There is hope for the future: national survey results reveal that geriatric medicine fellows are well-educated in end-of-life care

OBJECTIVES: To assess the status of geriatric medicine (GM) fellows' training experiences in end-of-life care via self-report. DESIGN: Anonymous surveys completed by mail, Web access, and telephone. SETTING: U.S. accredited GM fellowship training programs. PARTICIPANTS: Two hundred ninety-six surveys were sent to graduating GM fellows in 1- and 2-year programs across the Unites States. MEASUREMENTS: Measurements assessed self-reported attitudes, quantity and quality of end-of-life care education, preparation to provide care, and perceived value of caring for dying patients. RESULTS: Response rate was 74%. Ninety-five percent or more of respondents held positive views about physicians' responsibility and ability to help dying patients. Seventy percent of fellows had completed a rotation focused on end-of-life care. Fellows who had done such rotations rated their end-of-life care education as highly as their overall geriatrics training. Fellows frequently received teaching in many end-of-life care topics, with lower rates of teaching how to say goodbye and responding to requests for assisted suicide. Overall, fellows felt well prepared to care for dying patients. Four factors independently predicted such preparedness: having had a palliative or end-of-life care rotation, being female, having been taught how to say goodbye to patients, and perceiving that it is important to attending physicians that fellows learn to care for dying patients. CONCLUSION: GM fellows feel their end-of-life care education is excellent and feel prepared to take care of dying patients. It is critical that geriatricians in training have access to and take advantage of palliative and end-of-life care rotations.     

A Workshop to Teach Medical Students Communication Skills and Clinical Knowledge About End-of-Life Care

We describe a half-day workshop to teach third-year medical students three focused end-of-life care skills: breaking bad news, discussing advance directives, and assessing and managing pain. Our workshop included a readers' theater exercise and three role-play exercises. In two of the workshops, faculty members played the role of patients. We used readers' theater to engage the students on an emotional level and set a reflective tone for the workshop. Evaluations reflected that most respondents felt that the workshop enhanced their understanding and ability to address these skills with patients. By 6 months, many students reported applying these skills to patient care in a way they thought was effective.     

A workshop to teach medical students communication skills and clinical knowledge about end-of-life care

We describe a half-day workshop to teach third-year medical students three focused end-of-life care skills: breaking bad news, discussing advance directives, and assessing and managing pain. Our workshop included a readers’ theater exercise and three role-play exercises. In two of the workshops, faculty members played the role of patients. We used readers’ theater to engage the students on an emotional level and set a reflective tone for the workshop. Evaluations reflected that most respondents felt that the workshop enhanced their understanding and ability to address these skills with patients. By 6 months, many students reported applying these skills to patient care in a way they thought was effective. This project was supported by a grant from the Courts Foundation, Atlanta, Ga. We wish to thank Tanisha J. Sullivan, BA for coordinating the workshop.     

A survey of internal medicine residents and faculty about the duration of attendings’ inpatient rotations

OBJECTIVE: Some training programs are shortening the duration of attendings' rotations from 4 weeks to 2 weeks. Our objective was to determine the effect of 2-week inpatient rotation on self-reported impact on medical education, patient care practices, and faculty performance by internal medicine residents and teaching faculty. DESIGN: Cross-sectional study using an anonymous mailed and emailed survey. SETTING: University-based internal medicine residency program in Buffalo, New York that recently introduced 2-week rotations. PARTICIPANTS: One hundred nineteen residents (99 responded, 83%) and 83 teaching faculty (76 responded, 92%). MEASUREMENTS: Perceived impact on medical education, patient care, and attending performance on 7-point Likert scales ranging from negative (-3) across neutral (0) to positive (+3) ratings. RESULTS: In general, residents and attendings felt that the short rotation negatively affects the attending's ability to evaluate residents and some aspects of patient care, but that it has no negative impact on residents' or medical students' learning. Attendings thought the 2-week rotation positively affects their private life and overall productivity. Subgroup analysis indicated that residents who graduated from U.S. medical schools were more pessimistic about the 2-week rotation compared to their international counterparts. Attendings who had completed at least one short rotation had consistently higher ratings of the 2-week rotation. CONCLUSION: Residents and attendings' perceptions suggest that the shorter attending inpatient rotation might have negative impact on medical education and patient care but positive effects on the attending's work productivity and private life. This tradeoff requires further evaluation including objective medical education and patient care outcomes.     

