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Status Report and Future Directions

J. Andrew Billings, MD; Susan Block, MD

JAMA. 1997;278(9):733-738.

Abstract
Objective.—
To describe the status of palliative care education in the under-graduate medical curriculum and to offer recommendations for improvement.

Data Sources.—
Review of literature on palliative care and of recently submitted grants on medical education for end-of-life care.

Study Selection.—
English-language reports of educational programs targeted toward medical students were examined, as well as surveys of medical schools.

Data Extraction.—
Studies were reviewed by the authors to assess the quality of the educational program, evaluation methodology, and conclusions. From over 9000 citations on palliative care and related topics that were retrieved from MEDLINE searches from 1980 through 1995, and from reviewing 14 palliative care journals published from 1985 through 1996, 310 articles were identified that addressed medical education for end-of-life care, and 180 were carefully examined.

Data Synthesis.—
While nearly all medical schools offer some formal teaching about end-of-life care, there is considerable evidence that current training is inadequate, most strikingly in the clinical years. Teaching about palliative care is received favorably by students, positively influences student attitudes, and enhances communication skills. However, curricular offerings are not well integrated; the major teaching format is the lecture; formal teaching is predominantly preclinical; clinical experiences are mostly elective; there is little attention to home care, hospice, and nursing home care; role models are few; and students are not encouraged to examine their personal reactions to these clinical experiences.

Conclusions.—
The increasing attention to palliative care education has created major opportunities for improving education about care at the end of life. Educational programs should be rigorously evaluated to identify best educational practices.

Author Affiliations
From the Palliative Care Service, Massachusetts General Hospital and Harvard Medical School (Dr Billings) and the Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care and the Division of Psychiatry, Brigham & Women's Hospital (Dr Block), Boston, Mass.

Footnotes
Earlier versions of this article were presented at the 1995 Annual Meeting of the Association of Canadian Medical Colleges, Association of Canadian Teaching Hospitals, and Canadian Association for Medical Education, Quebec City, Quebec, May 2, 1995, sponsored in part by the Canadian Society of Palliative Care Physicians, and at the Project on Death in America Faculty Scholars' Retreat, Snoqualamie, Wash, July 9, 1995. A final, longer version was prepared, in part, for the National Consensus Conference on Medical Education for Care at the End of Life, May 16-17, 1997, sponsored by the Project on Death in America and the Robert Wood Johnson Foundation.

Reprints: J. Andrew Billings, MD, Palliative Care Service, Founders' House 600, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114-2698 (e-mail: jbillings@hms.harvard.edu).

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