Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

The Challenges of Integrating Palliative Care into Postgraduate Training

Robert Arnold, MD

[Citation: Arnold R. The challenges of integrating palliative care into postgraduate training. Innovations in End-of-Life Care. 2002;4(5):www.edc.org/lastacts ]

In the training of a physician, one's residency is of critical importance. It is when one goes from learning to be a doctor to being a doctor. During residency, one acquires the clinical habits and routines of a practicing physician. Residency's focus, in contradistinction to medical school, is on learning to make decisions independently and be responsible for one's patients. Physicians believe that the best way to learn medicine is to see large numbers of patients under supervision. It is only by talking to patients, making diagnoses, negotiating treatment plans, and seeing how patients respond that one really learns how to operationalize the textbook knowledge acquired in medical school. Residents learn to negotiate with patients regarding diagnostic and treatment plans, to care for critically ill patients with their multitude of physical and emotional needs, and to experience patient deaths as the "responsible physician." It is during this intensive period of training that residents' attitudes and values about what it is to be a doctor crystallize.

The emphasis on seeing patients severely limits the amount of didactic time available during the residency years. Moreover, the growth of medical knowledge, the increasing specialization of medicine, and the medicalization of many of life's experiences have dramatically increased the number of topics and amount of information that physicians need to learn. Topics that are regarded as centrally important are accorded clinical rotations. If everything cannot be taught in clinical rotations, then every subspecialty and interest group believes it should, at the least, get didactic time to ensure that young physicians know something about their critically important topic. For example, the Residency Review Committee (RRC) in internal medicine now requires that residencies teach information on women's health, occupational health, alternative medicine, sexually transmitted diseases and HIV, primary care dermatology, orthopedics, quality assurance, principles of managed care, domestic violence, geriatrics, malpractice and health law, informational systems, medical ethics, doctor patient communication, as well as traditional information on the diagnosis and treatment of both common, and uncommon diseases in adults.¹

In light of this competition, the emergence of palliative care training for residents over the last five years is impressive. When I was a resident, there was nothing taught on palliative care either in a didactic format (although we did have better than average programs in doctor-patient communication and medical ethics) or as a specific clinical rotation. My faculty, although superb, taught me nothing specifically about end-of-life care. From other residents, I learned to "start a morphine drip, and let the nurses titrate it to comfort." My experience was not atypical of physicians who trained prior to 1995.

This lack of training resulted in generations of physicians who were not trained to care for dying patients. Physicians' lack of knowledge of pain medicine correlates with studies of cancer patients showing inadequate treatment. We haven't been trained to talk to dying patients about their concerns and preferences, and consequently patients' families report miscommunication and frustration over their interactions with physicians. In addition, medicine's emphasis on curing diseases may lead physicians to either over-treat or withdraw from terminally ill patients.²

Today, things are, at least on the surface, changing rapidly for the better. Many medical schools and residency programs have developed educational programs in palliative care. In this issue of Innovations, one approach to residency training in palliative care featuring Dr. Eric Warm's work at the University of Cincinnati Internal Medicine Residency is highlighted; other programs have been described in the Journal of Palliative Medicine and Academic Medicine.^3,4.

Based on my experience, largely limited to internal medicine residencies, educational programs in the United States have a number of common features. Most frequently, palliative care infiltrates residencies through noon conferences, grand rounds, or other didactic sessions focusing on pain and symptom management. Lectures on ethical issues, such as Do-Not-Resuscitate (DNR) orders or forgoing artificial hydration and nutrition, are also quite common, as are complementary cognitively based educational interventions, such as "pain cards."

Much less common are clinical rotations in palliative care that allow for real responsibility for patients. This is probably due to the paucity of palliative care faculty and reflects the separation of hospices from academic medical centers. Also relatively infrequent are skills-based curricula focusing on the difficult doctor-patient communication issues that are central to palliative care, such as giving bad news, negotiating treatment decisions, and exploring spiritual and psychosocial issues. This absence also reflects that, within internal medicine at least, palliative care is generally not seen as a specialty deserving of residents' time. It is interesting to note that the situation seems different in countries where palliative care is more established. In the Australian model described by Dr. Kristen Turner and Dr. Norelle Lickiss in the International Perspectives department of this issue, educational opportunities in palliative care seem quite similar to what one might find for cardiology or nephrology in the United States.

Finally, one rarely finds experience-based educational opportunities that focus on the emotional or spiritual aspects of palliative care in residency training.⁵ These are more likely to come up in family medicine programs, which include Balint groups⁶ or informally in housestaff support groups. In Balint groups, for example, physicians discuss cases that cause them conflict in an attempt to better understand how they habitually respond and to explore alternative methods of responding. It is interesting that the writing/self reflection piece of Dr. Warm's curriculum discussed in this issue's Featured Innovation was the one segment that "did not work." It is perhaps a sign of how challenging it is to find effective ways to engage residents in self reflection during this stressful, task-driven period of intensive training when time is at a premium.

