills taught to the medical students and house staff.
Information alone does not change clinical practice, Dr. Weissman said. You need to impact on the behaviors and attitudes of the faculty, staff, patients, and caregivers in order to effect change in an institution.
It is crucial to identify key supporters of change and identify the primary objectives of a palliative care program, he said. Established programs should be expanded as needed, with continual assessment of efficacy. Institutional change will support the best possible patient care, Dr. Weissman concluded.