Palliative Medicine Physician Education in the United States: A Historical Review

Medical student education

Medical schools have been working to integrate hospice and palliative medicine into curricula for over 20 years.^13–25 In the United States prior to 1995 these efforts were largely reported as single institution experiences, mostly providing lecture-based teaching in the preclinical years with some schools including a hospice observational experience.^26–29 A review from 1997 revealed that nearly all medical schools offered some teaching about end-of-life care but little in the way of mentored, experiential training during the clinical years. ⁵ Curricular offerings were often elective and provided little attention to home care, hospice, and nursing home care. There were few physician role models and little attention to student attitudes and self reflection. ⁵

To push beyond these early efforts, pockets of more organized HPM education started at the Cleveland Clinic; Medical College of Wisconsin (MCW); University of California, Davis; University of Maryland; Northwestern; and Harvard. Two examples of new thinking about HPM teaching were programs started at MCW and the University of Rochester. In 1991 MCW replaced a preclinical six-hour lecture course focused on death and dying theory with a required course focusing on the clinical aspects of palliative medicine. ¹³ In 1993 a fourth-year medical school experiential elective was added, with students spending four weeks on the inpatient palliative care clinical consultation service; this was followed by development of a required third-year palliative care clinical experience. ¹⁴ In 1996 the University of Rochester School of Medicine began a major curricular reform, the Double Helix Curriculum, integrating basic science and clinical training over four years of medical school. This opened the door to successfully integrate palliative care into the curriculum of multiple medical school courses across the four-year curriculum. ²⁰ These are but two examples of an increasing interest in expanding palliative medicine education in medical schools during the 1990s.

In 2000, the Liaison Committee on Medical Education (LCME) mandated that end-of-life care be part of every school's curriculum. “Clinical instruction should cover all organ systems, and must include the important aspects of preventive, acute, chronic, continuing, rehabilitative, and end of life care.” ²³ At the same time, with encouragement from palliative care clinicians, the U.S. Medical Licensing Examination (USMLE) writers began an organized effort to include palliative medicine content in examination questions. ³⁰ By 2002, a survey found that 87 percent of medical schools' students were exposed to a hospice patient and several schools offered end-of-life curricular topics and experiential clerkships; the average number of teaching hours was 14 hours. ²⁴ The curriculum still included a preponderance of small group discussions and lectures, but several medical schools were introducing students to seriously ill patients and their families on clerkships using the palliative care interdisciplinary team. ²⁴ However, a systematic review of teaching and learning in palliative care within the medical undergraduate curriculum in 2004 found that there was still a lack of consistency and coordination, as well as difficulties with recruiting appropriate teachers. ²⁵ A study in 2009 explored the barriers to incorporating palliative care into the undergraduate curricula by interviewing coordinators of palliative care teaching. ³¹ An important theme was the need for an individual lead or “champion” to pursue palliative medicine curriculum reform, someone who has a firm belief in the importance of teaching medical students. Key qualities of the champion include a can-do attitude in the face of setbacks and an ability to speak up for the specialty and influence those in charge of curriculum time. Key factors identified for palliative care curriculum reorganization were: university support, a large enough clinical pool of patients for students to have exposure, and positive student feedback to the university after a good palliative care learning experience. ³¹

By 2006, despite the LCME requirement, the sense from many HPM educators was that there continued to be major educational gaps, especially during the clinical years. With funding from the Robert Wood Johnson Foundation (RWJF) and the Y.C. Ho Helen and Michael Chiang Foundation, the Medical School Palliative Care Education Project was launched under the auspices of the End of Life/Palliative Education Resource Center (EPERC) in 2007. The focus of this initiative was to assist medical schools develop mentored, experiential, required and elective clinical rotations in the last two years of medical school and to promote faculty development; 15 schools completed the project between 2007–2010, each developing new clinically focused training experiences and new student assessment tools.^32,33

New curriculum development and assessment of training is continuing to evolve in U.S. medical schools. ³⁴ Forward-thinking schools now have required clinical rotations under the mentorship of board-certified (BC) palliative medicine physician faculty along with robust didactic and small group curriculum (live or online). ³² Several schools are working toward an integrated interdisciplinary curriculum, bringing together medical, nursing, and social work students in a manner that reinforces a key principle of hospice and palliative medicine—that no single discipline can meet all the demands of the seriously ill patient and family.^35,36

