Medical school expands teaching of palliative care

Ryan Li routinely visited a patient with amyotrophic lateral sclerosis during his first year at the University of Pittsburgh School of Medicine. What he learned was invaluable.

"It gave me a dose of reality," said Li, now in his second year of medical school. "It was a real eye-opener for me to see how terminal illness affects everyday life. It inhibits you from doing so much, but I also saw how the patient and caregiver are still living and still have plenty to do."

Li is one of a limited number of medical students at the University of Pittsburgh who have elected to learn about end-of-life issues. But by the 2007-08 academic year, every third-year student in the medical school will get hands-on experience in palliative care. Armed with a $1.1 million four-year grant from the National Cancer Institute, the school is about to integrate technology, informational text and palliative care experts into clinical rotations. As far as the school is aware, this is the first initiative of its kind.

David Barnard, PhD, director of the university's Institute to Enhance Palliative Care, hopes the project will prove effective in changing the culture of medicine, which often focuses on finding cures while neglecting the dying. Third-year students will be the target group, but Dr. Barnard expects that the residents and attending physicians who work alongside the students will learn new end-of-life skills as well.

"We're still learning how to teach this well," Dr. Barnard said. "There are a lot of barriers to teaching about end-of-life care in hospitals. We've designed this particular project to swat as many of the barrier flies as we can."

Many physicians will welcome the training. A 1997 national survey of medical students, residents and faculty physicians found that almost all lacked confidence in their own abilities to provide end-of-life care. A 2000 survey of Michigan residency programs found that fewer than half offered formal end-of-life training. Among those that offered training, most programs didn't use published curricula on the topic. Also, few residencies offered specific clinical training, such as hospice care, according to the survey that family physician Karen Ogle, MD, conducted.

"This area has not been taught much, so physicians are understandably uncomfortable with it," said Dr. Ogle, a professor at Michigan State University. "Death feels like a failure, so we stay away from it."

Bedside learning

Dr. Barnard, along with James B. McGee, MD, head of the educational technology lab developing the tools for the University of Pittsburgh project, want to change this.

Their work will piggyback on the school's electronic system used to keep tabs on the variety of patients students see. When a student visits a patient, he or she enters information about the patient's condition into a log. If a student says that he or she has seen a patient with an advanced illness, a computer program is set to send the student background material on palliative care. A student will be able to reply with further questions, and the palliative care faculty will respond with supplementary material tailored to the situation.

The supervising resident and attending physician also will receive this information.

The next day, a palliative care faculty member will join the student's group on rounds to field questions or demonstrate relevant techniques.

"You can put lectures in the curriculum until you're blue in the face, but unless students see these issues brought up on rounds in the hospital, they'll not take it seriously," Dr. Barnard said.

Dr. McGee said that by relating the teaching to an actual case, the learner is more likely to recall and apply the information in the future. Under the current system, he said, there often is no physician experienced with end-of-life issues at rounds.

Dr. Barnard said it's important that residents and attendings are learning, because one of the barriers to getting end-of-life training to students is that practicing physicians often say they don't feel they're prepared to teach it.

"Once you give a clinician the techniques to use, they do tend to use them," Dr. Barnard said. "We're using the student as a good excuse to bring these topics up."

The big picture

While the initiative will expand palliative care training for the University of Pittsburgh's medical students, the leaders of the project intend to share the technology so that training in end-of-life care will improve nationwide.

For the University of Pittsburgh's medical school, the project will provide data to aid further fine-tuning.

"For the first time we'll know across the entire third year which of the end-of-life tasks students have been exposed to and which they haven't," Dr. Barnard said. "Our goal is to have a portrait of how much exposure we're actually giving our students over the year."

They also expect to uncover which clerkships give the most exposure and how often individual faculty are teaching it.

"This will help us to know if we're doing well or if the hidden curriculum is overwhelming all of our efforts," Dr. Barnard said.

This is all good news for Li, who would love to see all medical students experience how patients and their families cope with terminal illness.

"I came to medical school with my own firm beliefs about life and death," he said. "But it's very important to understand how patients accept death, and how they cope with it."