Original Article
Are Geriatric Medicine Fellows Prepared for the Important Skills of Hospice and Palliative Care?
American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(3) 322-328 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909113517050 ajhpm.sagepub.com
Qing Cao1, Tae J. Lee1, Stella M. Hayes2, Ann M. Nye1,3, Irene Hamrick4, Shivajirao Patil1, and Kenneth K. Steinweg1
Abstract Many geriatricians care for terminally ill and dying patients, but it is unclear whether the current geriatric medicine fellows receive sufficient training in hospice and palliative care (H&PC). A national cross-sectional survey was conducted between March and June 2011 to determine fellows’ experience and perceived competency with H&PC. Fellows (143 of 298, 48%) and program directors (PDs; 69 of 150, 46%) answered the surveys on paper or online. Three-fourths of the fellows planned to practice H&PC; however, only 35% fellows versus 42% PDs believed that fellows were well prepared in this area. Factors associated with fellows’ selfreported better preparation included completion of an H&PC rotation, experiences with an inpatient hospice facility, inpatient palliative care consulting service, and the presence of a formal H&PC curriculum. Keywords geriatrics, curriculum, hospice, palliative care, national survey, training
Introduction There are many pressing reasons for geriatricians to be well trained in end-of-life care. Since 80% of dying patients are in the geriatric age range, geriatricians must be prepared to care for significantly increasing numbers of patients in the last stages of life.1 In addition, a survey by the Association of Directors of Geriatric Academic Programs in 2008 indicated that 30% of geriatric-trained fellows would go on to work in hospice.2 Program directors (PDs) gave high ratings to the importance of end-of-life care education during their geriatric training. The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in geriatric medicine requires fellows to provide care to elderly patients with hospice and palliative care (H&PC) needs and requires the programs to provide experience with hospice care.3 However geriatric medicine fellow training in H&PC is not more specifically defined or standardized. Also, little is known about fellows’ training in this area of medicine or their perceived competency to practice end-of-life care. National surveys regarding the need of H&PC training for fellows were previously performed. In 2004, MedinaWalpole, Barker, and Katz assessed geriatric medicine fellowship training in the 1990s that revealed fewer than half of the survey respondents received formal training in H&PC. Many fellows identified the need for further H&PC training.4 In 2005, Pan et al conducted a national survey to assess the status of fellows’ experiences in end-of-life care.5 Geriatric medicine
fellows felt their end-of-life care education was excellent, and almost 60% felt that they were well prepared to take care of dying patients. Determinants of feeling better prepared included having completed a palliative care rotation, being taught how to say good-bye, and the perception that palliative care was important to attending physicians. It has been over 10 years since the previous studies on fellows’ H&PC training. The purpose of this study was to measure fellows’ self-reported attitudes, the perceived quantity and quality of their end-of-life care education, and their selfreported overall readiness to provide H&PC. The study was also designed to gauge the importance of H&PC training among PDs. This national survey of geriatric medicine fellows is similar in scope to prior studies with comparable questions. We added an assessment of PDs to get a better understanding of the importance of H&PC in geriatric medicine fellowship training.
1
East Carolina University Greenville, NC, USA Naval Hospital Jacksonville, Jacksonville, FL, USA 3 Campbell University Buies Creek, NC, USA 4 University of Wisconsin–Madison, WI, USA 2
Corresponding Author: Qing Cao, East Carolina University, 101 Heart Drive, Greenville, NC 27834, USA. Email: [email protected]
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Methods The survey was generated using the survey tool Qualtrics (Qualtrics Labs, Inc, Provo, UT, 2002). It sought to measure fellows’ self-reported attitudes about providing end-of-life care, the quantity and quality of their end-of-life care education, and their overall readiness to provide end-of-life care to the elderly patients. The survey was modified from an instrument developed to evaluate the end-of-life education experience and attitudes of national sample of medical students, residents, and faculty, which has been validated.5,6 This survey was based on focus group analysis, literature review, and recommendations from the 1997 National Consensus Conference for Medical Education in End-of-Life Care.7 The survey for fellows was 9 pages long and contained 27 questions. The survey for PDs was 2 pages in length and contained 4 questions. The questions for fellows were grouped into a few areas: end-of-life care training, attitudes toward caring for dying patients, and preparedness to provide end-of-life care. The survey defined hospice care as medical care to patients who have a terminal illness with a life expectancy of less than 6 months. End-of-life training availabilities at the responding fellows’ home institutions were measured with 7 questions. The questions assessed the respondents’ program type (family medicine or internal medicine), the availability of H&PC rotations, the length of the rotations, the presence of an inpatient hospice facility, the accessibility of inpatient palliative consult team in their home hospital, the availability of dedicated palliative care teaching faculty, and the presence of an official curriculum for H&PC. The attitudes toward caring for dying patients were measured with the following questions: the fellows’ and PDs’ perceptions of the importance of learning the skills of providing care to dying patients, fellows’ perception of who has the main responsibility to prepare patients for death, fellows’ future plans to use their H&PC training, and a few questions assessed fellows’ attitudes toward end-of-life care based on their personal experiences. Fellows’ interest in palliative care was measured with a series of 7-point Likert-scale-type questions. Respondents were asked to rate various hypothetical elements of end-of-life care education as most interesting, somewhat interesting, slightly not interesting, or least interesting. Also, fellows were requested to select from a list factors that compelled or discouraged them to discuss H&PC with patients and families: patient or family member request, palliative care consultation’s recommendations, medical indications such as having a terminal diagnosis, substantial functional deterioration, long intensive care unit stays, or frequent emergency visits. The preparedness to provide end-of-life care was measured by the fellows’ and PDs’ perceptions of fellows’ confidence: ‘‘Do you feel that you (your fellows for PDs) are prepared for taking care of dying patients?’’ The answer choices were wellprepared, moderately prepared, somewhat prepared, and not prepared. Also, fellows’ confidence in specific skills related to end-of-life care was assessed with a series of 10 Likerttype questions. The questions asked respondents to rate their comfort level with various tasks as very comfortable, moderately comfortable, somewhat comfortable, or not comfortable.
