Disagreements in surgical decision making for advanced cancer patients secondary to deficiencies in palliative care education.

Abstract

34 Background: Surgical decision making in advanced cancer patients requires careful thought and deliberation balancing the high risks with the potential palliative benefits. We sought to compare palliative care education and decision-making for palliative surgery among physicians who commonly treat advanced cancer patients. Methods: Practicing surgeons, medical oncologists, palliative care physicians and critical care intensivists from a large urban city and its surrounding areas were surveyed with a 32-item questionnaire consisting of a palliative care education survey and 4 clinical vignettes depicting patients with advanced cancer and symptomatic surgical conditions. Results: Of the 299 physicians surveyed, 102 responded with a response rate of 34.1%. Respondents reflected the demographics of the total cohort. Physicians reported minimal hours of palliative care education during residency (median 0, IQR 0-8), fellowship (median 0, IQR 0-20), and continuing medical education (CME, median 8, IQR 0-20). Surgeons reported the fewest hours of palliative care education during residency, fellowship, and CME combined (median 10, IQR 2-15) compared to medical oncologists (median 30, IQR 20-80) and intensivists (median 50, IQR 30-100), p < 0.05. 19.6% of surgeons reported receiving no palliative care education compared to none of the medical oncologists and 7.7% of intensivists. Analysis of physician treatment recommendations for the 4 clinical vignettes showed disagreement among physicians regardless of specialty. Absence of palliative care training was associated with recommending major surgical intervention more frequently compared to physicians with ≥40 hours of palliative care training (0.7 ± 0.7 vs. 1.6 ± 0.8, p = 0.01). Conclusions: Deficiencies in palliative care education persist and adversely impact quality of care. Recent national society recommendations for palliative care services are well founded given these deficiencies. Additionally, our findings highlight a sustained failure of the current postgraduate medical education system and the need for greater efforts system-wide in palliative care education across medical and surgical specialties.