Director perceptions of end-of-life care at geriatric health services facilities in Japan

Geriatric health services facilities (GHSF) are expected to assume a greater role in caring for the dying elderly in the future. However, very little research has dealt with the topic. The aim of this nationwide study is to clarify current end-of-life care policies and practices of GHSF. The subjects were 2876 managing directors of GHSF. Data was collected through mailed questionnaires in 2003. The content of the questionnaires included: (i) general characteristics; (ii) end-of-life care policies; (iii) available medical treatments; and (iv) staff education. To evaluate the factors associated with end-of-life care policies at GHSF, we divided the facilities into two groups, according to whether their policy toward end-of-life care was progressive or regressive. The response rate was 40.3%. The results indicated that a total of 513 GHSF implemented progressive policies for end-of-life care. The factors associated with a progressive policy for end-of-life care were: (i) availability of medical intervention within and outside of the facilities; (ii) staff education; and (iii) discussion about end-of-life care policy with residents and family. Duration of stay also was positively associated with a progressive policy. Our study highlights the need for a national consensus on reforming the end-of-life care system of long-term care facilities.     

End-of-life care in the curriculum in Japan: a national survey of senior medical students

AIM: We conducted a national survey of senior medical students' attitudes about end-of-life care teaching programs for undergraduate students of Japanese medical schools from April 2004 to May 2006. METHODS: Our questionnaire survey focused on the students' attitudes towards the following end-of-life areas: 1) end-of-life topics, 2) teaching methods, 3) putting theories into practice, and 4) overall end-of-life issue. RESULTS: Overall, 1,039 students from 16 medical schools responded to our survey. The students who took part in the program appreciated the class on communication techniques with dying patients or family members of dying patients. As for the students who did not participate in the program, they expressed the wish to join a class concerning these issues. These students also expressed an interest in visiting hospices or conducting interviews with dying patients as part of their training. Most of the students formulated good opinions toward end-of-life issues, but not toward end-of-life practices. Regardless of whether they joined the program or not, most of the students had a positive attitude towards end-of-life education programs. CONCLUSION: The survey highlighted the need to consider wider implementation and improvement of end-of-life care education in the Japanese curriculum.     

The last 48 hours of life in long-term care: a focused chart audit

OBJECTIVES: As a component of palliative care educational program development, the faculty at the University of Ottawa Institute of Palliative Care wished to assess end-of-life care for patients in long-term care (LTC) settings to develop an educational strategy for physicians. DESIGN: A chart audit, focusing on the last 48 hours of life of residents dying in LTC facilities. SETTING: Five LTC facilities in a city in Canada. PARTICIPANTS: Residents who died in the LTC facilities in a 12-month period. Those who died suddenly (i.e., with no palliation period) or in a hospital were excluded. MEASUREMENTS: Symptoms highlighted in the literature as commonly found in the terminally ill and the matching treatments were recorded on an audit form created by the authors. Included were pain, dyspnea, noisy breathing, delirium, dysphagia, fever, and myoclonus. RESULTS: One hundred eighty-five charts were reviewed. A large number of patients were cognitively impaired. Cancer was the final diagnosis in 14% of cases. Respiratory symptoms were the most prevalent symptom, with dyspnea being first and noisy breathing third. Pain was second, with a prevalence similar to that found in studies of cancer patients. Dyspnea was not treated in 23% of the patients with this symptom; opioids were used in only 27% of cases with dyspnea. Ninety-nine percent of patients who experienced pain were treated for it. Less than one-third of patients with noisy breathing were treated. Delirium was not treated in 38% of the cases, and no anti-dopaminergic medications were administered. Nurses were primarily responsible for documenting end-of-life issues, supporting the families of the dying residents, and communicating with other team members. CONCLUSION: The focused chart audit identified the high prevalence of cognitive impairment in the patient population, which complicates symptom management. Respiratory symptoms predominated in the last 48 hours of life. This symptom profile differs from that of cancer patients, who, according to the literature, have more pain and less respiratory trouble. Management of symptoms was variable. Nurses played a crucial role in the care of dying residents through their documentation and communication of end-of-life issues. Appropriate palliative care education can provide knowledge and skills to all health-care professionals, including physicians, and assist them in the control of symptoms and improvement of quality of life for patients dying in LTC facilities.     