At the time of the survey, there were 45 family medicine– based and 105 internal medicine–based geriatric medicine fellowship programs, with a total of 298 fellows. The survey was performed between March and June 2011 when the majority of fellows had completed most of their clinical training. Since there was no centralized database of geriatric medicine fellows in training in the Association of American Medical Colleges (AAMC)’s Electronic Residency Application Service (ERAS) system opposite to most other residency or fellowship training programs, the study team gathered data for this study from fellows and PDs of US-accredited geriatric medicine fellowship training programs by 4 different strategies: (1) A national electronic survey was conducted via e-mail in May 2011.The intention was to reach all fellows and PDs of records through PDs. The e-mail address for geriatric medicine fellowship programs in all states was listed by ACGME.8 (2) E-mails were sent out through the Geriatric Academic Career Award (GACA) recipient list in late March 2011, with the intention to reach some PDs and their fellows in this manner and reinforce the request for survey response. (3) The survey was administered on paper face to face with volunteers at the American Medical Director Association (AMDA) Annual Symposium in Tampa, Florida, in March 2011. (4) The survey was administered on paper face to face with volunteers at the American Geriatric Society (AGS) meeting in Washington, District of Columbia, in May 2011. The survey data were entered into Qualtrics and analyzed using STATA/IC 12.1 (StataCorp. 2011. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP) and SPSS (version 19.0). Descriptive statistics were used to summarize the data. The chi-square test compared categorical variables (the accessibility of inpatient hospice facility, inpatient palliative care consult team, H&PC rotation, the length of the rotation, fellows’ personal experiences of caring of dying loved ones, the availability of dedicated faculty, and official curriculum) with fellows’ overall preparedness to take care of dying patients or comfort levels in managing symptoms of dying patients. Similar analysis was conducted to study the relation between fellows’ preparedness to take care of dying patients and their decision on practicing H&PC after the fellowship. The Institutional Review Board of East Carolina University approved this study.
Results A total of 143 (48%) of 298 fellows and 69 (46%) PDs of 150 answered the survey either on paper or via the Qualtrics survey tool. In all, 48 fellows and 1 PD answered the paper survey at the AMDA Annual Symposium in March 2011; 56 fellows and 46 PDs responded to the paper survey at the AGS Annual Conference in May 2011. In addition, 13 fellows and 8 PDs answered the survey via GACA recipient list in late March 2011, and 26 fellows and 14 PDs took the electronic survey via the national e-mails in late May 2011. The distribution of fellows’ responses among internal and family medicine specialties closely mirrored the national data
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American Journal of Hospice & Palliative Medicine® 32(3)
324 on geriatric fellowship program sponsorship, with 70% of the fellows being internal medicine and 30% being family medicine. Among those programs, 87% were university-affiliated programs, 10% were community programs, and about 3% were Veteran Affair fellowship programs. Of the respondents, 71% were females. Among all the respondents, about 37% had decided to enter academic settings, 18% private practice mixed with some academic duties, 12% private practice only, 13% long-term care or home care, 7% government, and 13% others.
