“…tread with care…”

Palliative care education in US medical schools

CONTEXT Medical educators in the USA per- EoL to weeks of palliative care training or hos-
ceive the teaching of palliative care competen- pice-based clinical rotations.
cies as important, medical students experience
it as valuable and effective, and demographic IMPLICATIONS Palliative care competencies
and societal forces fuel its necessity. Although it are too complex and universally important to
is encouraged by the Association of American be relegated to a minimum of classroom time,
Medical Colleges, the only palliative care-related random clinical exposures, and the hidden
mandate in US medical schools is the Liaison curriculum.
Committee on Medical Education directive that
end-of-life (EoL) care be included in medical RECOMMENDATIONS Given the reality of
school curricula, reinforcing the problematic overstrained medical school curricula, devel-
conflation of EoL and palliative care. opmentally appropriate, basic palliative care
competencies should be defined and inte-
FINDINGS A review of US medical school sur- grated into each year of the medical school
veys about the teaching of palliative and EoL curriculum, taking care to circumvent the twin
care reveals varied and uneven approaches, threats of curricular overload and educational
ranging from 2 hours in the classroom on abandonment.

Medical Education 2014: 48: 59–65

Discuss ideas arising from the article at

Department of Medicine/Palliative Care, University of Rochester Correspondence: Dr Robert Horowitz, Department of Medicine/
Medical Center, Rochester, New York, USA Palliative Care, University of Rochester Medical Center, 601
Elmwood Avenue, Rochester, New York 14618, USA. Tel: +1 585
273 1154; E-mail: [email protected]

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R Horowitz et al

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Editor’s note: This article has relevance to the following and some will fully recover. Whatever their dis-
lines from Lasagna’s modernisation of the Hippocratic ease trajectory, palliative care tends to their
Oath1 needs throughout.
 Misconception #2: Palliative care is provided in lieu
‘I will respect the privacy of my patients, for their of disease-directed treatments. In fact, palliative care
problems are not disclosed to me that the world is ideally provided early in the course of illness
may know. Most especially must I tread with care and alongside disease-directed treatments, not
in matters of life and death. If it is given to me in place of them.3 Palliative care tools should
to save a life, all thanks. But it may also be within be part of the treatment plan for all seriously ill
my power to take a life; this awesome responsibil- patients, whether provided by their generalist or
ity must be faced with great humbleness and by a palliative care specialist.
awareness of my own frailty. Above all, I must not  Misconception #3: Palliative Care hastens death. In
play at God.’ addition to improving symptom management,
quality of life, patient satisfaction and caregiver
wellness, palliative care also is at times asso-
INTRODUCTION ciated with a survival advantage.4 Rarely, how-
ever, when suffering persists despite exhausting
As Medical Education celebrates the 50th anniver- all usual palliative measures, palliative care clini-
sary of the modern Hippocratic Oath1 the con- cians may have to explore difficult “last resort”
temporary hospice and palliative care movement options,5 not because we are “playing god”, but
in the USA also marks its first half-century. Both because of our obligation not to abandon
developments were galvanised by the pressures of patients whose needs are so great.6 Our guid-
modernisation, in the first case to make more ing mantras are helping people live as well as they
relevant an ancient professional pledge, and in can for as long as they can, and caring for the
the second to respond wisely to the potential patient and family throughout the course of illness, no
and limitations of medicine’s technological matter where it takes them.
advancements amidst an expanding and ageing
population. Inspired by this shared golden anni- Palliative care education must overcome the mis-
versary, we three palliative care doctor-educators conception that palliative care is restricted to end
welcome this invitation to reflect on the state of of life, and endorse it as integral to the care of
palliative care training in US medical schools, all seriously ill patients. Therefore, we conclude
and to publish reflections and suggestions that this article with a list of recommendations for pal-
we believe apply to medical school training every- liative care training that emphasizes this broader
where. mission rather than focusing primarily on death
and dying.
We must start by challenging the assignment of the
above line from the Hippocratic Oath to the prac- We believe that a more relevant line from the
tice of palliative care. The perception that this line Hippocratic Oath about palliative care, and one
is relevant to our specialty comports with three com- which merits our enthusiastic reflection about the
mon misconceptions about palliative care: state of palliative care education in US medical
schools, heads another article in this journal:
 Misconception #1: Palliative care is care of the
dying, or the same as hospice care. In fact, pallia- I will apply, for the benefit of the sick, all measures
tive care anticipates, prevents and treats suffer- [that] are required, avoiding the twin traps of over-
ing throughout the continuum of illness for all treatment and therapeutic nihilism.
seriously ill patients, including but not limited
to those who are at the very end of life.2 For Overtreatment can be defined as the provision of
those patients who do reach a point when dis- disease-directed medical interventions when theex-
ease-directed therapies are no longer useful to pectation of benefit is low, the burden is high, and
them based on their personal values and this equation conflicts with the patient’s character,
unique clinical circumstances, we help them values and preferences. Therapeutic nihilism is
and their families transition to a more purely reflected in the claim: ‘There is nothing more we
palliative approach, usually on hospice care. can do.’ The practice of palliative care is dominated
However, many of the patients we care for will by the negotiation of the tension between these two
live a long, fulfilling life with chronic illness, forces. For example, in our palliative care hospital

