WHITCOMB, MICHAEL E. MD
Among the many contemporary issues facing medicine, none appears to be more important to the American public than being confident that the doctors who will care for them in their final days will make certain that they have a good death. The sizes of the viewing audiences that watched the Public Broadcasting System television series, “On Our Own Terms: Moyers on Dying in America,” and that flocked to theaters across the country to view the Pulitzer Prize winning play, “W;t,” attest to this.
In recent years, medical journals have published myriad papers that have documented that the care of dying patients falls well short of the expectations of patients and their families. And in its 1999 “Report to the Congress: Selected Medicare Issues,” the Medicare Payment Advisory Commission noted that too many of the physical, emotional, and other needs of dying patients go unmet. The Robert Wood Johnson Foundation and other foundations have provided substantial funding to support studies designed to document the reasons care at the end of life doesn't meet expectations, and to identify strategies that can address the reasons for the current situation. It seems clear that improving care at the end of life is an imperative for the medical profession!
The deficiencies documented in the patterns of care provided to dying patients by current practitioners suggest that the education they received in end-of-life care was inadequate. Thus, many of those committed to improving end-of-life care have called for changes in both undergraduate and graduate medical education programs so that future practitioners will be better prepared to care for dying patients. Clearly, those responsible for the design and conduct of those programs must ensure that they are preparing future practitioners to care for dying patients in the way that society expects. This is a responsibility that the medical education community cannot avoid.
In the past few years, many articles in a large number of different journals, including Academic Medicine, have suggested how end-of-life-care education can be improved. The papers in this issue focus additional attention on this extremely important challenge and provide some insight into how medical educators have responded to the imperative to improve the way doctors are prepared to care for dying patients.
In the lead article, Delese Wear eloquently uses the words of medical students to make an extremely important point: Simply adding relevant content to lecture or seminar sessions will not suffice to prepare students to deal with the issues they will face when they ultimately encounter dying patients. Medical schools and residency programs must provide opportunities for medical students and residents to gain clinical experience in caring for dying patients. Furthermore, these experiences must be supervised by faculty who are prepared to help them confront the issues they will face in caring for patients who are dying, including their own feelings about these encounters.
Magnani and Serwint describe several approaches to begin preparing students and residents for caring for dying patients during their clinical training. Magnani describes how a small group of medical students was able to develop a course module on care at the end of life to address deficiencies in the curriculum of their school, and to recruit faculty to take responsibility for the module. The paper shows the importance that medical students place on end-of-life-care education. Serwint describes an innovative day-long seminar that makes use of standardized patients to introduce pediatrics residents to some of the dynamics that occur in caring for dying patients and their families.
Both Wood and Weissman emphasize the importance of having standard guidelines for end-of-life care education that can be used to ensure that medical education programs provide adequate educational experiences. Woods points out how a good curriculum-assessment tool can be used to improve end-of-life care education in medical schools. Weissman notes important deficiencies in the requirements for such education that have been set by the Residency Review Committees of the Accreditation Council for Graduate Medical Education. It seems clear that those deficiencies need to be addressed by that organization.
Finally, Bradley and her colleagues suggest that improving the education of doctors about end-of-life care issues really does make a difference in the kind of care that they provide.
Taken as a whole, these papers are a cause for optimism about the quality of the care that dying patients will receive in the future. They make it clear that medical students and residents are sensitive to the need to be better educated about end-of-life care, and that there are faculty who are committed to making this happen. But the papers also show that much work remains to be done. Most medical schools and residency programs have yet to organize their clinical curricula to ensure that all students and residents have experiences with dying patients, although some are beginning to do this. There is also a very real need to design and implement faculty development programs that will ensure that the clinical faculty who supervise medical students and residents are prepared to provide the kind of supervision and education that are needed when dying patients are encountered. Academic Medicine will continue to publish papers that provide insight into how these important educational objectives can be achieved.