End-of-Life Care Training Most participants (88% fellows and 90% PDs) stated that H&PC was a required rotation; and for 8% of fellows, H&PC was an elective rotation. About 2% of the surveyed fellows reported that this rotation was not offered in their programs. The length of rotations was 4 weeks for 86% of the programs and ranged from 2 days to 4 months. Slightly over half (54%) of the H&PC rotations were 4 to 6 weeks and the next most common duration was 7 to 8 weeks (18%). Seven programs included H&PC as a longitudinal rotation. The majority of fellows reported that they had dedicated faculty teaching the subject matter (89%) and an official curriculum (74%) for H&PC. The vast majority of PDs reported that they had curriculum in the areas of hospice referral indications (94%), end-of-life communication (94%), pain management (94%), nonpain symptom management (93%), medication management (88%), psychiatric symptom management (79%), and systems of care in hospice (91%). Training facilities were quite variable among the programs. Of the fellows, 65% reported that they had inpatient hospice facilities in the hospital or as a stand-alone inpatient unit; 82% fellows reported that they participated in inpatient palliative care consult services. Most fellows had recent experiences with end-of-life discussions. Of the 102 respondents, 75 (75%) had a discussion about hospice with a patient and/or a family member within the last month of the survey, and 42 (41%) of them had this discussion within a week prior to the survey. Virtually all (99%) of the fellow respondents thought that their patients benefited from H&PC during the previous 6 months of the survey, and 96% of them had referred patients to H&PC. Overall, a vast majority (>95%) of fellows showed significant interest in the main H&PC curriculum topics of pain management, hospice referral indications, communication skills, nonpain symptom control, and psychological issues related to end-of-life care. Additional topics that fellows thought needed more emphasis included breaking bad news, interdisciplinary team approach, roles of chaplain and social workers, prognostication of life expectancy, hospice certification/recertification requirements, insurance issues, indications for general inpatient status, and managing family dynamics. Program directors ranked H&PC 6th out of 8 geriatric care domains. Figure 1 displays the priorities of PDs regarding the geriatric core competencies.9 The largest barriers to providing more H&PC training, according to the PDs, were lack of curricular time (50%) and faculty time (35%).
Figure 1. Program directors’ rating of the importance of core competencies of geriatric medicine fellowship education.
Attitudes Toward Caring for Dying Patients Despite the low ranking that PDs gave end-of-life care in comparison with other core competencies, there was concurrence between fellows and their PDs regarding the importance of learning the skill of providing care to dying patients; the overwhelming majority (>95%) stated that it was very important or moderately important. When the question of ‘‘Who do you think has the main responsibility to prepare patients with terminal illness for death?’’ was posed, 81% of the fellows responded that the primary care provider such as a geriatrician had this main responsibility. Other choices included other subspecialty physicians related to the terminal diagnoses, spiritual guides, or families. Fellows’ future plans to use their H&PC training are revealing and demonstrate the subject’s importance. Three-fourths of the fellows planned to practice H&PC as part of routine geriatric care (72%). About 6% fellows reported that they were not going to practice H&PC and 4% reported that they would focus exclusively on H&PC. A few questions were asked to assess fellows’ attitudes based on their personal experiences. Most fellows (112 of 137, 82%) stated that they would definitely refer a loved one with a terminal illness near the end of their life to H&PC. Over half (87 of 137, 64%) of the fellows reported some death experiences of a family member or of someone very close to them. Among these fellows, 43% (35 of 87) stated that their loved ones had been under hospice care. Although the majority of the fellows’ dying loved ones were referred by the patient’s medical provider, surprisingly 38% (14 of 35) were referred by the fellow. Fellows were requested to select from a list factors that compelled them to discuss H&PC with patients and families. The most common compelling factor chosen by the respondents was patient or family member’s request, whereas medical indications such as having a terminal diagnosis, substantial
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325 comfort managing pain and depression. Other specific aspects of H&PC skills, such as referring to hospice, using team support, breaking bad news, reconciling and saying good-bye, telling patients that they are dying, or ordering palliative sedation, were not significantly affected by those training strategies, per our study.
Using team support Referring to hospice Breaking bad news Telling paents that they are dying
Discussion
Managing pain Managing depression Reconciling and saying good-bye Managing terminal delirium Ordering palliave sedaon 0%
50%
100%
Very comfortable
Moderately comfortable
Somewhat comfortable
Not comfortable
Figure 2. Fellows’ comfort level in providing specific aspects of endof-life care.
functional deterioration, long intensive care unit stays, or frequent emergency visits were considered less compelling.
