Skip to main content

Advertisement

SpringerLink
Log in

The status of medical education in end-of-life care

A national report

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

OBJECTIVE: To assess the status of medical education in end-of-life care and identify opportunities for improvement.

DESIGN: Telephone survey.

SETTING: U.S. academic medical centers.

PARTICIPANTS: National probability sample of 1,455 students, 296 residents, and 287 faculty (response rates 62%, 56%, and 41%, respectively) affiliated with a random sample of 62 accredited U.S. medical schools.

MEASUREMENTS AND MAIN RESULTS: Measurements assessed attitudes, quantity and quality of education, preparation to provide or teach care, and perceived value of care for dying patients. Ninety percent or more of respondents held positive views about physicians’ responsibility and ability to help dying patients. However, fewer than 18% of students and residents received formal end-of-life care education, 39% of students reported being unprepared to address patients’ fears, and nearly half felt unprepared to manage their feelings about patients’ deaths or help bereaved families. More than 40% of residents felt unprepared to teach end-of-life care. More than 40% of respondents reported that dying patients were not considered good teaching cases, and that meeting psychosocial needs of dying patients was not considered a core competency. Forty-nine percent of students had told patients about the existence of a life-threatening illness, but only half received feedback from residents or attendings; nearly all residents had talked with patients about wishes for end-of-life care, and 33% received no feedback.

CONCLUSIONS: Students and residents in the United States feel unprepared to provide, and faculty and residents unprepared to teach, many key components of good care for the dying. Current educational practices and institutional culture in U.S. medical schools do not support adequate end-of-life care, and attention to both curricular and cultural change are needed to improve end-of-life care education.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Field MJ, Cassel CK. Approaching death: Improving Care at the End of Life. Washington, DC: National Academy Press; 1997.

    Google Scholar 

  2. The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA. 1989;274:1591–8.

    Google Scholar 

  3. Billings JA, Block SD. Palliative care in undergraduate medical education: status report and future directions. JAMA. 1997;278:733–8.

    Article  PubMed  CAS  Google Scholar 

  4. Emanuel LL, von Gunten CF, Ferris FD. Gaps in end-of-life care. Arch Fam Med. 2000;9:1176–80.

    Article  PubMed  CAS  Google Scholar 

  5. Buss MK, Marx ES, Sulmasy DP. The preparedness of students to discuss end-of-life issues with patients. Acad Med. 1998;73:418–22.

    Article  PubMed  CAS  Google Scholar 

  6. Block SD, Billings JA. Nurturing humanism through teaching palliative care. Acad Med. 1998;73:763–5.

    Article  PubMed  CAS  Google Scholar 

  7. Solomon MZ, O’Connell L, Jennings B, et al. Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health. 1993;83:14–23.

    PubMed  CAS  Google Scholar 

  8. Teno JM, Hakim RB, Knaus WA, et al. Preferences for cardiopulmonary resuscitation: physician-patient agreement and hospital resource use. The SUPPORT Investigators. J Gen Intern Med. 1995;10:179–86.

    Article  PubMed  CAS  Google Scholar 

  9. Saunders CM. The Management of Terminal Illness. New York, NY: Hospital Medicine Publications; 1967.

    Google Scholar 

  10. Block SD. Perspectives on care at the close of life. Psychological considerations, growth, and transcendence at the end of life: the art of the possible. JAMA. 2001;285:2898–905.

    Article  PubMed  CAS  Google Scholar 

  11. Block SD. Medical education in end-of-life care: the status of reform. J Palliat Med. 2002;5:243–8.

    Article  PubMed  Google Scholar 

  12. Fins JJ, Nilson EG. An approach to educating residents about palliative care and clinical ethics. Acad Med. 2000;75:662–5.

    Article  PubMed  CAS  Google Scholar 

  13. Wood EB, Meekin SA, Fins JJ, Fleischman AR. Enhancing palliative care education in medical school curricula: implementation of the palliative education assessment tool. Acad Med. 2002;77:285–91.

    Article  PubMed  Google Scholar 

  14. Medical College of Wisconsin End of Life Palliative Education Resource Center. Available at: http://www.eperc.mcw.edu. Accessed July, 2003.

  15. Weissman DE. Pre-clinical palliative medical education at the medical college of Wisconsin. J Cancer Educ. 1993;8:191–5.

