Palliative Care Education: Focusing on Care and Not Just Disease
At the Institute for Palliative Medicine (IPM) in San Diego, medical residents are re-tooling for one of the most essential aspects of medicine: caring for seriously ill patients.
“The goal is to teach them the core competencies in palliative care,” explained Dr. Charles von Gunten, the institute’s provost.
These competencies include pain management, good communication skills, and the ability to provide patients with psychosocial and spiritual assessments and to work in interdisciplinary teams in hospitals, as well as through hospice and in nursing homes, he said.
Dr. von Gunten started the institute in 1989, when national data showed that patients rated doctors poorly in communications skills and end-of-life care. The need for palliative care has generally been overlooked in the problem-oriented approach that dominates the practice of medicine, he explained, one in which doctors make a list of patients’ problems and try to solve each of them.
“If you are paid per problem, it tends to foster more and more problems. So we end up doing a lot, rather than focusing on doing the most important thing. Our financing system promotes this,” he said.
“It’s very powerful. But it has a fatal flaw, which is that human beings are not a sum of their parts. And, particularly when some of the problems on the list cannot be cured, that system breaks down.”
Dr. von Gunten says technological advancements shouldn’t overshadow the human touch. “There’s the old joke about the Harvard death. It’s okay if the patient dies, as long as the tests are normal,” he said. “You shouldn’t have to choose one or the other. You can have the latest and greatest technology, but that should be in service to the overall goals of medical care, as determined by the patient.”
And addressing patients’ goals includes “not just the patient’s biology, but also his or her spiritual, emotional, and psychological state,” said Dr. von Gunten.
A New Cornerstone of Medical Training
Palliative care is now a mandatory part of the medical school curriculum for family medicine, internal medicine (of which oncology is a subspecialty), and surgery. In 2006, the American Board of Medical Specialties introduced a palliative care curriculum for those and other subspecialties, including anesthesiology, physical medicine and rehabilitation, pediatrics, radiology, psychiatry and neurology, obstetrics and gynecology, and emergency medicine.
Another program developed with NCI funding, called the Education in Palliative and End-of-Life Care (EPEC) curriculum, is teaching medical students, residents, social workers, and pharmacist throughout California about palliative care. Dr. Michael Wilkes, who led the team that implemented the program statewide at the University of California, said the online program includes four parts: patient stories, tutorials, blogs, and action plans, where students apply what they’ve learned to their own practices and document their competencies.
Dr. Wilkes says the response among students has been overwhelmingly positive. “You know you’ve done a good thing when students are asking for more of it,” he said. “The bottom line is that medical schools way over-focus on disease, and we under-focus on care—of the patient and the family. The end of life is really about care. This online, interactive, case-based curriculum is primarily focused on patients and families addressing such topics as pain control, hospice care, spirituality, ethical and legal issues, and cultural issues at the end of life.”
However, the tool is not all content. “EPEC also acknowledges that we as providers need to take care of ourselves and our colleagues,” Dr. Wilkes explained. “Because providing good care can often take a toll on clinicians, the curriculum helps learners become skilled at understanding and addressing self-care issues and addressing conflicts that arise at the end of life.”
Dr. von Gunten has also gotten positive feedback from his students. “Sometimes they will be on rotation at night, and come in the next morning and tell us, ‘I used your six steps for communication skills, and it was so different.’ That just gives us chills. To have them put it into practice immediately is so fabulous,” he said.
IPM is planning to develop international programs, possibly in Jordan, Mongolia, and the Ukraine. IPM staff will also start tracking U.S. military physician behavior according to palliative care measures, since the military keeps extensive records of physicians’ performance.
Embracing the Art of Healing Medicine
Information on physician behavior will, in turn, help tailor palliative care education programs. To that end, efforts to restore the “art” of healing medicine are actually becoming a science, according to Dr. David Hui of the University of Texas M. D. Anderson Cancer Center, who spoke about palliative care programs in U.S. cancer centers at a JAMA press briefing last week in Washington, DC.
“How do we talk to patients? Sitting down or standing up? These techniques can be taught. I think medical school is where we plant that seed,” said Dr. Hui.
His survey of cancer centers across the country found that fewer than half have fellowship programs for palliative care; of those, only 25 percent have mandatory rotations in palliative care for oncology fellows.
Palliative care education, particularly for oncologists, naturally includes discussions of death, which have not been previously addressed in an in-depth way, said Dr. von Gunten.
“There is such a thing as normal dying. Many residents have never heard those two words put together,” Dr. von Gunten said, adding that residents have had their most rewarding experiences witnessing and participating in end-of-life care.
“When you routinely see the best in human nature—bravery, altruism—that changes you,” he said, “and gives you renewed enthusiasm about medicine.”