Despite its importance, self-awareness may be difficult for residents because they do not perceive it as a top educational priority. Primary care doctors are doers and, in my experience, cognitively and empirically based. Housestaff, as young learners working in a hierarchical system, in which errors and mistakes are anathema and can have lethal consequences, understandably worry a lot about "knowing" enough and "doing the right thing." Emotions, both theirs and their patients', are ignored, as at best, extraneous and, at worst, a distraction. This attitude reduces doctor-patient communication to "figuring out the diagnosis," completely ignoring the importance of the ongoing relationship. In my experience, it is only after doctors feel competent as "doctors" that they have the leisure to ponder the importance of emotions and relationships in the care of patients. Figuring out innovative ways to focus on these "non-cognitive" aspects of palliative care is the major challenge facing educators in palliative care.

Reasons for Success

The glass is clearly half full, rather than half empty. When one considers the rapidity with which change has occurred, the field should take a moment and congratulate itself. It is also worth considering the reasons for this remarkable success.

Support of Academic Medicine

Organized and academic medicine have strongly supported the inclusion of palliative care in residency education. The American Medical Association's Education for Physician's on End-of-Life Care (EPEC) program,⁷ for example, has been used at countless residency programs to teach pain and symptom management. The American College of Physicians-American Society of Internal Medicine devoted an unprecedented amount of space in its flagship journal, Annals of Internal Medicine, to issues surrounding end-of-life care.⁸ The Veterans Administration has funded a program for Faculty Leaders in Palliative Care as well as multidisciplinary palliative care fellowships.⁹ The Institute of Medicine has published two reports on the importance of palliative care, one on care for adults.¹⁰ and one on palliative care for children.¹¹ Probably most important, in internal and family medicine, the Residency Review Committee's requirements that palliative care be taught provided important impetus to program development.¹²

The National Residency End-of-Life Physician Education Project (NRELEP) was created by Dr. David Weissman, director of the Palliative Care Program at the Medical College of Wisconsin, and colleagues in response to these new requirements to include end-of-life care in internal medicine residencies. This project is funded by The Robert Wood Johnson Foundation to help those residencies create the needed infrastructure to integrate palliative medicine into their existing curricula.¹³ NRELEP has now trained faculty and residents from more than 128 internal medicine, 52 family medicine, 29 neurology, and 10 surgery residency programs.¹⁴ The Featured Innovation in this issue offers a description of the impact of the project on Dr. Eric Warm and the University of Cincinnati internal medicine residency program four years after their initial involvement in the pilot program. Participants in NRELEP join with other educators and are able to share resources and experiences at two-day national meetings. For example, at one of these meetings, a chief resident described how Morbidity and Mortality conferences at his institution were used as an opportunity to teach palliative care. Having already worked the kinks out of the program and developed the supplementary readings, it would be easy for a faculty member at another institution to modify the curriculum for his or her program. Similarly, the Fast Facts concept pioneered by Dr. Eric Warm was quickly disseminated across participating residency programs. The project directors email these Fast Facts on a weekly basis to more than a hundred residents and fellows in internal medicine, family medicine, and surgery, and have received extraordinarily positive feedback. Individual faculty would never have thought or had the time or energy to develop each of these Fast Facts on their own, and they turned out to be one of the most popular educational interventions to come out of NRELEP. Programs participating in NRELEP were encouraged to write up their experiences and publish them in the Journal of Palliative Medicine, giving their efforts additional academic credibility.^15,16,17

Foundation Funding

Another result of ongoing commitment on the part of private foundations in promoting end-of-life care is the End-of-Life Physician Education Resource Center (EPERC),¹⁸ an educational catalyst designed to help programs institute effective curricula. EPERC is based at the Medical College of Wisconsin and funded by The Robert Wood Johnson Foundation. Drs. David Weissman and Deborah Simpson co-direct this online source of peer-reviewed materials to promote ongoing palliative care training of physicians. Starting a new program requires writing learning objectives, making handouts, preparing slides, and evaluating the program to see how it can be improved. Unfortunately, most academic physicians have little training in educational theory or curricular development, and starting a program from scratch is very time intensive.¹⁹ EPERC has helped programs avoid these growing pains by serving as a clearinghouse that collates and evaluates palliative care curricula. Faculty can easily find effective curricular material at the website, thereby decreasing the burden of starting a new program. For example, EPERC expanded on the success of Dr. Warm's short, learner-friendly, focused Fast Facts as an educational detailing mechanism in palliative care.²⁰ In the Featured Innovation, Dr. Warm describes the evolution of these one-page handouts, which answer one specific palliative care question and offer a few key references.

