Abstract
The specialty of palliative medicine developed in an effort to meet the unmet needs of patients and families described above. Studies in this Journal and others have provided increasing and conclusive evidence of the ability of hospice and nonhospice palliative care programs to reduce symptoms, improve doctor–patient–family communication and satisfaction with care, as well as enhance the efficiency and effectiveness of hospital services. Nevertheless, in order to ensure that all persons with serious illness and their families receive the quality of care they deserve, palliative care must become a routine and integral part of the U.S. health care landscape. The article by Billings and colleagues 3 provides both optimism for the future of palliative medicine but also illustrates a number of hurdles that the field must overcome to ensure that the delivery of high-quality palliative care is as routine as that of oncologic or cardiovascular care in our nation's hospitals.
Billings and colleagues report the results of a national survey of fourth-year medical students representing 50% of U.S. medical schools and asked about formal curriculum (“thinking about coursework and clerkships, have you been explicitly taught to … ”), informal curriculum (“how many times have you … ”), and hidden curriculum (during your clerkship, to what extent do you think residents and attendings … ”). At first glance, the result are highly encouraging: over 70% of respondents reported formal instruction in pain management and how to refer patients to hospice; over 60% reported formal instruction in assessing and treating depression at end-of-life and how to discuss withdrawal of life-prolonging treatments; and over half reported being taught how to tell a patient that they were dying. Furthermore, over 90% of respondents observed “bad news” being delivered well and good discussions about care at the end of life. Indeed, compared to data published previously by Billings and Block in 1997, 4 the current study is notable for a dramatic increase in the amount of palliative care content included in medical school curricula.
Whereas the above data are clearly encouraging, the additional data reported in the Journal are troubling. To their credit, Billings and colleagues 3 not only examined the formal and informal curriculum, but also the “hidden curriculum.” As described by the authors, the hidden curriculum is the implicit learning relayed through faculty and residents' behaviors and institutional constructs [and] is absorbed as students undergo socialization into physicianship. When the hidden curriculum is aligned with the formal and informal curricula, it can be a powerful reinforcer or enhancer of student's learning. In contrast, when the hidden curriculum conflicts with visible curriculum, it can lead to a devaluing of taught principles and ethical erosion. Indeed, as the authors note, an environment depersonalizing patients through hidden curriculum messages may hinder student development of palliative care skills. Thus, the fact that only 40% of respondents noted that their teachers conveyed that working with a dying patient was a rewarding experience, that 55% conveyed that dying patients are good teaching cases for students, and that 21% of teachers conveyed that the death of a patient is a medical failure is cause for concern. If we are to produce physicians who embody the skills and values of palliative care, use them in their practice, and consult with palliative medicine specialists as readily as they might seek a nephrologists opinion, it is clear that the hidden curriculum must be addressed. Specifically, there is an urgent need to enhance the palliative medicine workforce in academic medicine such that the values and skills of palliative medicine are included both in the formal curriculum and role-modeled by respected mentors throughout the institution — not just the lone palliative medicine physician.
The issue of the palliative care workforce, particularly in academic institutions, is perhaps the most important and challenging issue facing our field. Whereas there is 1 cardiologist for 71 persons experiencing a myocardial infarction and 1 oncologist for every 141 patients diagnosed with cancer, there is only 1 palliative medicine physicians for every 31,000 persons living with a serious and life-threatening illness. 5 Furthermore, despite the recognition of palliative medicine as an official American Board of Medical Specialties (ABMS) subspecialty, only 24 states have Accreditation Council for Graduate Medical Education (ACGME)-approved fellowship training programs. 6 Finally, because of the cap on GME residency training slots, the overwhelming majority of these fellowship slots are supported by tenuous philanthropic dollars and not by GME Medicare funding. Indeed, if our field is going to survive, let alone flourish, these issues must be addressed.
What can we do as a field to secure our future? There are several important policy initiatives that we need to initiate to ensure a sustainable workforce and improve care for persons with serious illnesses. First, the GME cap should be lifted to allow the development and expansion of palliative care fellowship training programs and currently unused GME slots should be redistributed to support ACGME-approved palliative medicine fellowship training. Expansion of palliative care fellowship training programs will produce both new leaders in the field and onsite role models for students and fellows. Second, loan forgiveness programs for palliative care physicians similar to those available to early clinician investigators through the National Institutes of Health (NIH) 7 should be established at the Health Resources and Services Administration (HRSA) in order to promote palliative care as a viable career path for young physicians. Third, HRSA Title VII-supported career development awards (similar to Title VII Geriatric Health Professions Training Programs) should be established to support early clinician educators in palliative care and ensure that palliative care becomes an integral part of medical school education and residency training. 8 This is a critical initiative in order to ensure sustainable numbers and a critical mass of teaching faculty to reform the hidden curriculum. Fourth, HRSA should establish midcareer training awards to support retraining of the current workforce into this new specialty. At present, despite interest in the field by established clinicians, no true mechanism exists to enable retraining of the current workforce. Fifth, the NIH should prioritize existing career development award mechanisms to support junior (K08, K23) and midcareer (K24) palliative care investigators in order to address the lack of established palliative care clinician investigators within U.S. academic medical centers. A precedent for this type of programs already exists at the NIH to enhance research in geriatrics (the Paul P. Beeson Career Development Awards). Finally, mandatory CME training in primary-level palliative care prior to state relicensing similar to California's provision for training in pain management 9 would ensure that all physicians were familiar with the core competencies of palliative medicine.
The data from Billings and colleagues 3 are highly encouraging and suggest that palliative care education is truly at the “tipping point.” It is our role as professionals to advocate and direct the policy initiatives that will bring our specialty to scale and ensure that all Americans have access to high-quality palliative care.