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September 3, 1997, Vol 278, No. 9 >
ARTICLE | September 3, 1997

Palliative Care in Undergraduate Medical Education: Title and subTitle BreakStatus Report and Future Directions FREE

J. Andrew Billings, MD; Susan Block, MD
[+] Author Affiliations

Earlier versions of this article were presented at the 1995 Annual Meeting of the Association of Canadian Medical Colleges, Association of Canadian Teaching Hospitals, and Canadian Association for Medical Education, Quebec City, Quebec, May 2, 1995, sponsored in part by the Canadian Society of Palliative Care Physicians, and at the Project on Death in America Faculty Scholars' Retreat, Snoqualamie, Wash, July 9, 1995. A final, longer version was prepared, in part, for the National Consensus Conference on Medical Education for Care at the End of Life, May 16-17, 1997, sponsored by the Project on Death in America and the Robert Wood Johnson Foundation.

Reprints: J. Andrew Billings, MD, Palliative Care Service, Founders' House 600, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114-2698 (e-mail: jbillings@hms.harvard.edu).


JAMA. 1997;278(9):733-738. doi:10.1001/jama.1997.03550090057033
Text Size: A A A
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Article
References

Objective.—  To describe the status of palliative care education in the under-graduate medical curriculum and to offer recommendations for improvement.

Data Sources.—  Review of literature on palliative care and of recently submitted grants on medical education for end-of-life care.

Study Selection.—  English-language reports of educational programs targeted toward medical students were examined, as well as surveys of medical schools.

Data Extraction.—  Studies were reviewed by the authors to assess the quality of the educational program, evaluation methodology, and conclusions. From over 9000 citations on palliative care and related topics that were retrieved from MEDLINE searches from 1980 through 1995, and from reviewing 14 palliative care journals published from 1985 through 1996, 310 articles were identified that addressed medical education for end-of-life care, and 180 were carefully examined.

Data Synthesis.—  While nearly all medical schools offer some formal teaching about end-of-life care, there is considerable evidence that current training is inadequate, most strikingly in the clinical years. Teaching about palliative care is received favorably by students, positively influences student attitudes, and enhances communication skills. However, curricular offerings are not well integrated; the major teaching format is the lecture; formal teaching is predominantly preclinical; clinical experiences are mostly elective; there is little attention to home care, hospice, and nursing home care; role models are few; and students are not encouraged to examine their personal reactions to these clinical experiences.

Conclusions.—  The increasing attention to palliative care education has created major opportunities for improving education about care at the end of life. Educational programs should be rigorously evaluated to identify best educational practices.