Resident education

Prior to the mid-1990s there were no requirements to provide end-of-life/palliative medicine education and no organized attempt to develop a coherent curriculum in postgraduate training programs. Starting with Internal Medicine in the mid 1990s, requirements for aspects of palliative medicine training were included in Accreditation Council for Graduate Medical Education/Residency Review Committee (ACGME/RRC) guidelines. ³⁷ With funding from the RWJF, an effort was begun in 1997 to improve residency education in Internal Medicine, the National Residency End-of-Life Education Project. This project was designed as a train-the trainer experience for internal medicine residency directors and selected key faculty. Based on the early success of this project and growing interest from other specialties, the project was expanded to include Family Medicine, Neurology, and Surgery residencies. In total, 358 residency programs completed the one-year curriculum development project between 1997–2004.^38,39 Outcome data from 224 residencies that submitted follow-up reports revealed that programs started new teaching in pain, nonpain symptom management, and communication skills. More than 50% of programs integrated palliative care topics into grand rounds, morbidity/mortality conferences, or morning report. More than 70% of internal medicine and family medicine programs began new direct patient care training opportunities utilizing hospital-based palliative care teams or hospice programs. However, as of 2001 there were still few residency or fellowship requirements to provide any palliative medicine training outside of Internal Medicine, Geriatrics, and Neurology. ³⁷

During the past ten years there has been significant growth in palliative medicine resident training along with studies to assess the impact of this training. In 2003 a study tested an innovative curriculum designed to improve medical resident knowledge and decrease anxiety surrounding end-of-life care. ⁴⁰ The baseline anxiety levels were high and knowledge scores were poor. Four one-hour sessions were provided as a classroom instructional intervention, and when compared with a control group, the intervention group did not show any significant improvement in attitudes or knowledge about palliative care. Prior palliative care experience resulted in higher baseline scores, which pointed to a value in education; but it was thought a clinical rather than didactic experience may be more effective. In 2009, a study evaluated a two-week required palliative care rotation for internal medicine residents, which, when given an objective exam post-rotation, showed a significant improvement in knowledge in palliative care. ⁴¹ In 2010 another study showed that residents' communication skills at breaking bad news, discussing direction of care, and responding to emotion statistically improved after being randomized to a day-long communication skills training retreat. ⁴² Residency curriculum development continues to evolve with a major emphasis on improving resident communication skills, development of structured curricula, and required clinical rotations with palliative care and hospice programs.^43–48

Perhaps the single biggest factor leading to the support of clinical palliative medicine education for both medical students and residents has been rapid expansion of hospital palliative care consultation teams located in academic medical centers. ⁴⁹ The consultation service is the ideal venue to provide a structured, mentored, clinical experience where residents can acquire new knowledge and skills and have the opportunity to do the necessary self-reflection to acquire competency in primary palliative care. Furthermore, consultation teams allow trainees to work with BC physicians, providing the all-important role modeling needed to change attitudes and positively influence practice behavior.

CME and other large national projects

Starting in the mid-1990s, philanthropy from the RWJF, the Soros Foundation, and others, helped start a series of national projects designed to foster sweeping improvements in palliative medicine physician education. The Soros Foundation established the Project on Death in America (PDIA) in 1994 to address through research and scholarship the barriers to appropriate care of the dying. One major component of the PDIA was the Faculty Scholars project. ⁵⁰ In recognition of the lack of academic palliative medicine practitioners, the Faculty Scholars project was designed to identify and support promising academicians in palliative medicine. Over an eight-year period 87 faculty scholars (physicians, nurses) were selected and completed a two to three year program that included project development, mentoring, and skill acquisition to be successful in academic medicine. Although designed as an initiative to support individual faculty at individual academic sites, a lasting impact of the Faculty Scholars project has been the collaborative efforts by scholars to pursue national educational and related projects; many of the national palliative medicine education projects developed in the past 15 years have been led by PDIA Faculty Scholars working together.

