Difficulties Facing Junior Physicians and Solutions Toward Delivering End-of-Life Care for Patients with Cancer: A Nationwide Survey in Japan

BACKGROUND

Junior physicians' perceived difficulty in end-of-life care of patients with cancer has not been structurally investigated; therefore, current challenges and solutions in this area remain unknown.

OBJECTIVES

To identify some difficulties junior physicians face in delivering end-of-life care for patients with cancer and to clarify the support required to reduce these difficulties.

DESIGN

A nationwide survey was conducted in over 300 institutions selected randomly from 1037 clinical training hospitals in Japan.

PARTICIPANTS

From each of these institutions, two resident physicians of postgraduate year (PGY) 1 or 2, two clinical fellows of PGY 3-5, and an attending physician were requested to respond to the survey.

MEASUREMENTS

The survey investigated issues regarding end-of-life care using the palliative care difficulties scale with two additional domains ("discussion about end-of-life care" and "death pronouncement"). Items related to potential solutions for alleviating the difficulties as well were investigated.

RESULTS

A total of 198 resident physicians, 134 clinical fellows, and 96 attending physicians responded to the survey (response rate: 33.0%, 22.3%, and 32.0%). The results revealed that junior physicians face difficulties within specific domains of end-of-life care. The most challenging domain comprised communication and end-of-life discussion with patients and family members, symptom alleviation, and death pronouncement. The most favored supportive measure for alleviating these difficulties was mentorship, rather than educational opportunities or resources regarding end-of-life care.

CONCLUSION

The findings of this study reveal the need for further effort to enrich the mentorship and support systems for junior physicians delivering end-of-life care.

Comparison of Perceptions and Smoking Cessation Experiences Between Smokers With and Without Serious Mental Illness in a Large Health Maintenance Organization

OBJECTIVE

Smoking prevalence is threefold higher among people with serious mental illness (PWSMI) than in the general population, yet smoking cessation rates for PWSMI are lower. Numerous reasons have been posited as to why tobacco use is higher and abstinence rates are lower among PWSMI. This study explores smoking cessation perceptions and experiences among PWSMI and people without serious mental illness (SMI).

METHODS

Participants in this cross-sectional study were recruited from among members of a large health maintenance organization (HMO) in Israel who had registered for or commenced a smoking cessation program in 2015 through 2017. The sample comprised 208 PWSMI and a matched sample of people without SMI (N = 428). Telephone surveys were used to collect information about smoking status and smoking/cessation history, use of smoking cessation programs and aids (prescription medications, nicotine replacement therapy, electronic cigarettes), motivation and intention to quit, self-efficacy (to quit), smoking cessation outcome expectancies, physician support to quit, barriers and facilitators for those who had not quit, and reinforcements/challenges for those who had quit.

RESULTS

Of those without SMI, 27% quit smoking compared to 20% of PWSMI (p = .051). Irrespective of mental health status, the most significant predictor of abstinence was the use of smoking cessation prescription medications. Family physicians were significantly less likely to inquire about motivation to quit, refer to smoking cessation programs, or prescribe smoking cessation medications for PWSMI than for people without SMI. Beyond these factors, no differences were noted between respondents with and without SMI regarding motivation to quit, intention to quit, and abstinence self-efficacy. PWSMI who had not quit were more likely to be concerned about how quitting might affect their functioning and how they would pass the time without cigarettes.

CONCLUSIONS

PWSMI have similar levels of motivation and intention to quit smoking as those without SMI. However, they are disadvantaged by the reduced support received from their family physicians and lower cessation medication usage. Efforts to promote the implementation of smoking cessation treatment guidelines will help promote smoking abstinence among PWSMI.

Barriers and facilitators of adherence to medical advice on skin self-examination during melanoma follow-up care

BACKGROUND

Melanoma is the fastest growing tumor of the skin, which disproportionately affects younger and middle-aged adults. As melanomas are visible, recognizable, and highly curable while in early stages, early diagnosis is one of the most effective measures to decrease melanoma-related mortality. Skin self-examination results in earlier detection and removal of the melanoma. Due to the elevated risk of survivors for developing subsequent melanomas, monthly self-exams are strongly recommended as part of follow-up care. Yet, only a minority of high-risk individuals practices systematic and regular self-exams. This can be improved through patient education. However, dermatological education is effective only in about 50% of the cases and little is known about those who do not respond. In the current literature, psychosocial variables like distress, coping with cancer, as well as partner and physician support are widely neglected in relation to the practice of skin self-examination, despite the fact that they have been shown to be essential for other health behaviors and for adherence to medical advice. Moreover, the current body of knowledge is compromised by the inconsistent conceptualization of SSE. The main objective of the current project is to examine psychosocial predictors of skin self-examination using on a rigorous and clinically sound methodology.

METHODS/DESIGN

The longitudinal, mixed-method study examines key psychosocial variables related to the acquisition and to the long-term maintenance of skin self-examination in 200 patients with melanoma. Practice of self-exam behaviors is assessed at 3 and 12 months after receiving an educational intervention designed based on best-practice standards. Examined predictors of skin self-exam behaviors include biological sex, perceived self-exam efficacy, distress, partner and physician support, and coping strategies. Qualitative analyses of semi-structured interviews will complement and enlighten the quantitative findings.

DISCUSSION

The identification of short and long-term predictors of skin self-examination and an increased understanding of barriers will allow health care professionals to better address patient difficulties in adhering to this life-saving health behavior. Furthermore, the findings will enable the development and evaluation of evidence-based, comprehensive intervention strategies. Ultimately, these findings could impact a wide range of outreach programs and secondary prevention initiatives for other populations with increased melanoma risk.