Perspectives on care at the close of life. Psychological considerations, growth, and transcendence at the end of life: the art of the possible.

Patients with life-threatening illnesses face great psychological challenges and frequently experience emotional distress. Yet, the end of life also offers opportunities for personal growth and the deepening of relationships. When physical symptoms and suffering are controlled, it is easier to address patients' central concerns-about their families, about their own psychological integrity, and about finding meaning in their lives. Optimal end-of-life care requires a willingness to engage with the patient and family in addressing these distinct domains. In addition to supporting growth of patients and their caregivers, physicians need to recognize the impact of psychiatric disorders such as depression, anxiety, and delirium at the end of life and develop skills in diagnosing and treating these syndromes. Comments of a patient with pancreatic cancer, his son, and his physician help illuminate the potential opportunities presented when coping with life-threatening illness. Enhanced understanding of the common psychological concerns of patients with serious illness can improve not only the clinical care of the patient, but also the physician's sense of satisfaction and meaning in caring for the dying.

The effect of medical education on primary care orientation: results of two national surveys of students' and residents' perspectives.

PURPOSE: To examine changes among a nationally representative sample of students and residents in their orientations toward primary care as reflected in their attitudes toward the psychosocial and technical aspects of medicine and their perceptions of the academic environment for primary care. METHOD: Confidential telephone interviews of stratified national probability samples of first- and fourth-year medical students and residents were conducted in 1994 and 1997. The 1997 survey included 219 students and 241 residents who had also been interviewed in 1994. Participants were asked about their attitudes toward addressing psychosocial issues in medicine and their perceptions of faculty and peer attitudes toward primary care. Responses were compared over time and across groups. RESULTS: Between the first and fourth years of medical school, there was a decline over time in students' reported orientations to socioemotional aspects of patient care (61.6% versus 42.7%, p =.001) and their perceptions that working with psychosocial issues of patients made primary care more attractive (56.3% versus 43.5%, p =.01). This pattern continued for 1997 residents (PGY-3), who were even less likely to say that addressing psychosocial issues made primary care more attractive (26.9%). For fourth-year students in 1994 who became PGY-3 residents in 1997, there was an increased perception that non-primary-care house officers and specialty faculty had positive attitudes toward primary care (20.8% versus 33.0%, p =.005; 28.3% versus 45.7%, p <.0001; respectively). CONCLUSIONS: Between 1994 and 1997 students and residents perceived a positive shift in the attitudes of peers and faculty toward primary care. During the course of their education and training, however, the students experienced an erosion of their orientations to primary care as they progressed through medical school into residency.

Long-term outcomes of the New Pathway Program at Harvard Medical School: a randomized controlled trial.

PURPOSE: To evaluate the long-term effects of an innovative curriculum, the New Pathway (NP) Program, on behaviors and attitudes related to humanistic medicine, lifelong learning, and social learning. METHOD: Long-term follow-up of Harvard Medical School students who participated in a randomized controlled trial. Descriptive study using 1998 telephone interviews of 100 1989 and 1990 graduates (50 who had studied the NP curriculum, 50 who had studied the traditional curriculum). The NP Program consisted of problem-based learning tutorials, with coordinated lectures, labs, experiences in humanistic medicine, and clinical experiences; the traditional program consisted of basic science lectures and labs. RESULTS: Of 22 measures on the survey, NP and traditional students differed significantly on only five (three humanism; two social learning): 40% of NP students and 18% of traditional students went on to practice primary care or psychiatry. NP students rated their preparation to practice humanistic medicine higher than did traditional students and expressed more confidence in their ability to manage patients with psychosocial problems. NP students were more likely than were traditional students to believe that faculty from the first two years continued to influence their thinking. NP students liked the pedagogic approaches of their program more than traditional students did. There was no difference between the groups on measures of lifelong learning. CONCLUSIONS: Differences between NP and traditional students in the humanism domain first appeared during medical school and residency and remained significant well into practice, suggesting that humanistic medicine can be taught and learned.

Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians - American Society of Internal Medicine.

Psychological distress often causes suffering in terminally ill patients and their families and poses challenges in diagnosis and treatment. Increased attention to diagnosis and treatment of depression can improve the coping mechanisms of patients and families. This paper reviews the clinical characteristics of normal grief and clinical depression and explains strategies for differential diagnosis. Although some literature discusses the psychological issues facing elderly patients and terminally ill patients with cancer, less is known about patients with end-stage pulmonary, cardiac, renal, and neurologic disease. Data on the effectiveness of interventions in terminally ill patients are lacking. Treatment recommendations in this paper represent extrapolations from existing literature and expert opinion. Diagnosing and treating depression in terminally ill patients involve unique challenges. Evidence of hopelessness, helplessness, worthlessness, guilt, and suicidal ideation are better indicators of depression in this context than neurovegetative symptoms. Although terminally ill patients often have suicidal thoughts, they are usually fleeting. Sustained suicidal ideation should prompt a comprehensive evaluation. Clinicians should have a low threshold for treating depression in terminally ill patients. Psychostimulants, because of their rapid onset of action, are useful agents and are generally well tolerated. Selective serotonin reuptake inhibitors and tricyclic antidepressants may also be used. Psychological interventions-including eliciting concerns and conveying the potential for connection, meaning, reconciliation, and closure in the dying process-can also facilitate coping.

Recommendations for incorporating palliative care education into the acute care hospital setting.

This article presents recommendations for improving the education of physicians about end-of-life care in the acute care hospital setting. The authors, who have a variety of backgrounds and represent several types of institutions, formulated and reached consensus on these recommendations as members of the Acute Care Hospital Working Group, one of eight working groups convened at the National Consensus Conference on Medical Education for Care Near the End of Life in May 1997. A recently published literature review on the status of palliative care education, a summary of recent research on education about end-of-life care, and expert opinion were helpful in developing the recommendations. The authors emphasize that the acute care setting offers many opportunities for education about care at the end of life. Faculty should support learners' appreciation of the importance of end-of-life care, and convey the meaning and privilege of attending to patients and families at this difficult time. Faculty should teach students and residents to provide care that embodies attention to the control of distressing physical, physiologic, and spiritual symptoms, appropriate awareness of patients' differing cultural backgrounds and their impact upon the experience of dying, excellent communication skills, the application of bioethical principles, timely referral and smooth transition to other care settings that meet patient and family goals, and the role of the interdisciplinary team in meeting the diverse needs of dying patients and their families.

Intention to practice primary care by pediatric residents: nature or nurture?

Factors associated with the intention to practice primary care were examined in a survey of a national sample of PL-2 residents (n = 98). Socioemotional orientation (nature), faculty and peer encouragement (nurture), and clinical experiences during residency (nurture) were independently associated with a primary care career choice. For residents who changed career intentions to primary care from a nonprimary care preference, gender, encouragement by faculty and peers, and outpatient experiences during residency were associated with the change. Encouragement by both faculty and peers had the strongest influence on primary care career choice for all residents.

Views of managed care--a survey of students, residents, faculty, and deans at medical schools in the United States.

