By Mindy Kim.

My mouse hovered over the flag and the words “Code: DNR.” Despite being four weeks into my Internal Medicine rotation, I wasn’t quite sure what to do with the information that popped up. Faced with an older patient with metastatic cancer weakened by several rounds of chemotherapy, the “right” path forward was less obvious. Months later in palliative care clinic, I faced a similar uncertainty. When my preceptor asked me if I wanted to lead the next goals-of-care conversation, it felt like being asked to perform a procedure I didn’t know the steps to.

Undergraduate medical education prepares us to diagnose, treat, and manage patients, but it overlooks the difficult reality for many patients for whom there is no clear diagnosis to chase or treatment to attempt. Palliative care specialists navigate these complex situations, with aims to improve quality of life by relieving the symptoms and pressure of serious illness. Palliative care specialists have honed the skills of goals of care conversations, but every physician should possess some level of palliative care skills to initiate these conversations. Physicians in any specialty will benefit from possessing core palliative care skills, such as discussing emotionally difficult information, shared decision-making, and prognostication,

Despite this need, a survey of physicians found that only 29% reported receiving formal training in end-of-life conversations even though 99% agreed that these conversations are important. We would never accept such low rates of training for a medical procedure, so why do we accept it for conversations that are integral to patient care?

The Current State of Palliative Care Education

The Liaison Committee of Medical Education (LCME) only requires that US medical schools include “education and experiential learning in…end-of-life care” but provides little guidance beyond this. Focusing only on end-of-life care overlooks the nuances of managing the symptoms and stress associated with a chronic and/or serious illness to improve quality of life. A study published in Academic Medicine proposed the following essential palliative care competencies for medical students: patient-centered communication techniques, discussing code status, understanding ethical decision-making principles, and reflecting on personal responses to death as essential skills. These are essential skills for future physicians in any specialty, so medical school curricula are the ideal setting to incorporate training in these competencies.

Vague LCME guidelines contribute to wide variation in medical school curricula. A review of palliative care education in U.S. medical schools found that instruction in end-of-life care is most often offered in occasional lectures and short course and can total as little as 2 hours across 4 years.  Some medical schools have robust curricula:  one medical school incorporates a four-year ‘Patient Experience’ thread on end-of-life and palliative care, another dedicates a week to hospice and palliative medicine. Even without such a robust program, another school showed that a 32-hour palliative care curriculum significantly increases self-reported competency in care planning and end-of-life management. Inconsistency in palliative care training means that residents are entering training with widely different experiences with end-of-life care.

What Palliative Care Education Could Look Like

Most students encounter patients who need palliative care in both inpatient and outpatient settings, and most likely receive at least some informal exposure to code status and goals-of-care discussions on rotations. But relying on chance experiences leads to unequal training, especially when many physicians themselves feel uncomfortable with these conversations. We need a more intentional, structured approach that incorporates the following:

1. Mandatory palliative care education for all medical students.
2. Clear, specific palliative care competencies, such as:
   1. Describing ethical principles that inform decision-making
   1. Navigating goals-of-care and care planning discussions
   1. Symptom management for serious illnesses.
3. Integration across all four years, including preclinical and clinical phases.
4. Skill practice through various modalities, including standardized patient scenarios and simulations for goals-of-care and advance care planning conversations.
5. Practical instruction on code status, advance care planning, and how to navigate these within the EHR.

We owe it to our future patients to become physicians who walk with them, both in wishing for the best, but more importantly, compassionately preparing for the worst.

The opinions expressed are the author’s own.

Bio:

Mindy Kim is a third-year medical student at the Duke University School of Medicine.