    Article  PubMed  CAS  Google Scholar 

  16. Weissman DE. Palliative medicine education at the Medical College of Wisconsin. Wis Med J. 1995;94:505–8.

    PubMed  CAS  Google Scholar 

  17. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861–71.

    Article  PubMed  CAS  Google Scholar 

  18. Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73:403–7.

    Article  PubMed  CAS  Google Scholar 

  19. Code of Federal Regulations. Title 45, Public Welfare, Part 46: Protection Of Human Subjects. Department Of Health And Human Services, National Institutes Of Health Office For Protection From Research Risks. Revised November 13, 2001. Available at: http://ohrp.osophs.dhhs.gov/humansubjects/guidance/45cfr46.Htm#46.101. Accessed January, 2001.

  20. American Medical Association Fellowship and Residency Electronic Interactive Database. Available at: http://www.ama-assn.org/ama/pub/category/2997.html. Accessed January, 2001.

  21. Hoyert DL KM, Murphy SL. National Vital Statistics Reports. Deaths: Final Data for 1997. PHS 99-1120. Hyattsville, Md: U.S. Department of Health and Human Services Centers for Disease Control and Prevention, National Center for Health Statistics; 1999:47.

  22. Hoyert DL KK, Murphy SL. National Vital Statistics Reports. Deaths: Final Data for 1997. Hyattsville, Md: U.S. Department of Health and Human Services Centers for Disease Control and Prevention, National Center for Health Statistics; 1999:48.

    Google Scholar 

  23. Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York, NY: John Wiley & Sons, Inc.; 1978.

    Google Scholar 

  24. Fowler FJ Jr. Improving Survey Questions: Design and Evaluation, vol 38. Thousand Oaks, Calif: Sage Publications, Inc.; 1995.

    Google Scholar 

  25. Agrawal M, Emanuel EJ. Attending to psychologic symptoms and palliative care. J Clin Oncol. 2002;20:624–6.

    PubMed  Google Scholar 

  26. Weissman DE. Consultation in palliative medicine. Arch Intern Med. 1997;157:733–7.

    Article  PubMed  CAS  Google Scholar 

  27. Ogle KS, Mavis B, Rohrer J. Graduating medical students’ competencies and educational experiences in palliative care. J Pain Symptom Manage. 1997;14:280–5.

    Article  PubMed  CAS  Google Scholar 

  28. Schonwetter RS, Robinson BE. Educational objectives for medical training in the care of the terminally ill. Acad Med. 1994;69:688–90.

    Article  PubMed  CAS  Google Scholar 

  29. Franks PJ, Salisbury C, Bosanquet N, et al. The level of need for palliative care: a systematic review of the literature. Palliat Med. 2000;14:93–104.

    Article  PubMed  CAS  Google Scholar 

  30. Curtis JR, Wenrich MD, Carline JD, Shannon SE, Ambrozy DM, Ramsey PG. Understanding physicians’ skills at providing end-of-life care: perspectives of patients, families, and health care workers. J Gen Intern Med. 2001;16:41–9.

    Article  PubMed  CAS  Google Scholar 

  31. Wenrich MD, Curtis JR, Shannon SE, Carline JD, Ambrozy DM, Ramsey PG. Communicating with dying patients within the spectrum of medical care from terminal diagnosis to death. Arch Intern Med. 2001;161:868–74.

    Article  PubMed  CAS  Google Scholar 

  32. Harvard Medical School Center for Palliative Care Program in Palliative Care Education and Practice. Available at: www.hms.harvard.edu/cdi/pallcare. Accessed July, 2003.

  33. Block SD, Bernier GM, Crawley LM, et al. Incorporating palliative care into primary care education. National Consensus Conference on Medical Education for Care Near the End of Life. J Gen Intern Med. 1998;13:768–73.

    Article  PubMed  CAS  Google Scholar 

  34. Danis M, Federman D, Fins JJ, et al. Incorporating palliative care into critical care education: principles, challenges, and opportunities. Crit Care Med. 1999;27:2005–13.

    Article  PubMed  CAS  Google Scholar 

  35. Steel K, Ribbe M, Ahronheim J, et al. Incorporating education on palliative care into the long-term care setting. National Consensus Conference on Medical Education for Care Near the End of Life. J Am Geriatr Soc. 1999;47:904–7.

    PubMed  CAS  Google Scholar 

  36. Weissman DE, Block SD, Blank L, et al. Recommendations for incorporating palliative care education into the acute care hospital setting. Acad Med. 1999;74:871–7.