To help jumpstart educational activity across a broad array of targets, the PDIA and RWJF sponsored a National Consensus Conference on Medical Education for Care Near the End of Life in 1997. The conference brought together leaders in palliative medicine with representatives of clinical societies across the spectrum of medicine including administrators, educators, humanities scholars, and policymakers. The conference was organized around working groups charged with the task of analyzing opportunities and barriers to improving medical education for palliative care. Recommendations were generated and published to guide palliative medicine educational reform in the preclinical years, primary care, surgery, and acute care hospitals, pediatrics, emergency medicine, intensive care, long term institutional care, and home/hospice care.^51–52

In furtherance of the effort to advance palliative care as an academic and clinical discipline through educational and research endeavors, the PDIA helped fund the American Academy of Hospice and Palliative Medicine (AAHPM) to expand its infrastructure and develop the College of Palliative Care. The AAHPM has been a significant force in advancing the palliative medicine education agenda. AAHPM secured a seat in the American Medical Association (AMA) House of Delegates and has an ACGME representative. The Academy has developed and published palliative medicine educational resources useful at all levels of physician training. ⁵³

In response to findings from the Study To Understand Prognosis and Preferences for Outcomes and Risks of Treatments (SUPPORT) trial, palliative care educators recognized a need to create a single palliative medicine core curriculum geared to the generalist physician. ³ In 1997, the Education in Palliative and End-of-life Care (EPEC) program was founded within the AMA with support of the RWJF, the National Cancer Institute, and others. EPEC is a comprehensive, modular, clinically focused curriculum, initially designed as a train-the-trainer project for physicians-in-practice. EPEC was designed to improve knowledge/skills in palliative care using learner-centered instructional techniques that emphasized both learner self-reflection and content retention. EPEC is now a sustaining educational program, which has collaborated with partners to adapt the original curriculum to new learning cohorts including Oncology, Emergency Medicine, Veterans, Long-term Care, Geriatrics, and Caregivers. ⁵⁴ In collaboration with the Duke Institute on Care near the End of Life, EPEC also helped developed A Progressive Palliative Care Educational Curriculum for the Care of African Americans at Life's End (APPEAL). ⁵⁵ Of note, RWJF also funded the comprehensive generalist nursing education program, the End-of-Life Nursing Education Consortium (ELNEC), now used by hundreds of hospitals to train nurses in primary palliative care knowledge and skills. ⁵⁶

A different approach to palliative care educational reform was the “textbook project.” Medical textbooks are often viewed as definitive sources of information used by trainees at multiple educational levels. To be considered a legitimate aspect of medical practice, HPM would need to be included in textbooks as a recognizable learning domain. The RWJF funded a study to examine the content of palliative care information included in contemporary medical textbooks. Researchers reviewed 50 textbooks from multiple medical specialties, revealing a scarcity of palliative care content. Based on the findings, 23 editors and 19 publishers of 50 medical textbooks reported a planned or completed expansion of palliative care content.^7,57

As medical schools and residencies began to expand their palliative care curriculum and evaluation portfolios, the need for a central platform to share curriculum materials was identified so that educators would not need to continually reinvent the wheel. To develop an repository of peer-reviewed educational content in palliative care, The RWJF funded creation of EPERC in 1999. EPERC was designed as a web-based platform to collect, review, and make available educational resources in palliative medicine to help spur widespread curriculum integration at all levels of physician training. After several years of operation, EPERC turned over much of its resources to the AAHPM. EPERC has evolved to a smaller mission and is now the home of Palliative Care Fast Facts and Concepts.^58–60

Another important unmet need in physician education identified in the 1990s was faculty development, both in terms of core palliative care content and just as importantly, educational methods best suited to teach and evaluate palliative care content. In 2000, a National Institutes of Health grant funded the Harvard Medical School Program in Palliative Care Education and Practice (PCEP), an intensive two-week faculty development course offering in-depth didactic, small group, and experiential learning experiences for physician and nurse educators. ⁶¹ PCEP is designed for faculty wishing to become clinical, educational, and administrative leaders in their setting. This course is unique in that it provides learning opportunities on specialty-level palliative care knowledge and skills along with a focus on instructional design and learner evaluation methods most applicable to palliative medicine content. Over 750 U.S. faculty have participated in PCEP, helping to disseminate best practices in palliative care education at their home institution.

