Primary Care Residents Improve Knowledge, Skills, Attitudes, and Practice After a Clinical Curriculum With a Hospice.

Effective approaches to teaching attitudes, knowledge, and skills to resident physicians in primary care that can be implemented in any residency program are needed. We examined the feasibility and impact of a single palliative care residency curriculum, including a clinical rotation with a hospice program, across 5 cohorts of residents in 7 divergent primary care residency programs (both family medicine and internal medicine). The didactic content was drawn from the national Education for Physicians on End-of-Life Care Project. A total of 448 residents completed the curriculum. A large effect size was seen in measures of knowledge change (*Cohen d = .89) when compared to a national sample of primary care residency programs. Additionally, measures of confidence to perform palliative care skills and ethical concerns also improved significantly ( P < .001). A frequent comment is wishing the rest of medicine were like that experienced in the hospice setting. In a separate, ancillary evaluation, the average length of stay of patients enrolled in hospice care was 18.5 days longer for the alumni of this program when compared to physicians referring for hospice care who hadn't experienced the curriculum.

The n-of-1 clinical trial: the ultimate strategy for individualizing medicine?

N-of-1 or single subject clinical trials consider an individual patient as the sole unit of observation in a study investigating the efficacy or side-effect profiles of different interventions. The ultimate goal of an n-of-1 trial is to determine the optimal or best intervention for an individual patient using objective data-driven criteria. Such trials can leverage study design and statistical techniques associated with standard population-based clinical trials, including randomization, washout and crossover periods, as well as placebo controls. Despite their obvious appeal and wide use in educational settings, n-of-1 trials have been used sparingly in medical and general clinical settings. We briefly review the history, motivation and design of n-of-1 trials and emphasize the great utility of modern wireless medical monitoring devices in their execution. We ultimately argue that n-of-1 trials demand serious attention among the health research and clinical care communities given the contemporary focus on individualized medicine.

Residents from five training programs report improvements in knowledge, attitudes and skills after a rotation with a hospice program.

BACKGROUND: The faculty of the Center for Palliative Studies teach residents from 5 different primary care residency training programs who rotate at San Diego Hospice: 3 in Internal Medicine, 2 in Family Medicine. Residents participate in the care of patients in the inpatient care setting and make joint home visits with physicians and other team members. A series of 4 lectures on end-of-life care is given on Tuesday mornings: management of pain, other symptoms, interdisciplinary roles of chaplains, social workers, nurses, and grief/bereavement are discussed. In addition, there is a Tuesday noon conference that follows a journal club format. Because of scheduling, residents from some programs are not able to attend all lectures and conferences. METHODS: A 27-item self-assessment evaluation tool was developed for administration to residents before and after their experience. A total of 65 evaluations for residents rotating in academic year 1997-98 and 1998-1999 were collated and analyzed. RESULTS: When evaluated as a whole, residents noted significant improvements in their ability to assess and treat symptoms, to tell patient/family about the dying process and to care for dying patients at home (range in improvement from 26% to 67%, p < 0.05 using paired t-test). About half of the residents perceived that the content was not available elsewhere in their training. CONCLUSION: We conclude that a single hospice rotation can effectively contribute to resident education in multiple programs.