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The Uphill Task of Improving End-of-Life Training in U.S. Internal Medicine Residency Programs

Cegelka, Derek PhD, MPH, CHES; Khan, Zubair MD; Assaly, Ragheb MD

doi: 10.1097/ACM.0000000000002875
Letters to the Editor

Assistant professor, Department of Kinesiology and Health Science, Stephen F. Austin State University, Nacogdoches, Texas.

Chief resident, Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio;

Program director, Internal Medicine Residency, Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio.

Disclosures: None reported.

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To the Editor:

The desire for older-age longevity achieved by innovations in health care has come with the price of comorbidities. Modern health care is challenged with the needs of a growing elderly population with multiple chronic ailments.1 However, in a society where death is perceived as the terminal point of futile care, improving end-of-life care and focusing on its components is not easy. Generally, the training programs lack adequate resources and opportunities to teach the end-of-life care skills physicians need.2 The result is patients and their families who are dissatisfied with care received at this most sensitive time. A survey of internal medicine residency program directors showed that

only 36% of programs reported having formal end-of-life curriculum in place for more than three years. Of those programs that taught end-of-life topics or skills, the majority did not formally evaluate residents’ competence. Moreover, 24% of residency programs did not have an end-of-life curriculum; 34% did not offer a rotation in hospice care; and 31% did not have structured conference teaching on topics dealing with end-of-life.3

The task of improving end-of-life training in internal medicine residency programs remains a challenge.

Residency programs without such training curricula face challenges with implementation since there are not standards or specific curricular guidelines by professional societies like the Accreditation Council for Graduate Medical Education and the American Medical Association. Also, the lack of emphasis on end-of-life training in internal medicine is reflected in the internal medicine certification exam blueprint,4 as well as various medical licensure and specialty certification exams, where a minute proportion of questions are assigned to hospice and palliative medicine. Apart from didactic teaching, the scarcity of resources, including few practice sites, is a big barrier. This can be overcome if internal medicine residency programs offer rotations at hospice organizations, palliative care agencies, and home health care agencies. Lastly, residency programs should explore creative ways to learn from the perspectives and experiences of family members of patients who died in the ICU or in the internal medicine wards.

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1. Zulman DM, Asch SM, Martins SB, Kerr EA, Hoffman BB, Goldstein MK. Quality of care for patients with multiple chronic conditions: The role of comorbidity interrelatedness. J Gen Intern Med. 2014;29:529–537.
2. Litauska AM, Kozikowski A, Nouryan CN, Kline M, Pekmezaris R, Wolf-Klein G. Do residents need end-of-life care training? Palliat Support Care. 2014;12:195–201.
3. Cegelka D, Jordan TR, Jiunn-Jye S, Dake JA, Ragheb A. End-of-life training in US internal medicine residency programs: A national study. J Med Educ Train. 2017;1:030. Accessed June 17, 2019.
4. American Board of Internal Medicine. Internal medicine: Certification examination blueprint. Published 2013. Accessed June 17, 2019.
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