Preparedness to Provide End-of-Life Care Three-fourths of the fellows planned to practice H&PC after graduation (either exclusively or as part of routine geriatric patient care), and those fellows were 3 times more likely to report that they were either moderately or well prepared for end-of-life care (odds ratio [OR] ¼ 3.31, 95% confidence interval [CI] ¼ 1.35-8.06, P ¼ .04); however, only 35% of the fellows felt they were well prepared and 45% felt moderately prepared. Program directors were more confident in their fellows’ preparation than were the fellows themselves (42% PDs vs 35% fellows believed that fellows were well prepared in this area). The study revealed that a completion of H&PC rotation was a significant contributive factor for fellows to feel moderately or well prepared in caring for patients at the end of life (OR ¼ 6.8, 95% CI ¼ 1.08-43.02, P ¼ .04). Fellows’ level of comfort regarding specific aspects of H&PC varied widely and is displayed in Figure 2. In general, the majority of fellows reported some level of comfort with all aspects of H&PC services. However, 20% of fellows surveyed were not comfortable ordering palliative sedation. Table 1 compares the significance of training strategies (inpatient hospice, inpatient palliative consult team, formal H &PC curriculum) on fellow-reported comfort levels with specific aspects of H&PC: management of pain, depression, or terminal delirium. An inpatient hospice facility had a significant effect on fellows’ comfort level managing delirium. Similarly, experience with an inpatient palliative consult team improved fellows’ comfort level managing delirium and depression and having an official H&PC curriculum improved fellows’
This survey reveals consistent weaknesses in fellow preparation for the core geriatric competencies embedded in H&PC. Only one-third of fellows felt well prepared to take care of dying patients and 20% felt only somewhat or not at all prepared for this critical role. Consistent with this, end-of-life care ranked low in PDs’ priorities due to pressures for curricular time and lack of adequate faculty time to teach this topic. Geriatric medicine fellows surveyed believed that it was their responsibilities as primary care providers to prepare patients for their deaths. Most fellows planned to practice H&PC either exclusively or as a part of their routine geriatric care. The inconsistency between training preparation and posttraining employment was very concerning. Fellows needed the confidence in identifying, initiating discussions, and caring for patients and families during this phase of life if they were going to have a meaningful role in appropriate health care for older patients. In the recent publication ‘‘Generalist plus Specialist Palliative Care—Creating a More Sustainable Model,’’10 primary care providers were expected to master the skills of pain, depression and anxiety management, and goals of care discussions. These expectations overlapped with many of the weaknesses identified by our study in fellow training. Our study demonstrated that most fellows felt more comfortable having discussions about H&PC if patients or family members brought up the topic rather than initiating the conversation based on patients’ prognosis or comorbidities. Geriatric medicine fellowship programs need to increase the confidence level of fellows in identifying and initiating H&PC discussions. Weaknesses in fellowship training revealed in our study could be categorized as skills or facility experiences. Hospice and palliative care skills needing improvement included the need for better training in breaking bad news, using interdisciplinary teams, the roles of the chaplain and social workers, prognostication of life expectancy, managing family dynamics, understanding hospice certification/recertification requirements and insurance issues, and indications for general inpatient status. There are growing resources available in other specialties to assist in these areas of H&PC where training appears to be weak. The online program OncoTalk11 utilizes key educational principles to assist with training in key concerns noted by geriatric fellows: giving bad news, managing transitions to palliative care when chemotherapy is failing, conducting a family conference, handling requests for therapies that you feel are futile, and cultivating your communication skills. This program has spawned spin-offs for slightly different audiences: IntensiveTalk and GeriTalk.
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Table 1. Fellow Training Strategy Associated With Fellows’ Comfort Level in H&PC.a Fellows’ comfort level in managing terminal delirium Training strategy
All (N ¼ 143)
Very/moderately comfortable (n ¼ 99)
Somewhat/not comfortable (n ¼ 38)
Inpatient hospice facility No 47 (34.31) 28 (28.28) 19 (50.00) Yes 90 (65.69) 71 (71.72) 19 (50.00) Palliative consult team No 25 (18.25) 14 (14.14) 11 (28.95) Yes 112 (81.75) 85 (85.86) 27 (71.05) H&PC curriculum No 35 (26.32) 25 (26.32) 10 (26.32) Yes 98 (73.68) 70 (73.68) 28 (73.68) Fellows’ comfort level in managing depression Training strategy All (N ¼ 139) Very/moderately comfortable Somewhat/not comfortable (n ¼ 108) (n ¼ 31) Inpatient hospice facility No 48 (34.53) 35 (32.41) 13 (41.94) Yes 91 (65.47) 73 (67.59) 18 (58.06) Palliative consult team No 26 (18.71) 16 (14.81) 10 (32.26) Yes 113 (81.29) 92 (85.19) 21 (67.74) H&PC curriculum No 36 (26.67) 22 (20.95) 14 (46.67) Yes 99 (73.33) 83 (79.05) 16 (53.33) Fellows’ comfort level in managing pain Training strategy All (N ¼ 142) Very comfortable (n ¼ 112) Moderately/somewhat /not Comfortable (n ¼ 20) Inpatient hospice facility No 45 (33.09) 35 (30.43) 10 (47.62) Yes 91 (66.91) 80 (69.57) 11 (52.38) Palliative consult team No 26 (19.12) 22 (19.13) 4 (19.05) Yes 110 (80.88) 93 (80.87) 17 (80.95) H&PC curriculum No 35 (26.52) 23 (20.54) 12 (60.00) Yes 97 (73.48) 89 (79.46) 8 (40.00)
OR (95% CI), P value 1.0b 2.54 (1.17-5.49), .018 1.0b 2.58 (1.01-6.09), .050 1.0b 1.00 (0.43-2.35), .999 OR (95% CI), P value 1.0b 1.51 (0.66-3.42), .330 1.0b 2.74 (1.09-6.88), .04 1.0b 3.30 (1.40-7.78), .007 OR (95% CI), P value 1.0b 2.08 (0.81-5.24), .132 1.0b 0.99 (0.30-3.25), .993 1.0b 5.80 (2.12-15.86),
Are Geriatric Medicine Fellows Prepared for the Important Skills of Hospice and Palliative Care?
