No relief in sight: postgraduate training in pain management.

This study investigated training in pain management in postgraduate medical education programs. A mail survey of program directors was conducted, evaluating the format of training in pain management and the self-assessed adequacy of the training. The response rate was 70%, with 188 total respondents. It included all programs in a large Midwestern state, representing most specialties. Just over half of all programs offered any formal training in pain management, and even fewer required it. Less than one quarter required a clinical component to such training. Nonetheless, an overwhelming majority of program directors (85%) rated their training as adequate or excellent. Improvements are clearly needed in postgraduate training in pain management, and external incentives, such as requirements in the accreditation process, will be needed.

Learning to provide end-of-life care: postgraduate medical training programs in Michigan.

PURPOSE: A statewide survey of postgraduate medical training programs was conducted to determine the current status of training related to end-of-life (EOL) care and hospice care training. METHODS: A mail survey of 275 program directors was conducted with a response rate of 70%. The questionnaire focused on information about training in EOL care and hospice care: specific content, required and elective experiences, teaching formats, and program directors' ratings of the perceived adequacy of training. This study received Institutional Review Board (IRB) approval. RESULTS: Less than half (46%) of the residency programs reported any formal training in EOL care, and less than one third (31%) reported training in hospice care. A majority of programs with EOL and/or hospice training required it for all residents. Of the programs with required hospice training, only half included a clinical component; fewer programs with EOL training reported a clinical component. Most program directors rated their programs as adequate or excellent in terms of EOL and hospice care, whether they had formal training or not. CONCLUSIONS: The results of the survey demonstrate considerable variability in training with respect to hospice and EOL care. Training through direct clinical experience was infrequently reported. There has been little formal adoption of published curricula in this area. The high level of adequacy in the rating of training by program directors contrasts with relative lack of reported curriculum content and implementation, suggesting that improvements in EOL care training will be slow to come if left in the hands of program directors.

Approaches to the office care of the older adult and the specter of dementia.

The influx of older patients into the office-based primary care setting is a demographic reality for most practices. A shift from the disease-driven model of care delivery to one that focuses on function and quality of life should occur if primary care clinicians are to provide appropriate services to their aging patients, especially as those patients reach a state of vulnerability as defined in the ACOVE studies. Incremental functional assessment may be a first step in making the shift and probably can be implemented in most office-based practices. The specter of dementia, however, is beginning to materialize and affect the approach to addressing the needs of older adults and the expected outcomes of care.

End-of-life care for older adults.

Caring for elderly patients and their families at the end of life gives physicians the opportunity to have a meaningful impact on the lives of others. By expanding our clinical expertise beyond the arena of cure and the preservation of life, we can discover new ways to encounter our patients as full human beings and to share a profound life passage that many of us might otherwise ignore. The skills that are needed to enter this new arena are well within the grasp of the office-based clinician, and physicians who employ them are rewarded with the fulfillment of knowing they have provided an invaluable service at a time of greatest need.

Medical students as standardized patients to assess interviewing skills for pain evaluation.

PURPOSE: The use of medical students as standardized patients in a performance assessment of pain evaluation was studied. METHODS: Fifty-two pairs of second-year medical students participated. One student portrayed a patient presenting with cancer pain and was interviewed by the other medical student. The student-patient then rated the interview using a checklist of pain assessment and general interviewing skills. The interviews were audiotaped and also rated independently. RESULTS: Based on student-patient ratings, 36 (69%) students demonstrated 9 or more of the 11 pain-specific checklist items, compared to 34 (65%) students according to the trained rater. Highly specific pain-related items had higher agreement than broader interviewing skill items. There would be differences in the summary assessments of students depending on which rating data were used. DISCUSSION: Medical students represent a readily accessible resource as patients for clinical simulations. Students tended to overestimate the performance of fellow students, but acting as a standardized patient had educational value, and can be used to extend simulated patient encounters within the curriculum. Further investigation is needed to improve the reliability of the feedback provided by student-patients.

Physicians and hospice care: attitudes, knowledge, and referrals.

Underutilization of hospice care continues to be a public health issue in the United States. Physician barriers related to incorrect knowledge and unfavorable attitudes have been hypothesized as part of the explanation. We conducted a mail survey of 264 area physicians, obtaining a response rate of 72% (n = 190). The survey examined attitudes toward, knowledge about, and perceptions of benefits and barriers to hospice care. Physicians demonstrated very positive attitudes toward hospice. They had correct knowledge about some aspects of hospice, but were uncertain about correct answers on the majority of items. They had erroneous knowledge on few items. Physicians perceived many benefits to hospice care, and identified patient and family readiness as the major barriers to earlier hospice referrals. Demographic and practice variables were related to responses on few of the survey items. These findings have many implications for outreach strategies for physicians as well as future research.

Why Johnnie Can't Apply Neuroscience: Testing Alternative Hypotheses Using Performance-Based Assessment.

When second year medical students were less successful than expected in solving an OSCE neurologic case, a subsequent performance-based assessment was modified to permit testing of four hypotheses related to knowledge application, ability decay over time, skill performance, and case complexity. Two cohorts of second year medical students were presented with neurologic cases in the context of performance-based assessment. Although many students demonstrated that they had the requisite knowledge, few were able to access the knowledge in less structured testing formats. Students had the skills necessary to conduct a physical examination but were unable to appropriately focus the examination. Case complexity also was related to some performance domains. There was evidence of knowledge and skill decay over time. In summary, it is apparent that multiple factors influence students' performance and are important considerations in designing performance assessments to evaluate competence.