Physicians "missing in action": family perspectives on physician and staffing problems in end-of-life care in the nursing home

OBJECTIVES: To understand the roles of physicians and staff in nursing homes in relation to end-of-life care through narrative interviews with family members close to a decedent. DESIGN: Qualitative follow-up interviews with 54 respondents who had participated in an earlier national survey of 1,578 informants. SETTING: Brown University interviewers conducted telephone interviews with participants throughout the United States. PARTICIPANTS: The 54 participants agreed to a follow-up qualitative interview and were family members or close to the decedent. MEASUREMENTS: A five-member, multidisciplinary team to identify overarching themes taped, transcribed, and then coded interviews. RESULTS: Respondents report that healthcare professionals often insufficiently address the needs of dying patients in nursing homes and that "missing in action" physicians and insufficient staffing create extra burdens on dying nursing home residents and their families. CONCLUSION: Sustained efforts to increase the presence of physicians and improve staffing in nursing homes are suggested to improve end-of-life care for dying residents in nursing homes.     

Non-medical palliative care and education to improve end-of-life care at geriatric health services facilities: A nationwide questionnaire survey of chief nurses

Background:   Geriatric health services facilities (GHSF) are expected to assume a growing role in caring for the dying elderly. However, research in this area has so far been scant. The purpose of the present study is to reveal the status of non-medical palliative care and staff education aiming at improving and enhancing end-of-life care at GHSF.
Methods:   The subjects were 2876 chief nurses of GHSF. Data was collected through a mailed questionnaire in 2003. The questionnaire covered the following: (i) staff perception of end-of-life care policies; (ii) staff education; and (iii) available non-medical care. To evaluate the factors correlated with end-of-life care policies at GHSF, we divided the facilities into two groups.
Results:   We analyzed the answers collected from 313 facilities with a progressive policy toward end-of-life care (PP group) and 818 with a regressive policy toward it (RP group). It was found that staff training was conducted more frequently among PP facilities. Generally, nurses in the PP facilities were more confident that they could provide comprehensive on-site end-of-life care and grieving support, but did not feel so sure about their ability to provide better end-of-life environments for dying residents and family by organizing outside support from voluntary and/or governmental organizations and religious organization for healing and to pursue appropriately a written follow-up communication with the bereaved family.
Conclusions:   Our results suggest that providing GHSF staff with education about end-of-life issues or setting up collaboration with the outside is an important factor to enhance overall end-of-life care at these facilities.     

Effect of end-of-life care teaching on the attitude of medical students to death

AIM: We conducted a national survey to examine how programs to teach end-of-life care to medical students in Japanese medical schools influence their death attitude. METHODS: Sixteen medical schools participated. We conducted a questionnaire survey on fifth- or sixth-year medical students' death attitude at each medical school. Attitude of death was analyzed by the Death Attitude Inventory formed by Hirai et al, which is composed of seven factors: Afterlife belief, Death anxiety, Death relief, Death avoidance, Life purpose, Death concern, and Supernatural belief. We studied how students' attitude to death relates to programs to teach end-of-life care. RESULTS: Overall 1,017 of 1,510 students (67.4%) from the 16 medical schools participated. The students who took a program to teach end-of-life care presented Afterlife belief, Death concern and Supernatural belief score higher than those who did not participate in any program. Multiple logistic regression analysis was conducted and it was found that those trend disappeared, and the students who took a program had greater Death anxiety significantly higher than those who took no program. CONCLUSION: We concluded that the attitude of medical students to death was not related to programs to teach end-of-life care in medical schools. Our survey suggested that improving end-of-life care education is needed to mold the attitude of medical students to death.     