REFERENCES

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2 +
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6 +
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7 +
Qvarnstrom U.  International standards provide guidelines for curriculum content . J Palliat Care . 1988;;4( (1&2) ):38-40.
8 +
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10 +
Blank LL.  Defining and evaluating physician competence in end-of-life care: a matter of awareness and emphasis . West J Med . 1995;;163:297-301.
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American Geriatrics Society Ethics Committee.  The care of dying patients: a position statement from the American Geriatrics Society . J Am Geriatr Soc . 1995;;43:577-578.
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McGrath PA.  Development of the World Health Organization guidelines on cancer pain relief and palliative care in children . J Pain Symptom Manage . 1996;;12:87-92.
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Goldberg R, Guadagnoli E, LaFarge S.  A survey of housestaff attitudes towards terminal care education . J Cancer Educ . 1987;;2:159-163.
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DiMaggio JR.  Educating psychiatry residents about death and dying . Gen Hosp Psychiatry . 1993;;15:166-170.
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Plumb JD, Segraves M.  Terminal care in primary care postgraduate medical education programs: a national survey . Am J Hospice Palliat Care . May-June 1992;;9( (3) ):32-35.
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Martini CJM, Grenholm G.  Institutional responsibility in graduate medical education and highlights of historical data . JAMA . 1993;;270:1053-1060.
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Grossman SA, Sheidler VR.  Skills of medical students and house officers in prescribing narcotic medications . J Med Educ . 1985;;60:552-557.
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Tolle SW, Elliot DL, Hickam DH.  Physician attitudes and practices at the time of patient death . Arch Intern Med . 1984;;144:2389-2391.
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Cantor JC, Baker LC, Hughes RG.  Preparedness for practice: young physicians' views of their professional education . JAMA . 1993;;270:1035-1040.
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Goodell BW, Donohue JI, Benoliel JQ.  Death education in medical school: a seminar on terminal illness . Death Educ . 1982;;6:363-389.
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Kitchen AD.  Potentials and pitfalls in death education in medical schools . In: DeBellis R, Marcus ER, Kutscher AH, Klagsbrun SC, Seeland IB, Preven DW, eds. Thanatology Curriculum—Medicine . New York, NY: Haworth Press; 1988;:3-13.
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Weissman DE.  Pre-clinical palliative medicine education at the Medical College of Wisconsin . J Cancer Educ . 1993;;8:191-195.
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Barton D, Flexner JM, vanEys J, Scott CE.  Death and dying: a course for medical students . J Med Educ . 1972;;47:945-951.
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Martin RW III, Wylie N.  Teaching third-year medical students how to care for terminally ill patients . Acad Med . 1989;;64:413-414.
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Mathew LM, Jahnigen DW, Scully JH, Rempel P, Meyer TJ, LaForce FM.  Attitudes of house officers toward a hospice on a medical service . J Med Educ . 1983;;58:772-777.
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Cassileth BR, Brown C, Liberatore C, et al.  Medical students' reactions to a hospice preceptorship . J Cancer Educ . 1989;;4:261-263.
42 +
Stedeford A, Twycross RG.  Care of the patient with advanced cancer: a course for clinical medical students at Oxford . J Cancer Educ . 1989;;4:103-108.
43 +
Knight CF, Knight PF, Gellula MH, Holman GH.  Training our future physicians: a hospice rotation for medical students . Am J Hospice Palliat Care . 1992;;9:23-28.
44 +
Cassileth BR, Egan TA.  Modification of medical student perceptions of the cancer experience . J Med Educ . 1979;;54:797-802.
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Blanchard CG, Ruckdeschel JC, Cohen RE, Shaw E, McSharry J, Horton J.  Attitudes toward cancer, 1: the impact of a comprehensive oncology course on second-year medical students . Cancer . 1981;;47:2756-2762.
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Lockard BE.  Immediate, residual, and long-term effects of a death education instructional unit on the death anxiety level of nursing students . Death Stud . 1989;;13:137-159.
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Kaye JM.  Will a course on death and dying lower students' death and dying anxiety? J Cancer Educ . 1991;;6:21-24.