Palliative Care Content Meets Other Curricular Goals

Palliative care educators have been politically savvy in developing their programs. Realizing that educational space in residency programs is at a premium, they figured out how to make program directors' lives easier by combining the teaching of palliative care with other Residency Review Committee required topics. Thus, palliative care faculty have taught residents how to do quality assurance by reviewing charts for documentation of pain management, combining teaching palliative care with doctor communication sessions on giving bad news or discussing advance care planning, or integrating palliative care education into medical ethics and health law. By doing this, they have been able to increase the amount of time dedicated to palliative care by killing "two birds with one stone," and so keep residency program directors happy.

Meets Real Needs of Residents

Finally, and probably most importantly, at least in the long run, residents want to learn palliative care. Housestaff, particularly interns, feel stress associated with their frequent confrontations with death and by having to deal with topics that we typically avoid in polite conversation. They know that they don't know how to care for dying patients or how to talk with families about emotional topics. Seeing patients die in pain (and often feeling responsible for the pain) evokes strong feelings for residents. They are stressed when their fear and lack of knowledge of opiates conflicts with their desire to use drugs to ease suffering (but not to cause death). They are stressed by the confrontation with medicine's limitations (and worried that these are personal limitations). Housestaff are motivated, therefore, to learn how to deal more competently with the common problems that increase their anxiety. The number of residents and chief residents who have started educational programs in palliative care shepherded by NRELEP is indicative of the grassroot support for palliative care education.

Caveats

Given all of these positive developments, one would assume the future of palliative care education is bright. I worry, however, that the next ten years will be much more difficult then the last five. It is easier to be successful in building something from nothing than to sustain it in the face of a dominant medical culture that views palliative care, at best, as "foreign" and, at worst, as the enemy. In the first five years, palliative care, like medical ethics, primary care, and women's health earlier, was "the next big thing." As palliative care is replaced by the next medical topic that catches the public interest, its financial and administrative support may wane. Some say this is already happening.

Addressing Longstanding Cultural Barriers to Change

Building on our successes will mean confronting thorny problems that are deeply embedded in the culture of academic medicine, making them more difficult to solve. The risk for palliative care is that it becomes so assimilated into the mainstream that it loses its unique messages for trainees. Rather than focusing on the emotional, spiritual, and existential aspects of medicine (for both the patient and the doctor), palliative medicine risks becoming merely another set of facts doctors need to learn and apply. Palliative care educators also will have to confront some of the underlying structural issues that plague all of medical education.

Sustaining Change

Insofar as resident teaching is ongoing, it requires constant curricular modification. Dr. Warm alludes to this challenge and the numerous changes he has made (and continues to make) to maintain the viability of his program. Residents are continually coming and leaving, and educational programs need to be revised in light of new data and changing circumstances. Residency program directors, department chairs, and deans change frequently; thus, political support for the teaching program needs to be continually renegotiated. People underestimate the time and energy needed to maintain a successful educational program.

The majority of palliative care educators are junior faculty, who struggle to survive in an increasingly competitive academic world. Dr. Warm has the advantage of now being an associate program director, but that was not his role at the outset. Teaching is not a highly valued activity in academia; as money gets tighter, the problem has become more acute. Local foundation money, which helped many programs get off the ground, will not persist. Many palliative care faculty, who are being hired to staff busy clinical programs, will find it hard to devote the time necessary to continually revise their educational programs. Finding the time and the educational, fiscal, and scholarly support to continually improve palliative care curricula will be a challenge.

Teaching Methods

Willie Sutton is reported as saying that he robbed banks because that is "where the money is." Similarly, when starting a palliative care educational program, most faculty wisely focus on topics that are easiest to teach. It is easier to give a didactic PowerPoint lecture on pain management than to attempt to get housestaff to examine their attitudes toward addiction. Didactic lectures fit within the traditional model of residency training. The lecturer – who is the expert – tells the learner what he or she needs to know. For a new faculty person, this model, which places the teacher in control, is relatively reassuring. For residents who merely need to absorb the information, it is also a relatively safe way to learn. One of the reasons I believe that Education for Physician's on End-of-Life Care (EPEC) has a tremendously popular educational program is that it fits well within the traditional methods of residency medical education.

The problem with this model is that it is not terribly effective. It is best suited for knowledge acquisition (and even that questionable).²¹ It does not work for altering attitudes or influencing behavior, e.g., teaching clinical judgment or communication skills.²² Behavioral and cognitive skills are better taught in a small group format in which learners must actively struggle with the problem, try out solutions, and receive feedback about their success.²³ The teacher, rather than lecturing, needs to engage the learner to think creatively about the problem, ensure a safe environment in which to hear reaction, and provide focused feedback. The process is more time intensive and requires a smaller faculty to resident ratio than a lecture. Traditionally, residents learn clinical skills, for example, in morning report or daily rounds. If one hopes to teach palliative care skills, we need to move much of our teaching to interface with the direct care of patients.

