VI. PROFESSIONAL EDUCATION

Palliative care represents a new health professional discipline in the United States focused on the care of seriously ill and dying patients, although not necessarily just for patients at the end of their lives. There is widespread agreement that all facets of the end-of-life experience have been neglected in health professional education, including, but not limited to, pain and symptom management, communication skills, ethics, personal awareness and hospice care. Educational initiatives have emerged, especially within medicine and nursing, to address these deficiencies. This discussion will focus primarily on physician education within palliative care, although the discussion is directly applicable to other health professions.

Requirements for End-of-Life Physician Education in the United States

Until recently, few medical schools offered comprehensive training in end-of-life care. The training that existed was largely elective, in lecture format, and with limited patient contact. Although some U.S. medical schools developed dedicated palliative care courses or comprehensive curricula, this was the exception until very recently. The Liaison Committee on Medical Education (LCME), the accrediting authority for United States medical schools, mandated in 2000 that all medical schools provide instruction in end of life care, which may improve the situation.

Graduate physician education requirements for end-of-life training are also highly variable. Since 1997 the oversight educational committees for Geriatrics, Family Medicine, Internal Medicine, Neurology, General Surgery and Hematology/Oncology have added requirements for end-of-life training. In the realm of testing, the National Board of Medical Examiners started work in 1999 to review, re-write and expand end-of-life content on test questions administered to all medical students and interns.

Although there is no national requirement for physicians already in practice to attend continuing education courses in end-of-life care, the American Medical Association (AMA) has encouraged all its member physicians to participate in Education for Physicians on End-of-life Care (EPEC), a comprehensive training program. In addition, starting in 2000, the state of California began requiring that all applicants for a medical license successfully complete a medical curriculum that provides instruction in pain management and end-of-life care. As with the LCME requirement for medical schools, the exact criteria to determine what constitutes end of life instruction have not been defined.

Curriculum Guides for End-of-Life Physician Education

Several groups have worked to define the components of a comprehensive end-of-life and palliative care curriculum. Curriculum guidelines have been developed for Canadian medical schools and separate guidelines exist for medical student training in Great Britain and Ireland. Palliative care teaching objectives for U.S. physicians were first published in 1994. In 1997, a national consensus conference on U.S. undergraduate and graduate education was held, outlining curriculum features and opportunities for education across different educational venues (e.g. ambulatory care, inpatient care). Although each venue presented somewhat different aspects of end-of-life care education, there is broad similarity on the major educational domains (see Table 1). Finally, a consensus document was developed by participants from eleven U.S. medical schools working on an end of life curriculum project. This document outlines goals and objectives for medical student education along with a discussion of potential student assessment measures and curriculum implementation strategies.

The American Academy of Hospice and Palliative Medicine (AAHPM) developed a curriculum designed for medical educators and practicing physicians. This curriculum includes twenty-two modules, each containing a listing of learning objectives and core content for key domains in symptom control, communication, hospice care, and ethics. The AAHPM curriculum was originally designed for physicians working as hospice medical directors, but can easily be adapted for other levels of physician education. The EPEC project, designed for physicians in practice, contains a comprehensive palliative care curriculum including pain

TABLE 1

and symptom control, communication skills, ethics, and legal aspects of care. The most recent curriculum for medical oncologists and oncology trainees, developed in 2001 by the American Society of Clinical Oncology, includes twenty-nine modules covering symptom control, communication skills, and related aspects of palliative care. Curriculum standards for palliative care fellowships have been proposed by the American Board of Hospice and Palliative Medicine and the AAHPM. An extensive listing of peer-reviewed educational tools, curriculum guides, reference articles, and palliative care links are available at the End-of-Life Education Resource Center.

In parallel to physician education, the nursing profession has been working to develop curriculum guidelines and materials for nursing education. Palliative care education content has been reviewed in nursing textbooks and two educational products have been developed for nursing education, ELNEC (end-of-life nursing education consortium) and TNEEL (the toolkit for nursing excellence at end-of-life transitions) (Ferrell et al.). In addition, a national consortium of nursing groups has come together to plan for institutional changes in nursing education and practice surrounding palliative care (Palliative Care).

Planning an End of Life Education Program

The first step in the design of any educational intervention is to conduct a needs assessment, to understand the gap between what is being taught and evaluated and the ideal. A variety of multidimensional palliative care needs assessments have been reported for different populations of learners.