BACKGROUND AND METHODS: Views of managed care among academic physicians and medical students in the United States are not well known. In 1997, we conducted a telephone survey of a national sample of medical students (506 respondents), residents (494), faculty members (728), department chairs (186), directors of residency training in internal medicine and pediatrics (143), and deans (105) at U.S. medical schools to determine their experiences in and perspectives on managed care. The overall rate of response was 80.1 percent. RESULTS: Respondents rated their attitudes toward managed care on a 0-to-10 scale, with 0 defined as "as negative as possible" and 10 as "as positive as possible." The expressed attitudes toward managed care were negative, ranging from a low mean (+/-SD) score of 3.9+/-1.7 for residents to a high of 5.0+/-1.3 for deans. When asked about specific aspects of care, fee-for-service medicine was rated better than managed care in terms of access (by 80.2 percent of respondents), minimizing ethical conflicts (74.8 percent), and the quality of the doctor-patient relationship (70.6 percent). With respect to the continuity of care, 52.0 percent of respondents preferred fee-for-service medicine, and 29.3 percent preferred managed care. For care at the end of life, 49.1 percent preferred fee-for-service medicine, and 20.5 percent preferred managed care. With respect to care for patients with chronic illness, 41.8 percent preferred fee-for-service care, and 30.8 percent preferred managed care. Faculty members, residency-training directors, and department chairs responded that managed care had reduced the time they had available for research (63.1 percent agreed) and teaching (58.9 percent) and had reduced their income (55.8 percent). Overall, 46.6 percent of faculty members, 26.7 percent of residency-training directors, and 42.7 percent of department chairs reported that the message they delivered to students about managed care was negative. CONCLUSIONS: Negative views of managed care are widespread among medical students, residents, faculty members, and medical school deans.

Comparison of osteopathic and allopathic medical Schools' support for primary care.

OBJECTIVE: To contrast prevailing behaviors and attitudes relative to prJgiary care education and practice in osteopathic and allopathic medical schools. DESIGN: Descriptive study using confidential telephone interviews conducted in 1993-94. Analyses compared responses of osteopaths and allopaths, controlling for prJgiary care orientation. SETTING: United States academic health centers. PARTICIPANTS: National stratified probability samples of first-year and fourth-year medical students, postgraduate year 2 residents, and clinical faculty in osteopathic and allopathic medical schools, a sample of allopathic deans, and a census of deans of osteopathic schools (n = 457 osteopaths; n = 2,045 allopaths). MEASUREMENTS: Survey items assessed personal characteristics, students' reasons for entering medicine, learners' prJgiary care educational experiences, community support for prJgiary care, and attitudes toward the clinical and academic competence of prJgiary care physicians. MAIN RESULTS: PrJgiary care physicians composed a larger fraction of the faculty in osteopathic schools than in allopathic schools. Members of the osteopathic community were significantly more likely than their allopathic peers to describe themselves as socioemotionally oriented rather than technoscientifically oriented. Osteopathic learners were more likely than allopathic learners to have educational experiences in prJgiary care venues and with prJgiary care faculty, and to receive encouragement from faculty, including specialists, to enter prJgiary care. Attitudes toward the clinical and academic competence of prJgiary care physicians were consistently negative in both communities. Differences between communities were sustained after controlling for prJgiary care orientation. CONCLUSIONS: In comparison with allopathic schools, the cultural practices and educational structures in osteopathic medical schools better support the production of prJgiary care physicians. However, there is a lack of alignment between attitudes and practices in the osteopathic community.

Incorporating palliative care into primary care education. National Consensus Conference on Medical Education for Care Near the End of Life.

The confluence of enhanced attention to primary care and palliative care education presents educators with an opportunity to improve both (as well as patient care) through integrated teaching. Improvements in palliative care education will have benefits for dying patients and their families, but will also extend to the care of many other primary care patients, including geriatric patients and those with chronic illnesses, who make up a large proportion of the adult primary care population. In addition, caring for the dying, and teaching others to carry out this task, can be an important vehicle for personal and professional growth and development for both students and their teachers.

Mixed messages about primary care in the culture of U.S. medical schools.