Our colleagues in Australia have done this by developing specialty services. If we hope to replicate this, we will need to develop a large cadre of palliative care physicians. Alternatively, we could train non-experts to stress palliative care precepts when engaged in clinical teaching. The latter approach has the advantage of integrating palliative care more fully into clinical medicine. Still, it means that over the next five years, faculty development must be a high priority.

Communication skills cannot be taught via lecture. Residents need to observe and be observed giving bad news, talking about goals, providing support, and so forth. A number of studies show that a three-day, interactive course on communication skills, utilizing standardized patients and role playing, results in measurable changes in physician behavior—behaviors that have been shown to influence patient satisfaction, compliance, and health outcomes.²⁴ Most residents do not receive this training, in part, because many residencies have no faculty member competent to teach a course like this. (Interestingly, in Australia, where I'm currently on sabbatical, every medical oncology fellow is required to take a day-long course in communication skills.) Again, providing this kind of training is more time and faculty intensive than presenting lectures and will require greater resources. Mobilizing resources (skilled faculty, time, and money to support the effort) to teach these skills effectively is a major challenge confronting those seeking full integration of palliative care into residency training.

Emotions as a Keystone

A central part of palliative care and the teaching of listening skills is attending to emotions. Patients who are gravely ill and their families often undergo difficult transitions. Changes in family structure, in physical ability, and preparing for death are all emotionally charged events. Sadness, anger, acceptance, frustration, and love are common emotions as people struggle with loss, meaning, and closure. If physicians are to be more than "symptomotologists," they need a high level of competence in the interpersonal domain. Doctors who care for palliative care patients need to be able to recognize emotions, empathize with patients and families, and allow space for emotions in their practice.²⁵

Yet, there is a great deal of data linking medical school and residency training to the development of cynicism and burnout among physicians.^26,27 Doctors who have become cynical, distancing themselves from their own feelings, will be less likely to attend to the complex range of feelings that emerge when patients are dying. Dealing with others' emotions requires some insight into one's own emotional state and recognizing how one's emotions influence relationships with others. It also requires a belief that attending to and responding to patients' and/or one's own emotional state is a legitimate part of medicine. The "informal curriculum" of medical school training compounds this problem with its focus on "science" and demeaning attitude toward emotions.^28,29 For example, in one study, medical students, more than any other professionals, felt that crying was a sign of weakness.³⁰ I do not believe that residency training is any different.

How emotions affect care is not often discussed in residency training. The culture of medicine, particularly academic medicine, ignores doctors' feelings, as no one wants to be tarred with the demeaning brush of "touchy-feely." It is certainly a mixed message to tell residents that they need to deal better with patients' emotions while the faculty ignore residents' own emotional reactions. There are some models for how to help residents recognize and deal with their emotions. Psychiatry programs spend a fair amount of time on countertransference, family medicine programs often have resident support groups and Balint sessions, and some oncology programs are developing bereavement rounds. As these existing programs demonstrate, teaching doctors to be more comfortable and proficient with patient emotions is possible. It involves a great deal of training in communication skills, with the same need for small group experiential learning, and expert feedback tailored to the individual learner. Dealing with emotions needs to be a major focus over the next five years.

Summary

These are exciting times for palliative care educators. We have finally been given the opportunity to teach the next generation of physicians how to care better for terminally ill patients. We have made tremendous strides in the last five years and, hopefully, this will improve the care of terminally ill patients and their families. My guess is that over the next five to ten years, palliative education in the United States will increasingly move from the classroom to the clinic in ways that emulate the Australian approach. Education will move from a focus on knowledge acquisition to clinical skills and attitudes conducive to caring for the dying and their families.

In the process, I hope we can keep the spotlight on the primacy of the physician as an attentive human being. Palliative care stresses the importance of "walking with the patient," of being present. This model of doctoring places less emphasis on doing something to another than on being with them. Residents who are busy and overworked are already inclined to view care for the dying as just another problem with which they need to deal. This way of looking at palliative care ignores the critical human experience involved in illness and death. Residents should be encouraged to see dying patients not as a problem to be solved, but as people who need our full attention. I am not sure the best way to teach this other than role modeling and allowing time and space for residents to talk about the "human" aspects of doctoring. I am sure that this is one of the most important things about providing good palliative care (not to mention good doctoring or good teaching). I think, in an increasingly busy and hectic residency training program, this maybe the most important lesson we can help residents learn.

Acknowledgment: This work has been supported in part by a UICC Yamagiwa-Yoshida Memorial International Cancer Study Grant.

References

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2. Institute of Medicine, Field MJ, Cassel CK (eds.). Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press, 1997.[Return to Editorial]

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