Once the needs assessment has defined important domains for focused education, specific learning objectives can be developed. Objectives communicate to the learner what is expected of the educational encounter and form the basis for evaluating the impact of training. Learning objectives are broadly defined as those directed at attitudes, knowledge or skills. Given the pervasive and often negative attitudes, which shape caring for the dying, it is advisable to include a mixture of attitude, knowledge, and skill objectives in all training experiences. Thus, it is also desirable to include a mixture of teaching methods in each educational exercise. Addressing attitudes tends to be the most challenging feature of end-of-life education. It is a truism of medical education that attitudes can not be taught. Rather, a shift in attitudes requires the learner to feel safe and respected enough to give up one attitude (e.g. I am afraid to use opioids for fear of causing addiction) for another (e.g. opioids rarely lead to addiction, they are safe and improve quality of life). Providing information to address knowledge objectives can be done via lectures, self-study guides, journal articles, videotapes and audiotapes. Teaching directed at skill objectives requires the learner to practice and demonstrate a defined skill such as patient counseling, calculating equianalgesic doses or pronouncing death.

As with teaching methods, different assessment methods work best when appropriately matched to the learning objective. Attitudes are best assessed through personal interactions, directed questioning and surveys. Knowledge can be assessed via oral or written examinations and skills through direct observation, feedback from patients, or written problem solving (e.g. calculating opioid equianalgesic doses).

Awareness of adult learning principles is essential when developing an end-of-life educational encounter. These include keeping the experience learner-centered, with relevant information keyed to the learners need to know, and understanding that adult learners make choices about their participation (e.g. they leave the room if the information is not relevant to their needs).

Educational Issues for Specific End-of-Life Domains

PAIN EDUCATION. Pain must be controlled before physicians can assist patients with the myriad of physical, psychological, and spiritual problems at end-of-life. Yet, physicians frequently fail to apply accepted standards of care for acute or chronic pain management. Moreover, it is clear that despite a multitude of clinical guidelines, position papers, workshops, lectures, grand rounds, journal articles, and book chapters written about pain management, clinical practice is still far from ideal.

The primary reason that conventional education formats fail to translate into a change in clinical practice is that physicians harbor a host of attitudes about pain and pain management that inhibit the appropriate application of knowledge and skills. These attitudes fall into two broad categories. First are physician attitudes about pain that reflect societal views about the meaning of pain and pain treatment. Second are the fears and myths about opioid analgesics. These include fears of addiction, respiratory depression, and regulatory scrutiny, along with the secondary consequences of these fears—malpractice claims, professional sanctions, loss of practice privileges, and personal guilt about potential culpability for causing death.

In addition to attitudes, deficits in pain knowledge and skills are widespread. These include how to conduct a pain assessment, clinical pharmacology of analgesic medications, use of non-drug treatments, and skills in patient education and counseling. Educational techniques and results from various pain education programs have been reported; key findings from these include the following principles: pain education must include attention to attitudinal issues along with knowledge and skills; pain education must be longitudinal across all years of medical training; and pain education must be coupled to other elements of institutional change, such as quality monitoring, team building with nonphysicians, development of routine assessment, and documentation and analgesic standards development.

ETHICS, LAW AND COMMUNICATION SKILLS EDUCATION. There is considerable content overlap between ethics and communication skills. For example, to effectively care for patients, trainees need to understand both the ethical and legal framework of advance directives and the communication skills necessary to discuss these with patients. Similarly, trainees need to understand the ethical and legal background to make decisions about treatment withdrawal and to acquire the skills to discuss these issues with patients and families.

There is a rich literature on educational methods and outcomes in ethics and communication skills education. Although ethics is generally considered a preclinical course in medical school, it is advisable that training in ethics be incorporated throughout medical school, residency, and fellowship training. As the level of professional responsibility increases with each year of training, such responsibility imposes demands on the trainee to make increasingly complex and ethically challenging decisions. Such decisions often strain the trainee's personal understanding of professionalism and altruism and thus merit dedicated time for self-reflection and mentoring. Although both ethics and communication skill training require attention to attitudes and knowledge deficits, communication skill training requires special and dedicated attention to the acquisition and demonstration of specific skills. Notably, trainees must be able to demonstrate their ability to give bad news and discuss treatment goals, treatment withdrawal, and issues surrounding hospice and palliative care empathetically and professionally.

CLINICAL TRAINING EXPERIENCES. Hospital-based palliative care teams are a valuable venue for clinical education in end-of-life care. Trainees, both physicians and nurses, can learn how to work within a multidisciplinary group and experience a collaborative process with the educational focus enlarged to include the physical, psychological, social, and spiritual dimensions of care. Since 1992 many medical schools and residency programs have established successful clinical experiences in hospice and palliative care at acute care hospitals, hospice residence facilities, and at home.