American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(3) 322-328 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909113517050 ajhpm.sagepub.com
Qing Cao1, Tae J. Lee1, Stella M. Hayes2, Ann M. Nye1,3, Irene Hamrick4, Shivajirao Patil1, and Kenneth K. Steinweg1
Abstract Many geriatricians care for terminally ill and dying patients, but it is unclear whether the current geriatric medicine fellows receive sufficient training in hospice and palliative care (H&PC). A national cross-sectional survey was conducted between March and June 2011 to determine fellows’ experience and perceived competency with H&PC. Fellows (143 of 298, 48%) and program directors (PDs; 69 of 150, 46%) answered the surveys on paper or online. Three-fourths of the fellows planned to practice H&PC; however, only 35% fellows versus 42% PDs believed that fellows were well prepared in this area. Factors associated with fellows’ selfreported better preparation included completion of an H&PC rotation, experiences with an inpatient hospice facility, inpatient palliative care consulting service, and the presence of a formal H&PC curriculum. Keywords geriatrics, curriculum, hospice, palliative care, national survey, training
Introduction There are many pressing reasons for geriatricians to be well trained in end-of-life care. Since 80% of dying patients are in the geriatric age range, geriatricians must be prepared to care for significantly increasing numbers of patients in the last stages of life.1 In addition, a survey by the Association of Directors of Geriatric Academic Programs in 2008 indicated that 30% of geriatric-trained fellows would go on to work in hospice.2 Program directors (PDs) gave high ratings to the importance of end-of-life care education during their geriatric training. The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in geriatric medicine requires fellows to provide care to elderly patients with hospice and palliative care (H&PC) needs and requires the programs to provide experience with hospice care.3 However geriatric medicine fellow training in H&PC is not more specifically defined or standardized. Also, little is known about fellows’ training in this area of medicine or their perceived competency to practice end-of-life care. National surveys regarding the need of H&PC training for fellows were previously performed. In 2004, MedinaWalpole, Barker, and Katz assessed geriatric medicine fellowship training in the 1990s that revealed fewer than half of the survey respondents received formal training in H&PC. Many fellows identified the need for further H&PC training.4 In 2005, Pan et al conducted a national survey to assess the status of fellows’ experiences in end-of-life care.5 Geriatric medicine
fellows felt their end-of-life care education was excellent, and almost 60% felt that they were well prepared to take care of dying patients. Determinants of feeling better prepared included having completed a palliative care rotation, being taught how to say good-bye, and the perception that palliative care was important to attending physicians. It has been over 10 years since the previous studies on fellows’ H&PC training. The purpose of this study was to measure fellows’ self-reported attitudes, the perceived quantity and quality of their end-of-life care education, and their selfreported overall readiness to provide H&PC. The study was also designed to gauge the importance of H&PC training among PDs. This national survey of geriatric medicine fellows is similar in scope to prior studies with comparable questions. We added an assessment of PDs to get a better understanding of the importance of H&PC in geriatric medicine fellowship training.
1
East Carolina University Greenville, NC, USA Naval Hospital Jacksonville, Jacksonville, FL, USA 3 Campbell University Buies Creek, NC, USA 4 University of Wisconsin–Madison, WI, USA 2
Corresponding Author: Qing Cao, East Carolina University, 101 Heart Drive, Greenville, NC 27834, USA. Email: [email protected]
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Methods The survey was generated using the survey tool Qualtrics (Qualtrics Labs, Inc, Provo, UT, 2002). It sought to measure fellows’ self-reported attitudes about providing end-of-life care, the quantity and quality of their end-of-life care education, and their overall readiness to provide end-of-life care to the elderly patients. The survey was modified from an instrument developed to evaluate the end-of-life education experience and attitudes of national sample of medical students, residents, and faculty, which has been validated.5,6 This survey was based on focus group analysis, literature review, and recommendations from the 1997 National Consensus Conference for Medical Education in End-of-Life Care.7 The survey for fellows was 9 pages long and contained 27 questions. The survey for PDs was 2 pages in length and contained 4 questions. The questions for fellows were grouped into a few areas: end-of-life care training, attitudes toward caring for dying patients, and preparedness to provide end-of-life care. The survey defined hospice care as medical care to patients who have a terminal illness with a life expectancy of less than 6 months. End-of-life training availabilities at the responding fellows’ home institutions were measured with 7 questions. The questions assessed the respondents’ program type (family medicine or internal medicine), the availability of H&PC rotations, the length of the rotations, the presence of an inpatient hospice facility, the accessibility of inpatient palliative consult team in their home hospital, the availability of dedicated palliative care teaching faculty, and the presence of an official curriculum for H&PC. The attitudes toward caring for dying patients were measured with the following questions: the fellows’ and PDs’ perceptions of the importance of learning the skills of providing care to dying patients, fellows’ perception of who has the main responsibility to prepare patients for death, fellows’ future plans to use their H&PC training, and a few questions assessed fellows’ attitudes toward end-of-life care based on their personal experiences. Fellows’ interest in palliative care was measured with a series of 7-point Likert-scale-type questions. Respondents were asked to rate various hypothetical elements of end-of-life care education as most interesting, somewhat interesting, slightly not interesting, or least interesting. Also, fellows were requested to select from a list factors that compelled or discouraged them to discuss H&PC with patients and families: patient or family member request, palliative care consultation’s recommendations, medical indications such as having a terminal diagnosis, substantial functional deterioration, long intensive care unit stays, or frequent emergency visits. The preparedness to provide end-of-life care was measured by the fellows’ and PDs’ perceptions of fellows’ confidence: ‘‘Do you feel that you (your fellows for PDs) are prepared for taking care of dying patients?’’ The answer choices were wellprepared, moderately prepared, somewhat prepared, and not prepared. Also, fellows’ confidence in specific skills related to end-of-life care was assessed with a series of 10 Likerttype questions. The questions asked respondents to rate their comfort level with various tasks as very comfortable, moderately comfortable, somewhat comfortable, or not comfortable.