Perceived preparedness to provide preventive counseling

OBJECTIVE: To assess the perceived preparedness of residents in adult primary care specialties to counsel patients about preventive care and psychosocial issues. DESIGN: Cross-sectional national mail survey of residents (63% response rate). PARTICIPANTS: Nine hundred twenty-eight final-year primary care residents in Internal Medicine (IM), family practice (FP), and Obstetrics/Gynecology (OB/GYN) at 162 U.S. academic health centers. MEASUREMENTS: Residents self-rated preparedness to counsel patients about smoking, diet and exercise, substance abuse, domestic violence, and depression. RESULTS: Residents felt better prepared to counsel about smoking (62%) and diet and exercise (53%) than about depression (37%), substance abuse (36%), or domestic violence (21%). In most areas, females felt better prepared than males. Rates of counseling preparedness varied significantly by specialty after adjustment for gender, race, medical school location, and percent of training spent in ambulatory settings. FP residents felt better prepared than OB/GYN residents to counsel about smoking, diet and exercise, and depression, while OB/GYN residents felt better prepared to address domestic violence than IM or FP residents. IM residents' perceptions of preparedness were between the other 2 specialties. Proportion of training spent in ambulatory settings was not associated with residents' perceived preparedness. CONCLUSIONS: Physicians completing residencies in adult primary care did not feel very well prepared to counsel patients about preventive and psychosocial issues. Significant differences exist among specialties, even after adjusting for differences in time spent in ambulatory settings. Increasing residency time in ambulatory settings may not alone be sufficient to ensure that residents emerge with adequate counseling skills.     

A survey on how medical student consider end-if-life care in the elderly

We examined the way medical students think about end-of-life care in the elderly by a questionnaire survey. The major variables of the evaluation instrument included the students' idea of the special nature of end-of-life care for the elderly, the necessity for disclosure of the name of disease, consideration for patient's age on disclosure, advance directives concerning their life-sustaining treatment, and communication concerning preferences for end-of-life care. The final items on the instrument asked for student comments about end-of-life care in the elderly. We analyzed this qualitative data using the process of immersion/crystallization. We received 95 responses, and of these 65 (68%) provided written commentaries that were analyzed using qualitative techniques. Fifty-nine (62%) students pointed out the special nature of end-of-life care in the elderly and most of them (96%) needed the disclosure of the name of disease. Fifty-two (55%) students agreed with advance directives for end-of-life care and 88 (93%) students pointed out the importance of communication with regard to patients' preferences. Medical students' concerns about end-of-life care in the elderly related to three major domains: 1) patient-physician relationship; 2) the procedures of end-of-life care; and 3) emotional and intuitive comments. These results suggest that in the education of geriatric medicine the patient-physician's relationship about end-of-life care is important and we may need to introduce systematic lectures and practical training.     

National survey on the current status of programs to teach end-of-life care to undergraduates of medical and nursing schools in Japan

AIM: We conducted a national survey to examine the current status of programs to teach end-of-life care to undergraduates of Japanese medical and nursing schools in 2004. METHODS: Our survey focused on the following areas: (1) the present status of curricula to teach end-of-life care, (2) topics covered in the curricula, (3) details of the timing of existing end-of-life care teaching programs and of departments responsible for it, (4) teaching methods, (5) education assessment tool, (6) reading list of textbooks. RESULTS: 50.6% of the medical schools and 40.9% of the nursing schools participated. Most of the schools offered end-of-life care education programs, and 45% of the medical schools and 68.9% of the nursing schools offered education concerning end-of-life care for elderly. The most frequent teaching timing was the fourth year of medical school and the third year of nursing school. Broader end-of-life topics were covered in the curriculum in the nursing schools than the medical schools. One fourth of the nursing schools offered a separate course in end-of-life care. The mean number of teaching hours was 7.6 in the medical schools and 35.5 in the nursing schools. More nursing schools offered educational programs in which students can gain experience with end-of-life care than medical schools. A few institutions used practiced examinations to evaluate students' learning. A reading list of end-of-life care textbooks was provided in 10% of the medical schools and 35.6% of the nursing schools. CONCLUSION: Our survey suggested that systematizing end-of-life care education and improvement in text content are on the way.     