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Irwin WG, McClelland R, Love AHG.  Communication skills training for medical students: an integrated approach . Med Educ . 1989;;23:387-394.
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Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
MacDonald N, Mount B, Boston W, Scott JF.  The Canadian palliative care undergraduate curriculum . J Cancer Educ . 1993;;8:197-201.
2 +
Doyle D, Hanks G, MacDonald N.  Introduction . In: Doyle D, Hanks G, MacDonald N. The Oxford Textbook of Palliative Medicine . Oxford, England: Oxford University Press; 1993;:3.
3 +
Scitovsky AA.  'The high cost of dying' revisited . Milbank Q . 1994;;72:561-591.
4 +
Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Rockville, Md: Agency for Health Care Policy and Research, US Dept of Health and Human Services, Public Health Service; March 1994. Clinical Practice Guideline No. 9, AHCPR Publication 94-0592.
5 +
Cassell EJ.  The nature of suffering and the goals of medicine . N Engl J Med . 1982;;306:639-645.
6 +
Kitchen AD.  Second-year medical students' experiences with death among their families and friends . J Med Educ . 1986;;61:760-761.
7 +
Qvarnstrom U.  International standards provide guidelines for curriculum content . J Palliat Care . 1988;;4( (1&2) ):38-40.
8 +
Working Party of the Association for PalliativeMedicine. Association for Palliative Medicine of Great Britain and Ireland Palliative Medicine Curriculum for: Medical Students, General Professional Training, Higher Specialist Training . Southampton, England: Association for Palliative Medicine; 1992;.
9 +
Field MJ, Cassel CK. Approaching Death: Improving Care at the End of Life . Washington, DC: Institute of Medicine Committee on Care at the End of Life, National Academy Press; 1992;.
10 +
Blank LL.  Defining and evaluating physician competence in end-of-life care: a matter of awareness and emphasis . West J Med . 1995;;163:297-301.
11 +
American Geriatrics Society Ethics Committee.  The care of dying patients: a position statement from the American Geriatrics Society . J Am Geriatr Soc . 1995;;43:577-578.
12 +
McGrath PA.  Development of the World Health Organization guidelines on cancer pain relief and palliative care in children . J Pain Symptom Manage . 1996;;12:87-92.
13 +
Portenoy RK.  Report from the International Association for the Study of Pain Task Force on Cancer Pain . J Pain Symptom Manage . 1996;;12:93-96.
14 +
American Pain Society Quality of Care Committee.  Quality improvement guidelines for the treatment of acute pain and cancer pain . JAMA . 1995;;274:1874-1880.
15 +
Palliative Oncology Education Section, American Association for Cancer Education.  Cancer pain education: objectives for medical students and residents in primary care specialties . J Cancer Educ . 1996;;11:7-10.
16 +
Ad Hoc Committee on Cancer Pain of the American Society of Clinical Oncology.  Cancer pain assessment and treatment curriculum guidelines . J Clin Oncol . 1992;;10:1830-1832.
17 +
Liston EH.  Education on death and dying: a survey of American medical schools . J Med Educ . 1973;;48:577-578.
18 +
Dickinson G.  Death education in U.S. medical schools . J Med Educ . 1976;;51:134-136.
19 +
Dickinson G.  Changes in death education in U.S. medical schools during 1975-1985 . J Med Educ . 1985;;60:942-943.
20 +
Merman AC, Gunn DB, Dickinson GE.  Learning to care for the dying: a survey of medical schools and a model course . Acad Med . 1991;;66:35-38.
21 +
Holleman WL, Holleman MC, Gershenhorn S.  Death education curricula in U.S. medical schools . Teaching Learning Med . 1994;;6:260-263.
22 +
Belani CP, Belcher AE, Sridhara R, Schimpff SC.  Instruction in the techniques and concept of supportive care in oncology . Support Care Cancer . 1994;; 2:50-55.
23 +
Hill TP.  Treating the dying patient: the challenge for medical education . Arch Intern Med . 1995;;155:1265-1269.
24 +
Foley KM.  Competent care for the dying instead of physician-assisted suicide . N Engl J Med . 1997;;336:54-58.
25 +
Billings JA.  Medical education for hospice care: a selected bibliography with brief annotations . Hospice J . 1993;;9( (1) ):69-83.
26 +
Goldberg R, Guadagnoli E, LaFarge S.  A survey of housestaff attitudes towards terminal care education . J Cancer Educ . 1987;;2:159-163.
27 +
Sack WH, Fritz G, Krener PG, Sprunger L.  Death and the pediatric house officer revisited . Pediatrics . 1984;;73:676-681.
28 +
DiMaggio JR.  Educating psychiatry residents about death and dying . Gen Hosp Psychiatry . 1993;;15:166-170.
29 +
Plumb JD, Segraves M.  Terminal care in primary care postgraduate medical education programs: a national survey . Am J Hospice Palliat Care . May-June 1992;;9( (3) ):32-35.
30 +
Martini CJM, Grenholm G.  Institutional responsibility in graduate medical education and highlights of historical data . JAMA . 1993;;270:1053-1060.
31 +
Grossman SA, Sheidler VR.  Skills of medical students and house officers in prescribing narcotic medications . J Med Educ . 1985;;60:552-557.
32 +
