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University of California San Francisco, CA
Correspondence to: Michael W. Rabow, MD, Department of Medicine, University of California, 1701 Divisadero St, #500, San Francisco, CA 94115; e-mail: mrabow{at}medicine.ucsf.edu
To the Editor:
The care that physicians provide to patients with pulmonary disease who are at the close of life has received increasing attention in the past year. Recommendations for professional standards on end-of-life care have been made by specialty boards and organizations, including the American College of Chest Physicians and the American Thoracic Society.1 2 3 Insufficient training of clinicians in this area is an important cause for deficiencies in care at the end of life.4 The textbooks used to train clinicians are partly to blame. Our research has identified major deficiencies in the end-of-life content of 50 best-selling medical textbooks, including 4 top pulmonary textbooks.5 On average, pulmonary textbooks had helpful information for only about one fifth (21.6%) of the expected end-of-life care content. Of the 12 specialties studied, pulmonary textbooks ranked lowest in average percentage of end-of-life care index citations (0.09%). Furthermore, chapters focused on end-of-life care were completely absent from each of these pulmonary textbooks.
In light of such deficiencies, we have undertaken an effort to encourage publishers, editors, and authors to improve the end-of-life content in their textbooks, including book chapters, cross-referencing, and indexing.6 In follow-up to this effort, we recently surveyed textbook publishers and editors to assess their progress in revising their texts.
Unfortunately, only one editor of the four pulmonary textbooks has responded. Overall, however, 23 editors and 19 publishers of 50 top-selling medical textbooks have responded to our follow-up survey. They report planned or completed expansion of end-of-life content in the next editions of 22 textbooks, including 17 textbooks with new end-of-life care chapters, 17 with revised indexes, and 11 with expanded cross-referencing. Thus, of the 50 textbooks, more than one third are planning to expand or have already expanded end-of-life care content in their next editions. Finally, we have received six personal letters from editors and publishers who have been supportive of this project, including a poignant one from a textbook editor who was himself dying of metastatic melanoma at the time he wrote.
Recently, the Robert Wood Johnson Foundation honored the textbook publishers, editors, and authors who have been working to make these important changes. On February 21, 2001, at an awards ceremony at the Last Acts Project National Meeting, the authors presented awards to one medical textbook publisher (Lippincott Williams and Wilkins) and to the editors of three medical textbooks (Emergency Medicine, 5th ed, Judith Tintinalli editor-in-chief; Nelson Textbook of Pediatrics, 16th ed, Richard Behrman, Robert Kliegman, and Hal Jensen, eds; and Textbook of Primary Care Medicine, 3rd ed, John Noble, senior editor).
Naturally, there is yet more progress to be achieved, especially among pulmonary textbooks. Numerous top-selling textbooks have not yet responded to the suggestions of specialty boards, their readers’ needs, or their patients’ and families’ ultimate demands to improve pulmonologists’ education in end-of-life care. We plan to continue monitoring textbooks over course of the next several years, and the Robert Wood Johnson Foundation will continue to offer awards to those editors, publishers, and authors who ameliorate the end-of-life content in their texts. It is of primary importance that the current palliative care knowledge and the ongoing research published in CHEST find its way into the best-selling pulmonary textbooks.
References
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