PURPOSE: To examine the contributions of school-level variables associated with primary care career choice to students' enthusiasm for and perceived encouragement toward primary care. METHOD: Multilevel analysis of 264 fourth-year students and 500 clinical faculty members at 59 medical schools using data obtained in 1993 to 1994 from telephone interviews of a national stratified probability sample of students (response rate 90%) and faculty (response rate 81%). RESULTS: On average, students reported slightly positive regard for primary care and felt neither supported nor unsupported in their interests in primary care. Students' reports of encouragement toward primary care showed some consistency within schools (intraclass correlation = .08); their regard for primary care did not (intraclass correlation = .02). Regard for primary care was associated with students' intended specialty choices (p < .001), with students who planned to enter primary care careers reporting more positive attitudes. Students' perceptions of encouragement toward primary care careers were unrelated to their intended specialty choices, but significantly related to their schools' historical primary care production (p < .0001), federal research funding (p < .01), and school ownership (p < .01). CONCLUSION: Schools that have primary care missions and have historically produced more generalists transmit higher levels of encouragement to their students about primary care. However, even at schools with strong primary care missions, students hold unenthusiastic attitudes about primary care practice.

Enthusiasm for primary care: comparing family medicine and general internal medicine.

OBJECTIVE: To compare attitudes and perceptions of primary care among faculty, students, and residents oriented toward family medicine (FM) and general internal medicine (GIM). DESIGN: Descriptive study using confidential telephone interviews. PARTICIPANTS: National stratified probability sample of FM and GIM faculty (n = 68), residents (n = 196), and students (n = 81). MEASUREMENTS AND MAIN RESULTS: We created indicators for attitudes toward primary care among the faculty that included perceptions of medical practice, experiences within the academic environment, and support for primary-care-oriented change. For the students and residents, we explored their perceptions of faculty and resident attitudes toward primary care, their perception of encouragement to enter primary care, and their satisfaction with training. Family medicine faculty showed more enthusiasm for primary care as manifested by their greater likelihood to endorse a primary care physician to manage a serious illness (FM 81.3% vs GIM 41.1%; p < .01), their strong encouragement of students to enter primary care (FM 86.2% vs GIM 36.3%; p < .01), and their greater support for primary-care-oriented changes in medical education (FM 56.8% vs GIM 14.7%; p < .01). Family medicine students and residents were more likely to perceive the primary care faculty as very satisfied with their work (FM 69.2% vs GIM 51.5%; p < .05), to feel strongly encouraged by peers toward primary care (FM 59.5% vs GIM 16.1%; p < .0001), and to have a primary care role model (FM 84.3% vs GIM 61.3%; p < .05). CONCLUSIONS: Family medicine faculty, students, and residents showed a consistent pattern of greater enthusiasm for primary care than their GIM counterparts. This may be a reflection of the different cultures of the two disciplines.

Gender-related group dynamics in problem-based learning : a retrospective study.

As problem-based learning (PBL) techniques play an increasingly important role in medical school curricula, programs will require an understanding of which variables enhance or inhibit learning. Through a retrospective study of an "experiment" in which male and female medical students were separated into single-gender tutorial groups, the authors describe gender differences in the styles of participation and subjective experi-ence of men and women in mixed-gender and single-gender tutorial groups. The women students noted an increase in their comfort level in the all-women tutorial group and felt that learning about their own styles in this group helped them participate more effec-tively in coed groups and later on in other professional settings. The authors make rec-ommendations concerning the implementation of PBL in medical school curricula.

Attitudes about end-of-life care: a national cross-sectional study.

BACKGROUND: Major concerns have been expressed about the preparation of physicians to provide end-of-life care. Little is known about how well academic health centers prepare students and residents to care for patients at the end-of-life and about the values about end-of-life care transmitted by faculty. METHODS: In 1997, we conducted a telephone survey of a nationally representative sample of first-year medical students (n = 287), fourth-year medical students (n = 173), residents (n = 473), clinical faculty (n = 728), internal medicine residency training directors (n = 143), department chairs (n = 186), and medical school deans (n = 101) within U.S. academic health centers (response rate = 80.2%). RESULTS: U.S. medical students, residents and faculty evaluate themselves as inadequately prepared to provide end-of-life care. Academic health center constituents perceive that providing care at the end of life requires medium to high levels of expertise. Academic health center constituents are divided about whether responsibility for providing care at the end of life rests with generalists or with specialists and view managed care as nearly equivalent to the fee-for-service sector in its capacity to provide excellent end-of-life care. CONCLUSIONS: Academic leaders and faculty, as well as their students, lack confidence in their own skills in providing end-of-life care. They also question the ability of the current and evolving health care delivery system to provide excellent end-of-life care.

