Physicians' confidence in discussing do not resuscitate orders with patients and surrogates.

PURPOSE: Physicians are often reluctant to discuss "Do Not Resuscitate" (DNR) orders with patients. Although perceived self-efficacy (confidence) is a known prerequisite for behavioural change, little is understood about the confidence of physicians regarding DNR discussions. SUBJECTS AND METHODS: A survey of 217 internal medicine attendings and 132 housestaff at two teaching hospitals about their attitudes and confidence regarding DNR discussions. RESULTS: Participants were significantly less confident about their ability to discuss DNR orders than to discuss consent for medical procedures (p<0.001), and this was true for both attendings (p = 0.002) and housestaff (p<0.001). In a multivariate logistic model of confidence regarding DNR discussions, women were less confident than men (OR = 0.52, CI = 0.29 to 0.92); house officers were less confident than attendings (OR = 0.35, CI = 0.20 to 0.61), those who were less confident of their ability to discuss medical procedures were less confident discussing DNR (OR = 0.12, CI = 0.06 to 0.25), and those who found talking to patients about DNR orders very difficult reported less confidence than those who did not (OR = 0.06, CI = 0.02 to 0.16). CONCLUSION: We conclude that physicians' confidence regarding DNR discussions is low compared with their confidence regarding other medical discussions and that confidence varies by sex and perceived difficulty of the task. Efforts to improve DNR discussions should explore the need to tailor educational interventions to fit these characteristics.

Physician practices in the diagnosis of dementing disorders.

Because there are both treatable and untreatable causes of dementia, the physician's ability to conduct (or refer a patient for) a differential diagnosis could have a profound effect on health outcomes for patients and on health care costs. This study was undertaken to assess physician practices with regard to the diagnosis of dementing disorders. Data from 53 physicians (a response rate of 48%) in several specialties were obtained from a self-administered mail questionnaire. Results indicate that the majority of physicians provided history taking, physical examination, and neurological examination. Physicians were more likely to refer patients for psychiatric and neuropsychological examinations than to provide these services themselves. The results also point to deficiencies in two key areas: the use of formal, published diagnostic criteria, and the use of mental status and cognitive function tests. Over 75% of physicians surveyed did not use either DSM-III or NINCDS-ADRDA diagnostic criteria, and 42% of physicians did not provide any mental status tests themselves. The need for continuing education to close knowledge gaps is emphasized.

A needs assessment for a palliative care curriculum.

To ensure the success of a new curriculum at an institution, information about the educational needs of learners, available resources, and potential obstacles needs to be systematically collected and analyzed prior to the development and implementation of the actual curriculum. This process, known as needs assessment, is important in the development of palliative care training for internal medicine residents, because internal medicine has only recently begun to address these issues in a formalized way and palliative care is a relatively new topic in medical education and clinical medicine. Therefore, institutional issues and resistance, lack of knowledge and appropriate attitudes among trainees and faculty, and a paucity of educational models for individual internal medicine training programs present potential obstacles. Although curricula that have been developed by national organizations can serve as "guideposts, " these documents are unable to address the specific needs and culture of an individual institution. This paper outlines a systematic methodology of needs assessment for palliative care curricula at individual institutions that could be applied to the development and implementation of palliative care training for different groups of learners. An institution-specific needs assessment was developed based upon the findings of a systematic literature review and interviews with experts in palliative medicine and medical education. The following methods were utilized: 1) an anonymous survey; 2) focus groups; 3) topic rankings; and 4) individual interviews. The needs assessment revealed the following educational, clinical, and institutional information: 1) interns had very little exposure to palliative care in medical school; 2) there was no formalized system formal education and clinical exposure; 3) tremendous interest in palliative care education existed; 4) patients, families, physicians, and nurses perceived a need to improve the quality of palliative care; and 5) there are several political, logistical, and resource (time and financial) obstacles that needed to be addressed. An institution-specific needs assessment is an important part of the successful development and implementation of any new curriculum for medical residents and was specifically necessary for our palliative care program. As a result of the needs assessment process, a curriculum consisting of ten units of case-based and problem-based teaching was successfully implemented.

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.