At the time of the survey, there were 45 family medicine– based and 105 internal medicine–based geriatric medicine fellowship programs, with a total of 298 fellows. The survey was performed between March and June 2011 when the majority of fellows had completed most of their clinical training. Since there was no centralized database of geriatric medicine fellows in training in the Association of American Medical Colleges (AAMC)’s Electronic Residency Application Service (ERAS) system opposite to most other residency or fellowship training programs, the study team gathered data for this study from fellows and PDs of US-accredited geriatric medicine fellowship training programs by 4 different strategies: (1) A national electronic survey was conducted via e-mail in May 2011.The intention was to reach all fellows and PDs of records through PDs. The e-mail address for geriatric medicine fellowship programs in all states was listed by ACGME.8 (2) E-mails were sent out through the Geriatric Academic Career Award (GACA) recipient list in late March 2011, with the intention to reach some PDs and their fellows in this manner and reinforce the request for survey response. (3) The survey was administered on paper face to face with volunteers at the American Medical Director Association (AMDA) Annual Symposium in Tampa, Florida, in March 2011. (4) The survey was administered on paper face to face with volunteers at the American Geriatric Society (AGS) meeting in Washington, District of Columbia, in May 2011. The survey data were entered into Qualtrics and analyzed using STATA/IC 12.1 (StataCorp. 2011. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP) and SPSS (version 19.0). Descriptive statistics were used to summarize the data. The chi-square test compared categorical variables (the accessibility of inpatient hospice facility, inpatient palliative care consult team, H&PC rotation, the length of the rotation, fellows’ personal experiences of caring of dying loved ones, the availability of dedicated faculty, and official curriculum) with fellows’ overall preparedness to take care of dying patients or comfort levels in managing symptoms of dying patients. Similar analysis was conducted to study the relation between fellows’ preparedness to take care of dying patients and their decision on practicing H&PC after the fellowship. The Institutional Review Board of East Carolina University approved this study.
Results A total of 143 (48%) of 298 fellows and 69 (46%) PDs of 150 answered the survey either on paper or via the Qualtrics survey tool. In all, 48 fellows and 1 PD answered the paper survey at the AMDA Annual Symposium in March 2011; 56 fellows and 46 PDs responded to the paper survey at the AGS Annual Conference in May 2011. In addition, 13 fellows and 8 PDs answered the survey via GACA recipient list in late March 2011, and 26 fellows and 14 PDs took the electronic survey via the national e-mails in late May 2011. The distribution of fellows’ responses among internal and family medicine specialties closely mirrored the national data
Downloaded from ajh.sagepub.com at Bobst Library, New York University on November 15, 2015
American Journal of Hospice & Palliative Medicine® 32(3)
324 on geriatric fellowship program sponsorship, with 70% of the fellows being internal medicine and 30% being family medicine. Among those programs, 87% were university-affiliated programs, 10% were community programs, and about 3% were Veteran Affair fellowship programs. Of the respondents, 71% were females. Among all the respondents, about 37% had decided to enter academic settings, 18% private practice mixed with some academic duties, 12% private practice only, 13% long-term care or home care, 7% government, and 13% others.