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practice at the University of Rochester Medical Cen- in ‘communication skills’ and ‘human values’10 and,
ter, referring doctors select ‘clarification of goals of although these are certainly relevant to the palliative
care’ as a reason for consultation in over two-thirds care skill set, they cannot be construed as unique
of our more than 1100 annual consultations – far palliative care competencies. The Association of
more than any other request. American Medical Colleges (AAMC) is more specific
and broader, recommending that medical schools
To facilitate best practice in these (and other) situ- teach prognostic reasoning, shared decision making,
tions, the Board of Hospice and Palliative Medicine the management of informed consent, inquiry
Competencies Work Group7 and others8 have enu- about meaning and spirituality, the communication
merated ‘palliative care competencies’, which can of bad news, and communication about advance
be distilled into: directives, EoL wishes, do not resuscitate (DNR)
orders, and palliative care.12
 patient and family communication (which
includes goals of care discussions, the discussion Hence, the only nominally specific palliative care
of emotionally difficult information, shared training required of US medical schools is instruc-
decision making and prognostication); tion in EoL care. Palliative care specialists fight
 pain and symptom management in those who the conflation between palliative and EoL care
are seriously ill or dying; because of two main reasons: (i) the temporal
 quality of life focus; threshold for defining when EoL begins varies
 coordination of care, and widely among people experiencing serious illness,
 interdisciplinary team involvement. and (ii) many seriously ill patients seen by pallia-
tive care specialists are unlikely to die in the near
These competencies are certainly not exclusive to future. Palliative care is clearly relevant to all seri-
palliative care specialists. This skill set has been the ously ill patients, including those who are receiving
province of all medical clinicians since long before disease-directed treatments, no matter what their
palliative care was named (1975) or granted spe- prognosis. Restricting palliative care interventions
cialty status by the American Board of Medical Spe- to dying patients would mean improving the care
cialties (2006). Basic palliative care competencies of only a fraction of the patients who might bene-
apply to all medical specialties and therefore to fit. Consequently, a medical school satisfying a pal-
every clinician who cares for seriously ill patients liative care requirement by addressing only EoL
and to every medical student, resident and fellow as care may well do a wonderful job in improving
a fundamental part of training. Palliative care spe- EoL clinical skills and awareness, but may also
cialists, whose work is dominated by this skill set, unwittingly perpetuate myths and restrictions that
should both help to apply such competencies to the the much broader field of palliative care is work-
most seriously ill and challenging patients, and serve ing diligently to overcome.
as educational champions of these universal ‘basic
palliative care competencies’.9
PALLIATIVE CARE INSTRUCTION WITHIN THE USA

OFFICIAL US PALLIATIVE CARE TRAINING How are US medical schools honouring the LCME’s
REQUIREMENTS EoL mandate and the AAMC’s recommendations
for the teaching of palliative care competencies?
The Liaison Committee on Medical Education Unlike the routinely scrutinised Year 3 clinical rota-
(LCME) does not require US medical schools to tions and other required competencies, the teach-
teach palliative care competencies; the word ‘pallia- ing of palliative care competencies is not easily
tive’ is not even mentioned in its Standards.10 The tracked. Such an investigation depends on two
only explicit palliative care-related standard is the modes: descriptions of individual medical school
directive since 2000 that accredited medical school approaches, and surveys of multiple sites.
curricula include ‘important aspects of …end-of-life
care’.10 Notably, although they describe LCME man- Single institutional descriptions depict how a few
dates as having ‘little actual impact’ on curriculum motivated US medical schools have confronted the
development, 43 of 51 surveyed medical school challenge of palliative care education. These are
deans support the spirit of such an end-of-life (EoL) limited in number, and markedly disparate in their
mandate, describing instruction in EoL care as ‘very approach. The University of Rochester creatively
important’.11 The LCME also mandates instruction integrates palliative care teaching into the general

