Section 781 is within title VII of the Public Health Service Act, which authorizes numerous programs for health professions education and training. The second phase is graduate medical education—or residency training—where residents receive 3 to 8 years of clinical training in a medical specialty. 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. 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. 1.) Instruction in palliative care for chronic illness was required by the fewest number of schools (56 percent). Many schools reported a need to change palliative care instruction, particularly in the area of clinical training. 2.) Plans to Use Section 781 for Palliative Care Projects Are Limited

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. 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 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. 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. Some of these projects directly address the types of research, training, and demonstration projects authorized in the Assisted Suicide Funding Restriction Act, including the following:
Research authorized by the act includes projects to advance biomedical knowledge of pain management and assess the quality of care for patients with terminal illness by measuring and reporting specific outcomes. Last Acts aims to raise awareness of the need to improve the care of persons who are dying, improve communication and decisionmaking related to end-of-life care, and change the way health care and health care institutions approach care for dying people. Private entities also provide funding for a variety of other projects in palliative care—some with a specific focus in physician education or improving access and quality to palliative care. Scope and Methodology

We discussed the extent that palliative care issues were taught and tested in medical schools, residency programs, and continuing medical education with representatives from cognizant professional associations including the AMA, the American Osteopathic Association, the AAMC, the American Association of Colleges of Osteopathic Medicine; faculty from various educational institutions; representatives from entities administering national examinations necessary for medical licensure and board certification, such as the National Board of Medical Examiners and the American Board of Internal Medicine; representatives from accrediting bodies for medical schools, residency programs, and continuing education, including the Liaison Committee for Medical Education, the Accreditation Council for Graduate Medical Education, and the Accreditation Council for Continuing Medical Education; and recognized experts in the field of palliative medicine. To gather more specific information about the extent to which the palliative care subjects addressed in the Assisted Suicide Funding Restriction Act were taught in medical schools, we developed and administered a survey to all accredited U.S. allopathic and osteopathic medical schools regarding their curriculum, training, and testing of student knowledge in pain management, depression identification and treatment, and palliative care. We discussed other federal and private palliative care research and education initiatives funded outside section 781 with HHS agencies and private entities involved in similar palliative care activities. Additional copies are $2 each.
Why GAO Did This Study

Pursuant to a legislative requirement, GAO reported on the extent to which projects under section 781 of the Public Health Service Act have furthered the knowledge and practice of palliative care, particularly with regard to curricula offered and used in medical schools. GAO's preliminary work showed that no fiscal year (FY) 1998 funding for section 781 projects would be awarded by its April 30, 1998 reporting date, so GAO focused on determining: (1) the extent to which the physician education and training process currently teaches and tests student competency in palliative care issues; (2) the Department of Health and Human Services' (HHS) plans for funding palliative care projects under section 781; and (3) other federal and private palliative care research and education initiatives.

What GAO Found

GAO noted that: (1) physicians receive varying amounts of instruction in palliative care topics as they progress through 4 years of medical school and 3 to 8 years of subsequent specialized training in a residence program; (2) each of the seven palliative care areas in GAO's survey was required by 56 percent or more of the 125 medical schools responding to its survey; (3) similarly, about half of the 7,787 specialty and subspecialty residency programs educated students in end-of-life care; (4) GAO's survey showed that many medical schools are interested in providing additional instruction and training in palliative care; (5) about one-third of the schools reported a need to change their curriculum for addressing palliative care for the chronically and terminally ill; (6) close to half reported a need to include more clinical training in managing pain and depression for these patient populations; (7) HHS officials plan to use $150,000 of the $452,000 specified for section 781 in the FY 1998 appropriations conference report to support seven medical education research projects, including one palliative care project; (8) officials from HHS and the medical education research center receiving these funds were not able to specify the amount being spent on the palliative care project because separate budgets are not developed for each project; (9) of the remaining section 781 funds, all $302,000 will be used to support research for improving the distribution and diversity of the health care workforce; (10) because of the higher priority that HHS has assigned to this other research, officials do not plan to use any funds for palliative care research, training, or demonstration projects in 1999; (11) nevertheless, a substantial amount of research related to palliative care is being funded in ways other than through section 781; (12) over the last few years, HHS and private entities have invested tens of millions of dollars into projects similar to those specified in the Assisted Suicide Funding Restriction Act; (13) some HHS agencies have more general projects, not specified in the act, that could also benefit palliative care in the areas of increasing health care access, improving quality of care, and advancing biomedical research; and (14) private foundations and other private organizations have spent millions of dollars to educate and train health care professionals in palliative care and improve the quality of care for the terminally and chronically ill.