Recognizing the central role of hospitals run by the U.S. Department of Veterans Affairs (VA) in providing education to medical students and residents, palliative care educators affiliated with VA hospitals have helped to make the VA a leading force in palliative medicine education. In 1998, with RWJF funding, the Faculty Leaders Project was formed to improve end-of-life and palliative care training in internal medicine residency training programs affiliated with the VA. ⁶² In 2000, a national VA workgroup, the Training and Assessment for Palliative Care (TAPC), established the VA Interprofessional Palliative Medicine Fellowship Program at six training sites across the country. The Palo Alto VA, affiliated with Stanford University, was the coordinating center for the VA Interprofessional Fellowship. In the late 1990s, educational leaders at Stanford developed the Stanford End-of-Life (ELC) project, the first comprehensive faculty development program in palliative care clinical content and instructional design methods, open to clinician-educators from anywhere in the United States. Subsequent work at the Palo Alto VA has included development of sophisticated online learning platforms for palliative care content including interactive communication skills training.^63–64

The lack of a solid research foundation in palliative medicine communication was noted in the 1990s and led to seminal research by PDIA Faculty Scholars from Duke University, University of Pittsburgh, and University of Washington. ⁶⁵ With support from the National Cancer Institute, this group developed a research-grounded approach to communication skill instruction for oncology fellows, Oncotalk. ⁶⁶ Oncotalk, arguably the most successful large-scale program in palliative care communication skills training, is now being updated to focus on intensive care unit and renal physician communication skill education.

Lastly, the more than 10-year effort by AAHPM and the American Board of Hospice and Palliative Medicine (ABHPM) to have Hospice and Palliative Medicine recognized as a specialty was successful when the American Board of Medical Specialties (ABMS) recognized HPM in 2006, a milestone for broad improvements in physician palliative medicine education. With funding from the Arthur Vining Davis Foundation and the Milbank Foundation for Rehabilitation, the ABHPM and the Harvard Medical School Center for Palliative Care collaborated to develop consensus-based core competencies in HPM, which are now being adapted to medical student education and other learning groups. ⁶⁷ The combination of HPM specialists and HPM fellows provides a growing cadre of experts to help influence both physicians-in-training and those in practice by sharing their content and skills.

Work yet to be done

When we surveyed national leaders of palliative medicine education activities, several themes emerged of work still to be completed to realize the goal of high-quality physician education at all training levels. First, despite the fact that HPM is now a recognized specialty, there is still a widespread belief that HPM is a “soft” specialty, not worthy of significant curriculum time. This is manifested by the fact that for most medical schools and residencies, much of the meaningful palliative medicine clinical training is elective rather than required. Second, although the numbers of BC physicians is increasing, there are still many medical schools and residency programs with either no BC physicians, or such a paucity, that educational needs fall victim to the overwhelming clinical demands placed on these physicians. ⁶⁸ A related issue is the lack of funding for HPM fellowship training, which is holding back many fellowship programs from expanding their ability to offer training opportunities to residents interested in HPM. Third, within the culture of academic medicine, reflecting the deteriorating system of U.S. health care financing, there has been a shift in priorities away from research and education towards clinical service, making it increasingly difficult for academicians interested in a career focused on education to have the necessary time to pursue educational scholarship. Without the time support necessary for academic educators to develop new curriculum and evaluation strategies in palliative medicine, we risk an erosion of gains made in the past 20 years.

Lessons learned

In pursuing a wide range of actions to advance palliative medicine education, some key lessons have been learned for the next generation of educators. First, as easy as it is to speak out against the U.S. medical education system for not caring about palliative medicine, it is far more productive to try to work within the system by building bridges to individuals and organizations, volunteering to work on committees, and providing leadership for new initiatives. The collective experience in the last 20 years is that most educators who control curriculum or develop policy are more than willing to look at data-defined problems and work collaboratively with palliative medicine experts to develop solutions. Second, changes in education occur slowly, far too slowly for many. As a field, we must take the long view, building incrementally to roll out ever more robust instruction and evaluation tools along with pursing a policy agenda that supports our goals. Third, most changes occur locally through the efforts of palliative medicine champions within medical schools and residency training programs, rather than by fiat from national policies and rules that filter down to local programs/schools. Thus, it is incumbent on palliative medicine practitioners to become champions for improving education. This means we need to work to improve our own knowledge and skills in instructional design and learner evaluation, not an easy task while we are busy caring for patients and trying to build sustainable programs, but essential none the less. Lastly, although education is a powerful tool for change, it is not the only tool. Education should be viewed as just one method to advance palliative medicine alongside other systems-change methods. ⁶⁹