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4-year curriculum, starting with gross anatomy in care were offered by less than a quarter of pro-
Year 1, extending into each subsequent year’s prob- grammes.
lem-based learning and integration conferences,
and culminating in a 2–4-week ethics and palliative Of the 47 medical school respondents to Van Aalst-
care elective during Year 4, which includes daily Cohen et al.18’s 2008 survey on palliative care offer-
rounding, weekly case conferences, core readings ings, 30% had a required course, 19% had a
and team meetings.13 Weill Medical College requires required rotation, 29% integrated palliative care
a 2-week palliative care clerkship, which emphasises within another required rotation, 15% offered an
reflective practice as a means to combat the destruc- elective and 7% had no course or rotation. Half of
tive influences of the informal and hidden curricula, the respondents believed medical students should
and focuses on caring for dying patients and their be evaluated in the care of patients with advanced
families, combining participant observation, medical incurable conditions during their clerkships, but
humanities seminars, pain and palliative care only 30% of respondents did so at the time of the
rounds, educational seminars and a hospice visit.14 survey.18 This study, like those in EoL education,
Other single-institution15 and multiple-institution16 portrays a markedly varied approach to teaching pal-
reports of medical school palliative care education liative care competencies in medical school, with
emphasise hospice rotations and other specifically most being incorporated into other courses, which
EoL-based training. These variably detailed descrip- suggests a primarily didactic approach to a field that
tive reports reveal creative responses to the chal- would ideally include observed interaction with sim-
lenge of teaching palliative care to medical students. ulated and real patients.
However, because they are so few and so varied, they
do not inform the larger question of how medical Does EoL and palliative care education matter to
education in the USA as a whole fares in this realm. US medical students? Year 4 medical students feel
dramatically better prepared to care for dying
Several surveys begin more definitively to answer patients after formal training and exposure to dying
this question. Since 1975, Dickinson17 has surveyed patients.19,20 Those who either witness a patient’s
US medical schools about EoL offerings every death or care for a terminally ill patient for an
5 years, eight times in total, achieving response rates extended period feel better prepared both to treat
of 79–96%. His data reveal consistently high and dying patients’ symptoms and to engage in difficult
increasing availability of EoL training, offered by conversations with them.21 Those medical students
80% of respondents in 1975 and by 100% since with formal training in palliative and hospice care
2000, with a corresponding increase in medical stu- experience substantial improvements in competence
dent participation, from 71% in 1975 to 100% in and knowledge, as well as decrements in their con-
2010.17 The majority of these offerings consist of cern about caring for seriously ill and dying
occasional lectures and short courses, but a small patients.15
minority of respondents offer separate courses in
death and dying (increasing from 7% in 1975 to
21% in 2010). Instruction in EoL care in US medi- PALLIATIVE CARE INSTRUCTION OUTSIDE THE USA
cal schools is characterised by dramatic variability.
The number of hours of offerings ranges from 2 to Canada, the UK and Australia have longer histories
80 throughout the 4 years of training, with an aver- of education in palliative and EoL care than do the
age of 17 hours in 2010. In another survey, just over USA and most of Western Europe, and the exis-
half of the 51 responding medical schools reported tence of similar programmes in other parts of the
the occasional incorporation of EoL care into world is very idiosyncratic. It is beyond the scope of
coursework, and less than one-third reported a this paper to present a systematic review of these,
course or clerkship focused on EoL, just half of but there are several outstanding programmes and
which were required.11 curricula of which educators should be aware. In
particular, Canada has provided a defined palliative
Dickinson17 also surveyed US medical schools’ non- care medical student curriculum since 1993,22
EoL offerings in palliative care (not further defined), although subsequent surveys show considerable vari-
and found in 2010 that all but one responding med- ation in its implementation.23,24 Similarly, the UK
ical school provided what it deemed to be palliative has a long history of hospice education through the
care training, up from 87% in 2000. For about half St Christopher’s Group and other agencies, and has
of the respondents, palliative care comprised part of had a defined palliative care curriculum since
a larger course, and separate courses in palliative 1992,25 but most of the evaluative studies have been

