Medical Schools Respond
Until recently, medical schools have been slow to equip students with the communication skills necessary to cope with a dying patient or their family. The Association of American Medical Colleges (AAMC) reports that only five of the nation's 125 medical schools offer separate courses on death and dying. Most incorporate medical humanities, ethics, or communication into an existing required course.
Dr. Mary Lee, dean of educational affairs at Boston's Tufts University Medical School, says her students complain that handling the needs of terminally ill patients "is something they feel very ill prepared in doing." Dr. Lee acknowledges that many of her peers who teach medical students and residents "are not trained how to talk comfortably with the patient about the fact they are dying and what can be done to support them and their family."
Changing Physician Attitudes
One of the biggest hurdles to overcome is convincing current and future physicians that dying and death is not a medical failure, says Mary Meyer, who coordinates education projects for Choice in Dying. Meyer says much of the death and dying education that now occurs in the teaching milieu "is heavily reliant on the exceptional person that happens to be around."
Her organization is currently working with a group of 11 medical schools that want to develop mentors and standards for teaching these issues. "This is an extraordinary bias to overcome," she says. Nobody teaches pain management or how to deliver bad news and help families cope with picking up the pieces, she says.
A New Awareness
Things are changing. The American Board of Internal Medicine (ABIM), which certifies internists, now requires residency training to incorporate care of the dying. ABIM has developed a guide for residency programs to define physician competence in end-of-life care. This includes a focus on good pain management. ABIM has also increased the number and quality of questions linked to end-of-life care in its certifying exam. That means residency programs will have to place more emphasis on these issues and provide training opportunities in hospices and home care settings.
AAMC's M. Brownell Anderson, associate vice president for medical education, says there is a "heightened consciousness" among medical schools to change their curriculums to graduate more humane, empathetic, and highly skilled physicians. AAMC is helping schools develop outcomes that measure whether graduates have met a set of core skills, values, attitudes, and knowledge related to patient relationships. One of those outcomes address communication skills, including the ability to talk with patients about end-of-life issues.
Training Medical Students
Several schools are tackling the issues directly. The University of Illinois Chicago College of Medicine, for example, has a course to teach pediatric residents to communicate with grieving parents. Loyola University of Chicago is trying to help students understand how important incorporation of a discussion of spirituality is to curing and healing. Students are learning to become comfortable with performing a spiritual inventory on most patients. New York Medical College in Valhalla has developed a two-month course for first-year medical students in empathy. George Washington University medical school has been teaching students how to deliver bad news to patients and understand the importance of talking to patients about advance directives and other end-of-life concerns.
Dr. Stanley Talpers, a part-time mentor at GW, has told students they are lucky to be learning these skills. "Nobody every taught me to talk about death and dying. It was something totally ignored."
Dr. Christina Puchalski, a medical resident at George Washington, says she conducts spirituality interviews with all of her patients and is teaching students to emulate her practice. "I always ask a spiritual history," she says. "Everyone has some belief that gives meaning." One of her terminally ill patients said she loved to be around nature. She told Dr. Puchalski that she would enjoy looking at trees from her hospice bed.
Dr. Joan Teno, an associate professor and co-director of George Washington's Center to Improve Care of the Dying, says one of the most important things she can do is listen and talk to patients about their illness and its implications. "I have been struck that something as simple as letting someone get off their chest what their frustrations are is a very therapeutic thing." Teno, a geriatrician, says she is frustrated at the emphasis medical schools place on learning "fancy" procedures. "They spent squat on teaching me how to talk to patients about sensitive issues, yet that is what I do on a daily basis."
Emily Sheffer, a second-year medical student at GW, recently participated in a role-playing exercise set up to teach students better communication skills with patients. Dr. Puchalski taught the course. She played a patient, and Sheffer played the doctor. Sheffer had to tell the patient that her cancer treatment wasn't working and it was time to start considering her end-of-life options. The process is meant to teach students how to deliver bad news, but in a way that shows empathy and sensitivity to the multitude of family, medical, and social concerns confronting the patient. Dr. Puchalski teaches students that it's okay to feel bad; listening is key; and that body language, such as simply squeezing a patient's arm, is comforting.
Sheffer says the course has been an invaluable tool. "This is why I want to be a doctor," she says. "It's really important to support patients emotionally. In the end it makes a difference."