    Article  PubMed  CAS  Google Scholar 

  37. Barnard D, Quill T, Hafferty FW, et al. Preparing the ground: contributions of the preclinical years to medical education for care near the end of life. Working Group on the Pre-clinical Years of the National Consensus Conference on Medical Education for Care Near the End of Life. Acad Med. 1999;74:499–505.

    Article  PubMed  CAS  Google Scholar 

  38. Billings JA, Ferris FD, Macdonald N, Von Gunten C. The role of palliative care in the home in medical education: report from a national consensus conference. J Palliat Med. 2001;4:361–71.

    Article  PubMed  CAS  Google Scholar 

  39. Sahler OJ, Frager G, Levetown M, Cohn FG, Lipson MA. Medical education about end-of-life care in the pediatric setting: principles, challenges, and opportunities. Pediatrics. 2000;105:575–84.

    Article  PubMed  CAS  Google Scholar 

  40. Rappaport W, Witzke D. Education about death and dying during the clinical years of medical school. Surgery. 1993;113:163–5.

    PubMed  CAS  Google Scholar 

  41. Ruddy S, Harris ED, Clement B, Sledge CB, eds. Kelley’s Textbook of Rheumatology, 6th ed., W. B. Saunders Company; 2001. Available at: http://home.mdconsult.com/das/book/28005583/view/917. Accessed May, 2003.

  42. Lee EU, Forthofer RN, Lorimer RJ. Analyzing Complex Survey Data, vol 71. Thousand Oaks, Calif: Sage Publications; 1989.

    Google Scholar 

  43. Levinson W, Gordon G, Skeff K. Retrospective versus actual precourse self-assessments. Eval Health Prof. 1990;123:445–52.

    Article  Google Scholar 

  44. Sapir R, Catane R, Strauss-Liviatan N, Cherny NI. Cancer pain: knowledge and attitudes of physicians in Israel. J Pain Symptom Manage. 1999;17:266–76.

    Article  PubMed  CAS  Google Scholar 

  45. Mullan P, Weissman DE, Ambuel PB, von Gunten CF. End-of-life care education in internal medicine residency programs: interinstitutional study. J Palliat Med. 2002;5:487–96.

    Article  PubMed  Google Scholar 

  46. Simon SR, Pan RJ, Sullivan AM, et al. Views of managed care: a survey of students, residents, faculty, and deans at medical schools in the United States. N Engl J Med. 1999;340:928–36.

    Article  PubMed  CAS  Google Scholar 

  47. Zinn WM, Sullivan AM, Zotov N, et al. The effect of medical education on primary care orientation: results of 2 national surveys of students’ and residents’ perspectives. Acad Med. 2001;76:355–65.

    Article  PubMed  CAS  Google Scholar 

  48. American Board of Internal Medicine. Portfolio for Internal Medicine residency programs. Evaluating your residents: new competencies, new forms. July 2001-June 2002. Available at: http://www.abim.org/pubs/competencies.pdf. Accessed May, 2003.

  49. Association of American Medical Colleges. Report 1: Learning objectives for medical student education: guidelines for medical students. Medical Schools Objectives Project. June 1998. Available at: http://www.aamc.org/meded/msop/msop1.pdf. Accessed May, 2003.

  50. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. March 2003. Available at: http://www.lcme.org/standard.htm. Accessed May, 2003.

Download references

Author information

Authors and Affiliations

  1. Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass

    Amy M. Sullivan EdD & Susan D. Block MD

  2. Division of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 44 Binney St., Room G420D, 02115, Boston, MA

    Amy M. Sullivan EdD, Matthew D. Lakoma & Susan D. Block MD

Authors
  1. Amy M. Sullivan EdD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Matthew D. Lakoma
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Susan D. Block MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Amy M. Sullivan EdD.

Additional information

Drs. Judith Singer and Alan Zaslavsky for statistical consultation; the Robert Wood Johnson Foundation for funding this work; and the students, residents, and faculty of this study for their time and participation.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sullivan, A.M., Lakoma, M.D. & Block, S.D. The status of medical education in end-of-life care. J GEN INTERN MED 18, 685–695 (2003). https://doi.org/10.1046/j.1525-1497.2003.21215.x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1046/j.1525-1497.2003.21215.x

Key words

Search

Navigation