Tolle SW, Elliot DL, Hickam DH.  Physician attitudes and practices at the time of patient death . Arch Intern Med . 1984;;144:2389-2391.
33 +
Cantor JC, Baker LC, Hughes RG.  Preparedness for practice: young physicians' views of their professional education . JAMA . 1993;;270:1035-1040.
34 +
Goodell BW, Donohue JI, Benoliel JQ.  Death education in medical school: a seminar on terminal illness . Death Educ . 1982;;6:363-389.
35 +
Kitchen AD.  Potentials and pitfalls in death education in medical schools . In: DeBellis R, Marcus ER, Kutscher AH, Klagsbrun SC, Seeland IB, Preven DW, eds. Thanatology Curriculum—Medicine . New York, NY: Haworth Press; 1988;:3-13.
36 +
Mason C, Fenton G.  How successful is teaching on terminal care? Med Educ . 1986;;20:342-348.
37 +
Weissman DE.  Pre-clinical palliative medicine education at the Medical College of Wisconsin . J Cancer Educ . 1993;;8:191-195.
38 +
Barton D, Flexner JM, vanEys J, Scott CE.  Death and dying: a course for medical students . J Med Educ . 1972;;47:945-951.
39 +
Martin RW III, Wylie N.  Teaching third-year medical students how to care for terminally ill patients . Acad Med . 1989;;64:413-414.
40 +
Mathew LM, Jahnigen DW, Scully JH, Rempel P, Meyer TJ, LaForce FM.  Attitudes of house officers toward a hospice on a medical service . J Med Educ . 1983;;58:772-777.
41 +
Cassileth BR, Brown C, Liberatore C, et al.  Medical students' reactions to a hospice preceptorship . J Cancer Educ . 1989;;4:261-263.
42 +
Stedeford A, Twycross RG.  Care of the patient with advanced cancer: a course for clinical medical students at Oxford . J Cancer Educ . 1989;;4:103-108.
43 +
Knight CF, Knight PF, Gellula MH, Holman GH.  Training our future physicians: a hospice rotation for medical students . Am J Hospice Palliat Care . 1992;;9:23-28.
44 +
Cassileth BR, Egan TA.  Modification of medical student perceptions of the cancer experience . J Med Educ . 1979;;54:797-802.
45 +
Blanchard CG, Ruckdeschel JC, Cohen RE, Shaw E, McSharry J, Horton J.  Attitudes toward cancer, 1: the impact of a comprehensive oncology course on second-year medical students . Cancer . 1981;;47:2756-2762.
46 +
Lockard BE.  Immediate, residual, and long-term effects of a death education instructional unit on the death anxiety level of nursing students . Death Stud . 1989;;13:137-159.
47 +
Kaye JM.  Will a course on death and dying lower students' death and dying anxiety? J Cancer Educ . 1991;;6:21-24.
48 +
Anderson JL.  Evaluation of a practical approach to teaching about communication with terminal cancer patients . Med Educ . 1982;;16:202-207.
49 +
Irwin WG, McClelland R, Love AHG.  Communication skills training for medical students: an integrated approach . Med Educ . 1989;;23:387-394.
50 +
Evans BJ, Stanley RO, Mestrovic R, Rose L.  Effects of communications skills training on students' diagnostic efficiency . Med Educ . 1991;;25:517-526.
51 +
Maguire P, Booth K, Elliott C, Jones B.  Helping health professionals involved in cancer care acquire key interviewing skills—the impact of workshops . Eur J Cancer . 1996;;32A:1486-1489.
52 +
Hanson LC, Tulsky JA, Danis M.  Can clinical interventions change care at the end of life? Ann Intern Med . 1997;;126:381-388.
53 +
Rappaport W, Witzke D.  Education about death and dying during clinical years of medical school . Surgery . 1993;;113:163-165.
54 +
Block SD, Moore GT.  Project evaluation . In: Tosteson DC, Adelstein SJ, Carver ST, eds. New Pathways to Medical Education: Learning to Learn at Harvard Medical School . Cambridge, Mass: Harvard University Press; 1994;:114-122.
55 +
MacLeod RD.  Teaching hospice medicine to medical students, house staff, and other caregivers in the United Kingdom . Hospice J . 1993;;9( (1) ):55-67.
56 +
Lattanzi ME.  Learning and caring: education and training concerns . In: Corr CA, Corr DM, eds. Hospice Care: Principles and Practice . New York, NY: Springer Publishing; 1983;:223-236.
57 +
Schmidt HG.  Problem-based learning: rationale and description . Med Educ . 1983;;17:11-16.
58 +
Garvin DA.  Barriers and gateways to learning . In: Christensen CR, Garvin DA, Sweet A, eds. Education for Judgment: The Artistry of Discussion Leadership . Cambridge, Mass: Harvard Business School Press; 1991;:3-14.
59 +
Schmidt HG, Machiels-Bongaerts M, Hermans H, ten Cate TJ, Venekamp R, Boshuizen HPA.  The development of diagnostic competence: comparison of a problem-based, an integrated, and a conventional medical curriculum . Acad Med . 1996;;71:658-664.
60 +
Block SD.  Using problem-based learning to enhance the psychosocial competence of medical students . Acad Psychiatry . 1996;;20:65-75.
61 +
Barton D.  The need for including instruction on death and dying in the medical curriculum . J Med Educ . 1972;;47:169-175.
62 +
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To understand the clinical management of acute heart failure syndromes.
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