PERSONAL AWARENESS TRAINING. Very few health professionals have had formal training in how to deal with the emotions that arise when caring for patients with progressive fatal illness. Undergraduate course, residency, and fellowship directors have a number of options that can help trainees gain the needed personal awareness including support groups, family of origin group discussions, meaningful experiences discussion, personal awareness groups, literature in medicine discussion groups, and psychosocial morbidity and mortality conferences.

Future Directions

One important avenue to improve of end of life care is through health professional education. Much progress has been made since the early 1990s in defining curriculum content and establishing standards for education for medical students and primary care residencies. The most recent development in end of life education is the focus on training existing academic faculty and fellows in palliative care. Faculty development is needed if the established goals and standards in undergraduate and graduate palliative care education are to be met. Several courses have been developed in the United States, with the explicit goal of training academic faculty to become role models for end-of-life education. Fellowship training in palliative care is needed to prepare medical trainees for community or academic careers focused on care of the seriously ill and dying. In 2003 there are approximately twenty-five fellowship programs in the United States.

david e. weissman

SEE ALSO: Care; Compassionate Love; Emotions; Life Sustaining Treatment and Euthanasia; Literature and Healthcare; Medical Education; Nursing, Theories and Philosophy of; Nursing Ethics; Palliative Care and Hospice;Suicide; and other Death subentries

BIBLIOGRAPHY

Billings, J. Andrew, and Block, Susan D. 1997. "Palliative Care in Undergraduate Medical Education." Journal of the American Medical Association 278: 733–743.

Billings, J. Andrew; Block, Susan D.; Finn, John W.; et al. 2002. "Initial Voluntary Program Standards for Fellowship Training in Palliative Medicine." Journal of Palliative Medicine 5: 23–33.

Branch, William; Lawrence, Robert S.; and Arky, Ronald. 1993. "Becoming a Doctor: Critical Incident Reports from Third-Year Medical Students." New England Journal of Medicine 329: 1130–1132.

Ferrell, B.; Virani, R.; Grant, M.; and Juarez, G. 2000. "Analysis of Palliative Care Content in Nursing Textbooks." Journal of Palliative Care 16(1): 39–47.

Lo, Bernard; Quill, Timothy; and Tulsky, James. 1999. "Discussing Palliative Care with Patients." Annals of Internal Medicine 130: 744–749.

Novak, Dennis H.; Suchman, Anthony L.; Clark, William; et al. 1997. "Calibrating the Physician: Personal Awareness and Effective Patient Care." Journal of the American Medical Association 278: 502–509.

Ross, Douglas D.; Fraser, Heather C.; and Kutner, Jean S. 2001. "Institutionalization of a Palliative and End-of-Life Care Educational Program in a Medical School Curriculum." Journal of Palliative Medicine 4: 512–518.

Schonwetter, Ronald S., ed. 1999. Hospice and Palliative Medicine: Core Curriculum and Review Syllabus, American Academy of Hospice and Palliative Medicine. Dubuque, IA: Kendall/l/Hunt.

Simpson, Deborah E. 2000. "National Consensus Conference on Medical Education for Care Near the End-of-Life: Executive Summary." Journal of Palliative Medicine 3: 87–91.

Simpson, Deborah E.; Rehm, Judy; Biernat, Kathy; et al. 1999. "Advancing Educational Scholarship Through the End of Life Physician Education Resource Center." Journal of Palliative Medicine 2: 421–424.

von Gunten, Charles F.; Ferris, Frank D.; and Emanuel, Linda. 2000. "Ensuring Competency in End of Life Care Communication and Relational Skills." Journal of the American Medical Association 284: 3051–3057.

Weissman, David E. 2000. "Cancer Pain as a Model for the Training of Physicians in Palliative Care." In Topics in Palliative Care, ed. Russell K. Portenoy and Eduardo Bruera. New York: Oxford University Press.

Weissman, David E., and Abrahm, Janet. 2002. "Education and Training in Palliative Care." In Principles and Practice of Palliative are and Supportive Oncology, 2nd edition, ed. Ann M. Berger, Russell K. Portenoy, and David E. Weissman. Philadelphia: Lippincott Williams and Wilkins.

INTERNET RESOURCES

Emanuel, Linda L.; von Gunten, Charles F.; and Ferris, Frank D., eds. 1999. The EPEC Curriculum: Education for Physicians on End-of-life Care. Available from <www.EPEC.net>.

End-of-Life/Palliative Education Resource Center. Available from <www.eperc.mcw.edu>.

Palliative Care web site. 2003. Available from <http://www.palliative carenursing.net>.