Palliative care is an important and emerging issue for health care providers, educators, and the general public. As medical advances increase life expectancy, more and more people suffer from chronic and progressively disabling diseases that require treatment for depression and assistance with pain and symptom management. Some recent studies have pointed to significant problems within the health care system that preclude the achievement of the best possible quality of life for patients and their families. Areas identified for improvement include education and training for health care providers, improved pain and symptom management, and access to appropriate and quality health care services. The Assisted Suicide Funding Restriction Act of 1997 contains a provision designed to focus federal funding on research, training, and demonstration projects that would address these specific problem areas. The act authorizes funding in a number of palliative care topics (see table 1) and directs the Secretary of HHS to emphasize palliative medicine among its research and funding priorities under section 781. Section 781 is within title VII of the Public Health Service Act, which authorizes numerous programs for health professions education and training. Section 781 was first funded in 1993 to conduct health professions education research in four broad topic areas related to (1) educational indebtedness, (2) effect of programs for minority and disadvantaged individuals, (3) extent of investigations and disciplinary actions by state licensing authorities, and (4) primary care. The Bureau of Health Professions within the Health Resources and Services Administration (HRSA) is the HHS agency responsible for administering grants funded under section 781 of title VII. The extent of palliative care instruction varies considerably across and within the three major phases of the physician education and training process. The first phase is undergraduate medical education—or medical school—where students typically receive 2 years of classroom, or didactic, instruction followed by 2 years of clinical training. The United States has 144 accredited medical schools. The second phase is graduate medical education—or residency training—where residents receive 3 to 8 years of clinical training in a medical specialty. The United States has over 7,700 accredited residency programs. The third phase is continuing medical education, which provides physicians who are already practicing medicine with the education and training necessary to maintain or learn new skills. Continuing medical education courses are provided primarily by medical schools and state medical societies, but such courses are also provided by medical associations and consultants. Throughout these three phases, a variety of formal accreditation and certification processes are used to test student competency and to judge the quality of instruction and training. Our review at medical schools showed mixed amounts of attention given to palliative care issues. Accrediting organizations have generally steered away from standards requiring instruction in topics as specific as pain management, preferring to leave such matters to the discretion of the faculty at each school. To determine the extent to which the schools addressed these topics, we surveyed all U.S. medical schools on seven palliative care topics. For each of the seven palliative care topics we asked about, at least half of the 125 U.S. medical schools that responded to our survey said they had some degree of required instruction. (See fig. 1.) Instruction in palliative care for chronic illness was required by the fewest number of schools (56 percent). For the remaining topics, the percentage of schools requiring the topic was higher; for example, over three-quarters required instruction in the topic of pain management for the terminally or chronically ill, and 94 percent required instruction in depression identification and treatment. Our survey responses showed that some schools have added these topics fairly recently. For example, 24 percent of schools reported adding pain management as a required subject within the last 3 years. (For a more detailed summary of our medical school survey results, see app. II.) Many schools reported a need to change palliative care instruction, particularly in the area of clinical training. Overall, 30 percent of schools reported a need to change their classroom curriculum in palliative care, and close to 50 percent reported wanting to provide students with more hands-on training experience in diagnosing and treating patients with pain due to chronic or terminal illness. Evaluation processes vary in the extent to which they measure students’ knowledge of palliative care issues. (See fig. 2.) The percentage of medical schools that reported testing competency in the topics we surveyed ranged from 36 percent for interdisciplinary health care for end of life to 72 percent for identifying and treating depression. Many medical schools also rely heavily on national examinations—the U.S. Medical Licensing Examination or the National Board of Osteopathic Medical Examiners’ exam—to evaluate student knowledge. A study is currently under way to examine the degree to which the U.S. Medical Licensing Examination tests student knowledge in end-of-life care issues and to develop a method to evaluate student performance on these test questions in the future. Our review also indicated that attention to palliative care issues in residency programs varied as well. Accrediting bodies at the graduate level generally require some specific areas of instruction, although, as in medical schools, the