End-of-Life Care Training Most participants (88% fellows and 90% PDs) stated that H&PC was a required rotation; and for 8% of fellows, H&PC was an elective rotation. About 2% of the surveyed fellows reported that this rotation was not offered in their programs. The length of rotations was 4 weeks for 86% of the programs and ranged from 2 days to 4 months. Slightly over half (54%) of the H&PC rotations were 4 to 6 weeks and the next most common duration was 7 to 8 weeks (18%). Seven programs included H&PC as a longitudinal rotation. The majority of fellows reported that they had dedicated faculty teaching the subject matter (89%) and an official curriculum (74%) for H&PC. The vast majority of PDs reported that they had curriculum in the areas of hospice referral indications (94%), end-of-life communication (94%), pain management (94%), nonpain symptom management (93%), medication management (88%), psychiatric symptom management (79%), and systems of care in hospice (91%). Training facilities were quite variable among the programs. Of the fellows, 65% reported that they had inpatient hospice facilities in the hospital or as a stand-alone inpatient unit; 82% fellows reported that they participated in inpatient palliative care consult services. Most fellows had recent experiences with end-of-life discussions. Of the 102 respondents, 75 (75%) had a discussion about hospice with a patient and/or a family member within the last month of the survey, and 42 (41%) of them had this discussion within a week prior to the survey. Virtually all (99%) of the fellow respondents thought that their patients benefited from H&PC during the previous 6 months of the survey, and 96% of them had referred patients to H&PC. Overall, a vast majority (>95%) of fellows showed significant interest in the main H&PC curriculum topics of pain management, hospice referral indications, communication skills, nonpain symptom control, and psychological issues related to end-of-life care. Additional topics that fellows thought needed more emphasis included breaking bad news, interdisciplinary team approach, roles of chaplain and social workers, prognostication of life expectancy, hospice certification/recertification requirements, insurance issues, indications for general inpatient status, and managing family dynamics. Program directors ranked H&PC 6th out of 8 geriatric care domains. Figure 1 displays the priorities of PDs regarding the geriatric core competencies.9 The largest barriers to providing more H&PC training, according to the PDs, were lack of curricular time (50%) and faculty time (35%).
Figure 1. Program directors’ rating of the importance of core competencies of geriatric medicine fellowship education.
Attitudes Toward Caring for Dying Patients Despite the low ranking that PDs gave end-of-life care in comparison with other core competencies, there was concurrence between fellows and their PDs regarding the importance of learning the skill of providing care to dying patients; the overwhelming majority (>95%) stated that it was very important or moderately important. When the question of ‘‘Who do you think has the main responsibility to prepare patients with terminal illness for death?’’ was posed, 81% of the fellows responded that the primary care provider such as a geriatrician had this main responsibility. Other choices included other subspecialty physicians related to the terminal diagnoses, spiritual guides, or families. Fellows’ future plans to use their H&PC training are revealing and demonstrate the subject’s importance. Three-fourths of the fellows planned to practice H&PC as part of routine geriatric care (72%). About 6% fellows reported that they were not going to practice H&PC and 4% reported that they would focus exclusively on H&PC. A few questions were asked to assess fellows’ attitudes based on their personal experiences. Most fellows (112 of 137, 82%) stated that they would definitely refer a loved one with a terminal illness near the end of their life to H&PC. Over half (87 of 137, 64%) of the fellows reported some death experiences of a family member or of someone very close to them. Among these fellows, 43% (35 of 87) stated that their loved ones had been under hospice care. Although the majority of the fellows’ dying loved ones were referred by the patient’s medical provider, surprisingly 38% (14 of 35) were referred by the fellow. Fellows were requested to select from a list factors that compelled them to discuss H&PC with patients and families. The most common compelling factor chosen by the respondents was patient or family member’s request, whereas medical indications such as having a terminal diagnosis, substantial
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Cao et al
325 comfort managing pain and depression. Other specific aspects of H&PC skills, such as referring to hospice, using team support, breaking bad news, reconciling and saying good-bye, telling patients that they are dying, or ordering palliative sedation, were not significantly affected by those training strategies, per our study.
Using team support Referring to hospice Breaking bad news Telling paents that they are dying
Discussion
Managing pain Managing depression Reconciling and saying good-bye Managing terminal delirium Ordering palliave sedaon 0%
50%
100%
Very comfortable
Moderately comfortable
Somewhat comfortable
Not comfortable
Figure 2. Fellows’ comfort level in providing specific aspects of endof-life care.
functional deterioration, long intensive care unit stays, or frequent emergency visits were considered less compelling.
