Despite clear endorsement of the importance of learning end-of-life care and nearly universal agreement that physicians have a responsibility to help patients prepare for death, students and residents in the United States feel unprepared to provide, and many faculty and residents unprepared to teach, key components of good care for the dying. Even basic pain management is not being taught to 30% of students and moe than 20% of residents. Educational deficiencies appear to be particularly pronounced in psychological aspects of end-of-life care, including treatment of depression, bereavement care, and attention to the fears and concerns of dying patients.
In the clinical arena, students are systematically protected from, or deprived of, opportunities to learn from caring for dying patients. When they do participate in this care, they lack role models with expertise to learn from, as well as feedback and support that facilitate clinical growth. Although faculty profess that end-of-life care is an important learning domain for trainees, students and residents perceive a much lower level of faculty support for learning about care of the dying. Less than one fifth of students have taken a course in end-of-life care, and one third of students and residents rate the quality of their education in this area as fair or poor. Although students and residents regularly break bad news to patients and talk with them about their wishes and values about end-of-life care, 39% of students and 31% of residents feel ill-prepared to address patients' fears about dying, about half feel poorly prepared to address cultural and spiritual issues, and almost half feel ill-equipped to manage their own feelings about their patients' deaths. While preparation is likely to improve with clinical experience, these levels of preparation are unacceptably low and not likely to improve without focused teaching. Our finding that students who conduct complex end-of-life discussions with patients receive feedback only half the time—a stark contrast to the performance of lumbar punctures, another common clinical task, for which only 2% fail to receive feedback—demonstrates educational neglect by residents and attendings of these critical communication tasks.
Residents, who oversee more than half of students' clinical training (), feel unprepared to teach students about many aspects of care. It is hardly surprising, then, that many residents fail to provide feedback about end-of-life communication and decide not to assign dying patients to students, in part with the intention of protecting families or students, as well as because they judge these cases to possess too few learning opportunities or, at the other extreme, too many complexities. But goals of protecting families and students might be better served by providing students and residents adequate training in how to interact with and adequately care for dying patients and their families, sufficient exposure to good teaching, appropriate learning opportunities, and excellent role models for end-of-life care.
The hidden curriculum in end-of-life care emerges from this study as a potential major, and modifiable, contributor to inadequacies in physician education. The cultural milieu in which formal education about end-of-life care takes place is characterized by:
- a paucity of teaching about end-of-life care,
- lack of exposure to care of dying patients at home and to models of care for the dying such as hospice,
- perceived communications by teachers that end-of-life care is less important than other aspects of clinical care,
- tolerance of lack of preparation for clinically ubiquitous psychosocial and communication tasks related to end-of-life care, and
- perceived mixed messages about end-of-life care.
This communicates that competency in state-of-the-art end-of-life care is not expected of our trainees and faculty in academic health centers. Would medical schools and residency training programs tolerate 21st century students and residents learning about management of myocardial infarction outside of a coronary care unit as they do students' learning about end-of-life care with no exposure to hospice care? Would we accept students' performing lumbar punctures without supervision or feedback?
There are several limitations to this study. Other research has shown that self-reports tend to overestimate knowledge and skills,43–45
which suggests that our findings may overestimate actual preparation. In addition, the survey instruments have not been validated; however, we reviewed the research and education literature in end-of-life care to ensure content validity of the instrument, submitted the surveys for extensive review by physicians from a range of specialties and training levels, and have evidence for convergent validity in similarities of responses across groups in attitudes and perception of the culture for end-of-life care, and for discriminant validity in expected differences such as greater reported preparation in providing or teaching end-of-life care among physicians at higher training levels.
The high faculty refusal rate is both a limitation and an important finding. In part, it suggests that faculty responses reported here may not adequately represent the views of U.S. medical faculty and that findings may overestimate actual faculty support and experience in this area. However, we also believe that this reflects a fundamental obstacle to end-of-life care education, i.e., a distinct lack of interest among a large portion of faculty. Despite intensive recruitment efforts—which in our prior experience have yielded response rates of over 75% among the same population (but on a different topic)46
—a large portion of faculty remained uninterested in the study. This lack of response is consistent with students' and residents' perceptions that medical faculty consider end-of-life care a low priority. In contrast, rates of refusal among residents and students were very low, and response rates in these groups were limited only by difficulties obtaining telephone contact information.
Our data suggest that current educational practices in the United States are not adequate to ensure excellent physician education and patient care at the end of life. The causes that underlie and perpetuate these deficits are likely to be found at multiple levels: medical culture is focused on cure, acute care, and high technology, and therefore often views death as a failure and dying as a time when there is “nothing more to be done”; medical schools have been shown to socialize students to value the technological and devalue the psychosocial aspects of care47
that are essential in providing care for dying patients and their families; institutions are often lacking in faculty role models and expertise needed to provide the needed teaching and leadership in this area3
; and at the individual level, unresolved or unacknowledged feelings about death and loss may compel physicians to avoid the emotional discomfort of addressing patients' and families' needs at the end of life. The adoption of curricular objectives and clinical training requirements related to end-of-life care by the American Board of Internal Medicine,48
the Association of American Medical Schools Medical Objectives Project,49
and the Liaison Committee in Medical Education50
are important steps toward validating and improving competencies in end-of-life care among students and internal medicine residents, but major efforts that address this problem at the institutional, cultural, and individual level are still needed to bring the standard of care to an acceptable level.
We believe that improving physician education in end-of-life care requires implementation of structured, system-wide plans for education of students, residents, and faculty. Optimally, this would include more required teaching for undergraduates integrated throughout the curriculum, with systematic attention to teaching about end-of-life care during clinical clerkships. Clinical training for students and residents also should include required rotations in palliative care, with hospice and home care experience requisite for all physicians-in-training. Attention to both technical and psychosocial dimensions should be addressed whenever possible. Physicians should be able to experience firsthand the possibility of excellent end-of-life care, the great benefit it can offer to patients and families, and the professional and personal rewards it can bring to physicians. Whether or not their long-term practice involves caring for patients at the end of life, the skills acquired in communication, psychosocial care, ethical decision making, and pain and symptom management can enhance later clinical practice in a wide range of settings.
Finally, educational leaders need to take seriously the impact and pervasiveness of the hidden curriculum, which in its current form appears to undermine end-of-life care education nationwide. Explicit mission or policy statements supporting care for the dying, better integration of palliative care services in academic health centers, continuing medical education for attending physicians, and sustained attention to observation and feedback on clinical skills related to end-of-life care would send unambiguous messages about the value of education and practice in caring for dying patients. The clinical competencies required to provide excellent end-of-life care are well defined, model curricula are available for education of students, residents, and faculty, and students and residents have affirmed, on a national level, their interest and willingness to develop expertise in this area. The resources exist for realizing the vision of skilled and compassionate care for patients at the end of life and their families; it is now up to academic health center faculty and leaders to take on the task of translating good intentions into action.