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sporadic and conducted at single sites. Australia has experience, including role-play and observed inter-
a strong history of palliative care research and a actions with real and simulated patients, impart
well-developed undergraduate curriculum,26 but both meaningful change and learner satisfac-
there are no published reports of studies evaluating tion.27–30 Without such explicit and practical clinical
the curriculum on a countrywide basis. Most other training in core palliative care competencies, medi-
reports of palliative care education outside the USA cal students will rely upon the ‘informal curriculum’
revolve around isolated courses or rotations, which to learn these essential skills. Rabow et al.31 investi-
may well represent a good beginning, but are gated this informal curriculum in medical student
nowhere near what is needed for systematic imple- EoL education by surveying 141 Year 3 medical
mentation. students and discovered that, although 96% had at
least cursory interactions with patients at the EoL,
just 64% had observed an attending doctor in the
THE MISMATCH BETWEEN PROVISION OF act of breaking bad news and only 37% had seen
PALLIATIVE CARE TRAINING AND ITS PERCEIVED an attending doctor conduct an advance directive
IMPORTANCE discussion. The same survey also found that discus-
sions about the challenges of addressing EoL issues
In summary, there is a consensus in the USA and with attending doctors and housestaff were infre-
most of the developed world that teaching palliative quent, and a third of students reported that they
care competencies to medical students is vital: medi- had never received any feedback from supervisors
cal educators perceive this as important; governing about EoL clinical activities.31
bodies identify it as essential, even if it is not man-
datory; medical students experience it as valuable In the absence of sufficient formal classroom and
and effective, and demographic and societal forces, clinical instruction, medical students’ learning about
such as the ageing of the population, the increasing palliative care competencies may largely depend
prevalence of chronic illness, and technological upon two other modes of learning: (i) informal
approaches to EoL care, conspire to fuel its neces- palliative care education, which is often passive,
sity. happens ‘on the fly’ and is guided (if at all) by
residents or attending doctors who are often unin-
How well do US medical schools satisfy this need? terested or unskilled in these competencies, and (ii)
Most students are exposed at least superficially to the ‘hidden’ curriculum, in which lie the messages,
some palliative care content, but it is of extremely implied and explicit, inherent in the medical
variable depth, ranging from 2 hours of EoL con- school’s cultural and organisational structure.32 The
tent delivered in the classroom to weeks of direct hidden curriculum may be taught by default, such
patient care during palliative care or hospice rota- as when the very absence of explicit palliative care
tions. Why is there such a mismatch between the content from a school’s curriculum denotes that
provision of palliative care instruction and its per- palliative care competencies are not as important as
ceived importance? Simply, medical school curricula those of other domains. The hidden curriculum
are overstrained by an exponentially expanding may also be taught by example, such as when a
knowledge and skill base within all medical fields. medical student is not assigned a dying patient,
With regard to EoL care specifically, medical school because there is ‘nothing to learn’ from them,33
deans cite insufficient time, faculty expertise and ‘caring for dying patients is depressing’ or because
funding, combined with the overwhelming demands ‘death is a medical failure’.20 The hidden curricu-
of too many interests as the reasons they simulta- lum may actually undermine explicit classroom EoL
neously lament the curricular under-representation and palliative care pedagogy, and, as Fins et al. note,
of EoL care and oppose its becoming a curricular ‘give students the impression that compassion and
requirement.11 humanistic practice are of more theoretical than
practical import’.14
However, if palliative care competencies are of uni-
versal importance, they cannot be relegated to a
minimum of classroom time and random clinical RECOMMENDATIONS
exposures. The data are perhaps clearest in
research about medical communication: in learning US medical schools are complicated organisations,
complicated systems and processes, spotty didactic and they have responded idiosyncratically to the
classroom exposure alone offers little benefit, demand to teach palliative care competencies, with
whereas more extensive coursework and practical marked variability in their offerings. At a certain

