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Are Neurology Residents Prepared to Deal With Dying Patients?
Claire J. Creutzfeldt, MD;
Ted Gooley, PhD;
Melanie Walker, MD
Arch Neurol. 2009;66(11):1427-1428.
Palliative care and symptom-based management play a central role in the care of patients with neurologic disease. With daily frequency, neurologists diagnose and treat patients with life-threatening, life-limiting, or significantly life-altering disease. It is, therefore, surprising that such a pervasive theme is inadequately addressed during neurology residency training.1 The purpose of this study was to assess the basic palliative care (PC) knowledge of neurology residents throughout the country.
Methods
A 5-question survey was developed that included questions regarding the major clinical topics of PC (Table). From November 2007 to March 2008, program directors from all Accreditation Council for Graduate Medical Education–certified neurology residency programs were contacted and voluntary/anonymous resident participation requested. After receiving approval from our institutional review board, the survey was mailed to participating programs and given during teaching conferences at approximately the same time to reduce cross-communication. Participants were asked to refrain from discussion or reference materials while responding.
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Table. Palliative Knowledge Care Surveya
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Our primary outcome measure was the percentage of questions correctly answered. Logistic regression was used to assess the correlation between a correct answer and amount of training (program year and months of PC training). Each training function was modeled both as continuous linear variables and categorical variables. Two-sided P values from regression models were derived from the Wald test; no adjustments were made for multiple comparisons.
Results
Thirty-four neurology programs agreed to participate, and 338 questionnaires were returned. This corresponds to one-third of neurology programs and one-fifth of neurology residents in the United States. Only 9 of the participants were first-year residents; there was an even distribution of second-, third-, and fourth-year residents (100, 108, and 100 residents, respectively); 9 participants were in their fifth year (fellows); 2 had been in neurology training for more than 6 years; and 4 did not indicate their year of training.
Palliative care training (PCT) was assessed for the number of months in care. Most participants (n = 181) had no PCT, and another 80 declined to provide their amount of PCT. The maximum times spent in PCT were 20 months in 1 case and 12 months in 3 cases. One program with 6 participants reported that their 2 youngest (second-year) residents had no PC experience, while all older residents had one-fourth of a month of PCT, suggesting this was an inherent part of their program. The 77 residents who reported having PCT were dispersed among 28 of 34 participating programs (82%).
The overall mean knowledge score was 44%. Residents scored the highest on the question relating to advanced directives and were least knowledgeable about pharmacology (Table). There is insufficient evidence from the regression models to suggest that months of training in PC or year of residency will predict whether a resident will answer any question correctly.
Comment
Prior efforts7-8 to improve the quality of PC training in Accreditation Council for Graduate Medical Education–certified residency programs have met with minimal enthusiasm and little visible change to the status quo. According to neurology residency program directors, only 52% of programs offer a didactic experience in end-of-life and/or palliative care, and fewer than 8% provide clinical rotation.9 Our study showed no correlation between program and PCT, suggesting that PCT is rarely a compulsory part of a program's curriculum.
Recently, the American Board of Psychiatry and Neurology took a bold step in offering the Initial Certification in the Subspecialty of Hospice and Palliative Medicine. While this advanced training will motivate some physicians to address PC in the neurologic setting, it does little to train the vast majority of graduating residents. The results of this preliminary study support earlier studies10-11 and confirm the dire need to enhance PC education of neurology resident physicians, who play a vital role in the care of patients faced with a life-threatening, life-limiting, and/or life-changing disease.
AUTHOR INFORMATION
Correspondence: Dr Creutzfeldt, Department of Neurology, University of Washington, Harborview Medical Center, Box 359775, 325 Ninth Ave, Seattle, WA 98104-2420 (clairejc{at}u.washington.edu).
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Creutzfeldt and Walker. Acquisition of data: Creutzfeldt and Walker. Analysis and interpretation of data: Creutzfeldt, Gooley, and Walker. Drafting of the manuscript: Creutzfeldt and Walker. Critical revision of the manuscript for important intellectual content: Creutzfeldt, Gooley, and Walker. Statistical analysis: Gooley. Administrative, technical, and material support: Creutzfeldt and Walker. Study supervision: Creutzfeldt and Walker.
Financial Disclosure: None reported.
This article was corrected online for typographical errors on 11/9/2009.
REFERENCES
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1. Schuh LA, Biondo A, An A; et al. Neurology resident learning in an end-of-life/palliative care course. J Palliat Med. 2007;10(1):178-181.
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2. Centers for Medicare and Medicaid. Medicare hospice benefits: a special way of caring for people who are terminally ill. Department of Health and Human Services Web site. http://www.medicare.gov/Publications/Pubs/pdf/02154.pdf. Accessed July 2007.3. Living wills and advance directives for medical decisions. Mayo Clinic Web site. http://www.mayoclinic.com/health/living-wills/HA00014. Accessed July 2007.4. Arnold R. Fast fact and concept #55: decision making capacity. End of Life Palliative Education Resource Center Web site. http://www.eperc.mcw.edu/fastFact/ff_55.htm. Accessed July 2007.5. Lorazepam injection, USP. Baxter Healthcare Corporation Web site. http://www.baxter.com/products/anesthesia/anesthetic_pharmaceuticals/downloads/lorazepam.pdf. Accessed July 2007.6. Physician's handbook on medical certification of death, 2003 revision. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/nchs/data/misc/hb_cod.pdf. Accessed July 2007.7. Mullan PB, Weissman DE, Ambuel B, von Gunten C. End-of-life care education in internal medicine residency programs: an interinstitutional study. J Palliat Med. 2002;5(4):487-496.
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8. Weissman DE, Ambuel B, von Gunten CF; et al. Outcomes from a national multispecialty palliative care curriculum development project. J Palliat Med. 2007;10(2):408-419.
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9. Schuh LA, Adair JC, Drogan O, Kissela BM, Morgenlander JC, Corboy JR. Education research: neurology residency training in the new millennium. Neurology. 2009;72(4):e15-e20.
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10. Ury WA, Berkman CS, Weber CM, Pignotti MG, Leipzig RM. Assessing medical students' training in end-of-life communication: a survey of interns at one urban teaching hospital. Acad Med. 2003;78(5):530-537.
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