Opinion survey of nursing or caring staff at long-term care facilities about end-of-life care provision and staff education

Although long-term care facilities are expected to assume a growing responsibility in caring for the dying elderly, research in this area is still in its early stages. The present study aims to explore the educational and support needs of nursing home care staff in comparison with geriatric hospital, which provide 24-h physician service. The subjects in this study were caring staff of 45 long-term care facilities in Nagoya City as of December 2006. Data was collected through questionnaires covering the following: (i) possible barriers to end-of-life care provision at own facilities and (ii) areas in which a need for education was perceived. One thousand and fifty nine staff responded. Approximately three-fourths of the staff felt that additional staff, physician or nurse available 24 h, and staff education were crucial in the provision of end-of-life care at their facilities. Dementia care, physical care, communication with residents and families, psychological aspects of dying, and pain/symptom control were listed as the five items deemed most important to address. This study indicated that nursing and caring staff recognize a need in 24-h medical service and hospital involvement of end-of-life care provision at their facilities, and that staff are eager to be educated concerning end-of-life.     

Combining the Creative Arts and the House Call to Teach Medical Students About Chronic Illness Care

As the number of people living with chronic illness in the United States rises, it is imperative that medical school prepare physicians who are capable of caring for these patients. This article outlines a creative educational intervention to teach third‐ and fourth‐year medical students about caring for chronically ill people. All students at Weill Medical College, Cornell University, make home visits to homebound older adults with an interdisciplinary team as part of a mandatory Primary Care Clerkship. Under their guidance, students observe the myriad challenges facing homebound older adults. Afterward, students create a project, using original or found art, to express their reactions and thoughts. Students present projects to peers in a small group, with multidisciplinary faculty mentors framing the discussion. To evaluate the intervention, students responded to a nine‐item questionnaire and a series of open‐ended questions. Quantitative and qualitative analyses show consistently strong positive responses to the experience. Most students (95.0%) felt that they learned about the complexities of chronic illness care from their home visits. The opportunity to express reactions through a creative project received positive responses with 97.0% of students responding favorably. Ninety‐seven percent felt that the discussions with colleagues and faculty increased knowledge of chronic illness care. Nearly all (97.0%) felt they had a better understanding of team and that attitudes toward the chronically ill were positively affected. The coupling of the creative arts with home visits is an effective tool for teaching about chronic illness and may be a useful model for medical schools interested in expanding their chronic illness curriculum.     

Medical student interest in internal medicine. Initial report of the Society of General Internal Medicine Interest Group Survey on Factors Influencing Career Choice in Internal Medicine

OBJECTIVE: To determine the factors that attract students toward and push students away from a career in internal medicine. DESIGN: National survey of senior U.S. medical students using a stratified random cluster sampling of medical schools. PARTICIPANTS: The survey included 1650 U.S. senior students from 16 medical schools, of whom 1244 (76%) responded. MEASUREMENTS AND MAIN RESULTS: A survey instrument was developed and pilot tested at 17 medical schools. Twenty-four percent of the respondents to the final survey chose a career in general internal medicine (9%) or subspecialty internal medicine (15%). A career in internal medicine had been "seriously considered" by 608 respondents (50%) who finally chose a career other than internal medicine (the "switchers"). Compared with other specialties, internal medicine was perceived as being more stressful to residents, more demanding of time and workload as a career and a residency, and as an easier residency to enter. Internal medicine was also seen as providing less satisfaction for residents, having lower income potential, and allowing less leisure time. For the 608 switchers, the most important influences leading to their decision to switch were the type of patient seen in internal medicine (for example, chronically ill, alcohol and drug abusing patients) as well as dissatisfaction and stress among internal medicine residents. Factor analysis showed that three factors, "intellectual challenge of internal medicine," "primary care interests," and "the medicine clerkship" attracted students toward internal medicine, whereas three others, "taking care of chronically ill patients," "level of satisfaction among internists and medical residents," and "workload and stress" pushed students away from internal medicine. Factors pushing students away from internal medicine were significantly more negative with regard to a career in general as opposed to subspecialty internal medicine (P less than 0.001). CONCLUSION: Medical students have serious reservations about internal medicine as a career choice. Perceptions about the medical residency, the patients they expect to see, and the dissatisfaction among residents and internists are foremost in their thinking. Changes to improve the attractiveness of internal medicine should address these adverse perceptions while building on the positive influences identified by the respondents.     