Caring for patients at the end of life in an HMO.

BACKGROUND: Increasing numbers of Americans are receiving care within managed care organizations (MCOs), and the ability of MCOs to provide high-quality end-of-life care is under greater scrutiny. Although many anecdotal reports have been published, almost no research has been published on patient/family experiences with end-of-life care in MCOs. METHODS: We undertook a qualitative study of end-of-life care during 1996 and 1997 in the closed-panel staff-model, not-for-profit, health center division of Harvard Pilgrim Health Care. We collected and analyzed data from five focus groups composed of family members of patients who had died during the preceding year (n = 22) and four focus groups composed of clinicians and administrators who routinely care for dying patients and/or have responsibility for managing end-of-life care resources and systems (n = 31). RESULTS: Problems noted in this setting that are also reported in other health care settings included divergent expectations and unclear primary care/specialist roles and hospice/primary physician roles, difficulties in transitions across care settings, ineffective communication between physicians and patients/families about end-of-life care preferences, and lack of systematic attention to bereavement care. More unique to managed care settings were problems related to the absence of a consistently applied hospice benefit and concerns about the impact of cost containment on the quality of care, reflecting the conflict between the dual roles of MCOs as both insurers and providers of care. CONCLUSIONS: Our findings highlight specific issues involved in providing quality end-of-life care in MCOs and suggest areas for further exploration.

Academia's chilly climate for primary care.

OBJECTIVE: To describe the attitudes toward and perceptions of primary care education and practice among academic health center constituents. DESIGN AND PARTICIPANTS: Descriptive study using confidential telephone interviews (October 1993 to March 1994) of national stratified probability samples of first- and fourth-year medical students, residents, clinical faculty, internal medicine and pediatrics residency training directors and chairs, and deans (N=2293). RESULTS: Five areas were examined: respondents' specialty orientation, attitudes toward the competence of primary care physicians, encouragement and positive regard for primary care, exposure to primary care-related educational experiences, and socioemotional orientation. The response rate was 84%. Respondents generally perceive primary care tasks as not requiring high levels of expertise; nearly half believe that generalists are not the best physicians to manage patients with serious illness and that the quality of primary care research is inferior to that in other fields. Attitudes are more positive toward the quality of primary care teaching. Learners perceive little encouragement for generalist careers and negative attitudes toward generalists among faculty, and view the quality of their primary care training as inferior to that for specialty practice. Those who have progressed further in the academic medicine hierarchy generally report lower levels of socioemotional orientation than individuals at earlier phases of career development. CONCLUSIONS: Despite changes in the health care system and in education, students and residents encounter an atmosphere that is chilly toward primary care. If medical educators seek to optimize enthusiasm and preparation for primary care careers, they must develop approaches to changing the attitudes, values and composition of their faculties.

Using problem-based learning to enhance the psychosocial competence of medical students.

This article provides an overview of adult learning principles and reviews their applicability and effectiveness in enhancing learner acquisition of psychosocial competencies. It presents a brief critique of traditional models of teaching medical students, reviews general principles of adult learning, describes the method of problem-based learning (PBL), summarizes data about outcomes of PBL, and suggests mechanisms through which PBL may enhance psychosocial learning. The author emphasizes the roles of small group interaction, exposure to diverse viewpoints, integrated presentation of psychosocial issues in cases, learning to adapt to uncertainty, and similarities with the process of psychotherapy as possible mediators for enhanced psychosocial learning through PBL.