primary responsibility for curriculum and training content is assumed by the program director and faculty. Required topics of instruction, such as domestic violence, vary by specialty, and few specialties have requirements including specific palliative care topics.Because of the large number of accredited residency programs in the United States, we did not administer a survey similar to the one we developed for medical schools. We relied on existing surveys done by professional associations that asked residency programs to report whether the subjects of end-of-life care and suicide were included in their training programs. The American Medical Association’s (AMA) 1996 survey showed that nearly half of the nation’s 7,787 residency programs include instruction in end-of-life care and over a third teach issues related to suicide. While historical data on the subject of suicide prevention are not available, AMA’s data show greater numbers of residency programs now offer instruction in end-of-life care than in the past. In 1996, nearly 50 percent of residency programs taught end-of-life care, compared with 38 percent in 1994. To some extent, the percentage of residency programs that taught palliative care subjects corresponded to the degree to which these skills might be needed in the specialty area covered by the program. For example, 93 percent of family practice residency programs in the subspecialty of geriatrics reported teaching end-of-life care, while only 10 percent of pathology residency programs in the subspecialty of pediatric pathology reported teaching the subject. However, the percentage of programs that reported teaching end-of-life care was surprising for some specialties for which the need for physicians skilled in end-of-life care seems more evident. For example, nearly half of internal medicine residency programs in the subspecialty of oncology reported not teaching end-of-life care, although physicians treating patients with cancer often deal with terminal patients. (See app. III for a detailed summary of AMA’s 1996 residency program survey results.) The knowledge and skill of resident physicians is evaluated by each residency program’s internal evaluations and national examinations. These examinations include the U.S. Medical Licensing Examination as well as examinations some physicians take to become certified in a medical specialty. The extent to which board examinations include questions related to palliative care has not been quantified, and student performance on palliative care questions that may be included on the exams has not been evaluated. The availability of continuing medical education courses that focus on palliative care issues for terminally or chronically ill people appears limited. Many states and medical associations require physicians to continue their medical education to maintain their medical license or membership benefits, but they generally do not require courses on specific topics such as palliative care. Because of the number and variety of continuing medical education providers, information on the existence of continuing medical education courses dedicated to palliative care issues was not readily available. However, we queried the AMA’s database of over 2,000 accredited continuing medical education activities and found that few specifically addressed palliative care. In addition, an official with the American Osteopathic Association said there are few continuing medical education courses related to palliative care for doctors of osteopathy. An example of a course that specifically addresses palliative care issues is a self-study program developed by the American Academy of Hospice and Palliative Medicine, which covers a variety of palliative care topics. Recognizing a need for more courses in this area, private efforts are under way to develop more conferences on end-of-life care issues as well as promote those that already exist. The fiscal year 1998 conference committee report on HHS appropriations specifies $452,000 for section 781. Officials in HRSA plan to use $150,000 of this amount for seven medical education projects, including one project on palliative care. All seven projects will be conducted by one medical education research center. HRSA plans to provide the funds for the seven projects in May 1998. Because budgets are not maintained separately for each project, HRSA and medical education research center officials were not able to specify the amount of funding dedicated for the palliative care project. The project will assess current medical school courses on death and dying to determine if they meet recommended methods for teaching end-of-life care. The remaining $302,000 will be used to support projects focused on increasing the knowledge about the needs and resources of the nation’s health professions. Information obtained through these projects will be used to assess the effectiveness of current workforce programs. HRSA officials said they consider this research as higher in priority. In addition, the officials said that due to the importance of health workforce research, future funding of palliative care projects in medical education is uncertain. HRSA did not include palliative care research for medical education in its fiscal year 1999 budget justification. HRSA officials do not plan to fund any of the other types of palliative care topics authorized under the Assisted Suicide Funding Restriction Act. They said these other initiatives, such as demonstration projects to reduce restrictions on access to hospice programs, are not related to the traditional focus of title VII to support health professions education and training.