Primary Care Resident Perceived Preparedness to Deliver Cross-cultural Care: An Examination of Training and Specialty Differences

Objective Previous research has shown that resident physicians report differences in training across primary care specialties, although limited data exist on education in delivering cross-cultural care. The goals of this study were to identify factors that relate to primary care residents’ perceived preparedness to provide cross-cultural care and to explore the extent to which these perceptions vary across primary care specialties. Design Cross-sectional, national mail survey of resident physicians in their last year of training. Participants Eleven hundred fifty primary care residents specializing in family medicine (27%), internal medicine (23%), pediatrics (26%), and obstetrics/gynecology (OB/GYN) (24%). Results Male residents as well as those who reported having graduated from U.S. medical schools, access to role models, and a greater cross-cultural case mix during residency felt more prepared to deliver cross-cultural care. Adjusting for these demographic and clinical factors, family practice residents were significantly more likely to feel prepared to deliver cross-cultural care compared to internal medicine, pediatric, and OB/GYN residents. Yet, when the quantity of instruction residents reported receiving to deliver cross-cultural care was added as a predictor, specialty differences became nonsignificant, suggesting that training opportunities better account for the variability in perceived preparedness than specialty. Conclusions Across primary care specialties, residents reported different perceptions of preparedness to deliver cross-cultural care. However, this variation was more strongly related to training factors, such as the amount of instruction physicians received to deliver such care, rather than specialty affiliation. These findings underscore the importance of formal education to enhance residents’ preparedness to provide cross-cultural care.     

Contributions of general internal medicine teaching units

OBJECTIVE: To identify and describe general internal medicine teaching units and their educational activities. DESIGN: A cross-sectional mailed survey of heads of general internal medicine teaching units affiliated with U.S. internal medicine training programs who responded between December 1996 and December 1997. MEASUREMENTS AND MAIN RESULTS: Responses were received from 249 (61%) of 409 eligible programs. Responding and nonresponding programs were similar in terms of university affiliation, geographic region, and size of residency program. Fifty percent of faculty received no funding from teaching units, 37% received full-time (50% or more time), and 13% received part-time (under 50% time) funding from units. Only 23% of faculty were primarily located at universities or medical schools. The majority of faculty were classified as clinicians (15% or less time spent in teaching) or clinician-educators (more than 15% time spent in teaching), and few were clinician-researchers (30% or more time spent in research). Thirty-six percent of faculty were internal medicine subspecialists. All units were involved in training internal medicine residents and medical students, and 21% trained fellows of various types. Half of the units had teaching clinics located in underserved areas, and one fourth had teaching clinics serving more than 50% managed care patients. Heads of teaching units reported that 54% of recent graduating residents chose careers in general internal medicine. CONCLUSIONS: General internal medicine teaching units surveyed contributed substantial faculty effort, much of it unfunded and located off-campus, to training medical students, residents, and fellows. A majority of their graduating residents chose generalist careers. Presented at the national meeting of the Society of General Internal Medicine, April 1998, and the Bureau of Health Professions, June 1998. This work was supported by the Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Md, grant 103HR960470P000-000; and the Society of General Internal Medicine.