Preparedness to Provide End-of-Life Care Three-fourths of the fellows planned to practice H&PC after graduation (either exclusively or as part of routine geriatric patient care), and those fellows were 3 times more likely to report that they were either moderately or well prepared for end-of-life care (odds ratio [OR] ¼ 3.31, 95% confidence interval [CI] ¼ 1.35-8.06, P ¼ .04); however, only 35% of the fellows felt they were well prepared and 45% felt moderately prepared. Program directors were more confident in their fellows’ preparation than were the fellows themselves (42% PDs vs 35% fellows believed that fellows were well prepared in this area). The study revealed that a completion of H&PC rotation was a significant contributive factor for fellows to feel moderately or well prepared in caring for patients at the end of life (OR ¼ 6.8, 95% CI ¼ 1.08-43.02, P ¼ .04). Fellows’ level of comfort regarding specific aspects of H&PC varied widely and is displayed in Figure 2. In general, the majority of fellows reported some level of comfort with all aspects of H&PC services. However, 20% of fellows surveyed were not comfortable ordering palliative sedation. Table 1 compares the significance of training strategies (inpatient hospice, inpatient palliative consult team, formal H &PC curriculum) on fellow-reported comfort levels with specific aspects of H&PC: management of pain, depression, or terminal delirium. An inpatient hospice facility had a significant effect on fellows’ comfort level managing delirium. Similarly, experience with an inpatient palliative consult team improved fellows’ comfort level managing delirium and depression and having an official H&PC curriculum improved fellows’
This survey reveals consistent weaknesses in fellow preparation for the core geriatric competencies embedded in H&PC. Only one-third of fellows felt well prepared to take care of dying patients and 20% felt only somewhat or not at all prepared for this critical role. Consistent with this, end-of-life care ranked low in PDs’ priorities due to pressures for curricular time and lack of adequate faculty time to teach this topic. Geriatric medicine fellows surveyed believed that it was their responsibilities as primary care providers to prepare patients for their deaths. Most fellows planned to practice H&PC either exclusively or as a part of their routine geriatric care. The inconsistency between training preparation and posttraining employment was very concerning. Fellows needed the confidence in identifying, initiating discussions, and caring for patients and families during this phase of life if they were going to have a meaningful role in appropriate health care for older patients. In the recent publication ‘‘Generalist plus Specialist Palliative Care—Creating a More Sustainable Model,’’10 primary care providers were expected to master the skills of pain, depression and anxiety management, and goals of care discussions. These expectations overlapped with many of the weaknesses identified by our study in fellow training. Our study demonstrated that most fellows felt more comfortable having discussions about H&PC if patients or family members brought up the topic rather than initiating the conversation based on patients’ prognosis or comorbidities. Geriatric medicine fellowship programs need to increase the confidence level of fellows in identifying and initiating H&PC discussions. Weaknesses in fellowship training revealed in our study could be categorized as skills or facility experiences. Hospice and palliative care skills needing improvement included the need for better training in breaking bad news, using interdisciplinary teams, the roles of the chaplain and social workers, prognostication of life expectancy, managing family dynamics, understanding hospice certification/recertification requirements and insurance issues, and indications for general inpatient status. There are growing resources available in other specialties to assist in these areas of H&PC where training appears to be weak. The online program OncoTalk11 utilizes key educational principles to assist with training in key concerns noted by geriatric fellows: giving bad news, managing transitions to palliative care when chemotherapy is failing, conducting a family conference, handling requests for therapies that you feel are futile, and cultivating your communication skills. This program has spawned spin-offs for slightly different audiences: IntensiveTalk and GeriTalk.
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American Journal of Hospice & Palliative Medicine® 32(3)
326
Table 1. Fellow Training Strategy Associated With Fellows’ Comfort Level in H&PC.a Fellows’ comfort level in managing terminal delirium Training strategy
All (N ¼ 143)
Very/moderately comfortable (n ¼ 99)
Somewhat/not comfortable (n ¼ 38)
Inpatient hospice facility No 47 (34.31) 28 (28.28) 19 (50.00) Yes 90 (65.69) 71 (71.72) 19 (50.00) Palliative consult team No 25 (18.25) 14 (14.14) 11 (28.95) Yes 112 (81.75) 85 (85.86) 27 (71.05) H&PC curriculum No 35 (26.32) 25 (26.32) 10 (26.32) Yes 98 (73.68) 70 (73.68) 28 (73.68) Fellows’ comfort level in managing depression Training strategy All (N ¼ 139) Very/moderately comfortable Somewhat/not comfortable (n ¼ 108) (n ¼ 31) Inpatient hospice facility No 48 (34.53) 35 (32.41) 13 (41.94) Yes 91 (65.47) 73 (67.59) 18 (58.06) Palliative consult team No 26 (18.71) 16 (14.81) 10 (32.26) Yes 113 (81.29) 92 (85.19) 21 (67.74) H&PC curriculum No 36 (26.67) 22 (20.95) 14 (46.67) Yes 99 (73.33) 83 (79.05) 16 (53.33) Fellows’ comfort level in managing pain Training strategy All (N ¼ 142) Very comfortable (n ¼ 112) Moderately/somewhat /not Comfortable (n ¼ 20) Inpatient hospice facility No 45 (33.09) 35 (30.43) 10 (47.62) Yes 91 (66.91) 80 (69.57) 11 (52.38) Palliative consult team No 26 (19.12) 22 (19.13) 4 (19.05) Yes 110 (80.88) 93 (80.87) 17 (80.95) H&PC curriculum No 35 (26.52) 23 (20.54) 12 (60.00) Yes 97 (73.48) 89 (79.46) 8 (40.00)
OR (95% CI), P value 1.0b 2.54 (1.17-5.49), .018 1.0b 2.58 (1.01-6.09), .050 1.0b 1.00 (0.43-2.35), .999 OR (95% CI), P value 1.0b 1.51 (0.66-3.42), .330 1.0b 2.74 (1.09-6.88), .04 1.0b 3.30 (1.40-7.78), .007 OR (95% CI), P value 1.0b 2.08 (0.81-5.24), .132 1.0b 0.99 (0.30-3.25), .993 1.0b 5.80 (2.12-15.86),