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level, more appears to be better; a consistent, expli- care skills might be taught by a broad range of
cit, detailed, involving curriculum is probably better clinicians who might include, but not be limited
at teaching these universally needed skills than an to, palliative care subspecialists.9
occasional, hidden, passive one. Several guidelines  An integrated curriculum should be defined
exist on performing an institution-specific needs using overarching national standards, and then
assessment for medical education in general,34 and locally interpreted and implemented (in some
for education in palliative care, specifically,35 as well schools this might include a separate required
as methods for developing curricula in palliative course, but in most it would comprise required
care competencies.36 However, any additions to the parts of other courses and rotations).
already overburdened curriculum should avert the  In terms of ‘last resort’ options5 when standard
opposing temptations to: (i) demand a detailed, palliative care treatments are insufficient to
multifaceted new course (which will probably not relieve patient suffering, we recommend the
be approved or implemented), or (ii) fully surren- following:(i) challenging-case conferences at all
der these essential teachings to the uncertainties of levels of clinical training, with an emphasis on
the informal and hidden curricula. Furthermore, addressing persistent suffering despite all stan-
the number of trained palliative care clinicians dard measures, and the imperative of seeking
available to provide palliative care consultation is help from those with palliative care and ethics
so inadequate37 that this strained pool of specialists expertise, (ii) a general conference devoted to
simply does not have the time and resources they the subject in years 3 or 4, covering the poten-
need to develop and teach expanded palliative care tial and limitations of palliative measures, and
curricula throughout all the years of every medical the range of palliative options of last resort,
school. including their relative level of societal consensus.
 Palliative care training should not be limited to
The imperative to deliver basic, developmentally electives; opportunities for more focused pallia-
appropriate palliative care training to all medical tive care and hospice electives should be avail-
students who will be involved in the care of seriously able for interested students, but basic primary
ill patients must be balanced with the need to meet palliative care competency requirements should
the many other competing demands on medical be identified and systematically implemented
school curricula, the limited number of pedagogi- for all trainees.
cally trained palliative care faculty staff, and the
developmental nature of palliative care learning.
CONCLUSIONS
In this light, we offer the following suggestions.
With respect to this issue’s honouree, the modern
 In most instances, palliative care training should Hippocratic Oath, it is certainly necessary to face
be fully and systematically integrated into exist- the “awesome responsibility” of enhancing and
ing courses, including but not limited to medi- expanding medical school curricula “with great
cal interviewing, patient–doctor relationships, humbleness.” Palliative care proficiencies are a
ethics, pharmacology, and clinical teaching necessity for all doctors who care for seriously ill
rounds in internal medicine, paediatrics, sur- patients, yet mandating them threatens to further
gery, psychiatry and family medicine. strain the already overloaded US medical school
 Palliative care training should focus on the pro- curriculum. This 50th anniversary reflection of the
vision of developmentally appropriate knowl- state of palliative care education in US medical
edge and skills that will be needed and used by schools reveals the resultant mismatch between the
students in their delivery of care, such as: (i) perceived need for instruction in palliative care
medical interviewing around suffering and goals competencies and its current level of implementa-
of treatment in Years 1 and 2; (ii) basic pain tion. This tension might best be reconciled by estab-
and symptom management, and resuscitation lishing a new construct in which the teaching of
preferences in Years 3 and 4, and (iii) basic self- developmentally appropriate, basic palliative care
awareness around suffering, loss and counter- competencies is uniquely incorporated into each
transference in Years 1–4. medical school’s overarching curriculum. To impose
 Developmentally appropriate competencies to anything more might be unachievable or unsustain-
be achieved at each stage of training should be able; to do less shirks the imperative of firmly teach-
defined by national leaders in palliative care. ing these ever more necessary competencies to the
For medical students, basic primary palliative developing doctors of tomorrow. To paraphrase

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our preferred line from the Oath: ‘Palliative care 11 Sullivan A, Warren A, Lakoma M, Liaw K, Hwang D,
competencies should be integrated into medical Block S. End-of-life care in the curriculum: a national
school curricula, being ever mindful of the twin study of medical education deans. Acad Med 2004;79
traps of curricular overload and educational (8):760–8.
12 Association of American Medical Collages Task Force
abandonment.’
on the Clinical Skills Education of Medical Students.
Recommendations for Clinical Skills Curricula for
Undergraduate Medical Education, 2005. https://
Contributors: each author contributed to the conception of members.aamc.org/eweb/upload/Recommendations
the article, its drafting, re-evaluation and revision, and %20for%20Clinical%20Skills%20Curricula%202005.
approved the final version for publication. pdf. [Accessed 19 January 2013].
Acknowledgements: none. 13 Quill TE, Dannefer E, Markakis K, Epstein R,
Funding: none. Greenlaw J, McGrail K, Milella M. An integrated
Conflicts of interest: none. biopsychosocial approach to palliative care training
Ethical approval: not applicable. of medical students. J Palliat Care 2003;6 (3):
365–80.
14 Fins JJ, Gentilesco BJ, Carver A, Lister P, Acres CA,
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