***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE : To assess the status of medical education in end-of-life care and identify opportunities for improvement . DESIGN : Telephone survey . SETTING : U.S. academic medical centers . PARTICIPANTS : National probability sample of 1,455 students , 296 residents , and 287 faculty ( response rates 62 % , 56 % , and 41 % , respectively ) affiliated with a r and om sample of 62 accredited U.S. medical schools . MEASUREMENTS AND MAIN RESULTS : Measurements assessed attitudes , quantity and quality of education , preparation to provide or teach care , and perceived value of care for dying patients . Ninety percent or more of respondents held positive views about physicians ’ responsibility and ability to help dying patients . However , fewer than 18 % of students and residents received formal end-of-life care education , 39 % of students reported being unprepared to address patients ’ fears , and nearly half felt unprepared to manage their feelings about patients ’ deaths or help bereaved families . More than 40 % of residents felt unprepared to teach end-of-life care . More than 40 % of respondents reported that dying patients were not considered good teaching cases , and that meeting psychosocial needs of dying patients was not considered a core competency . Forty-nine percent of students had told patients about the existence of a life-threatening illness , but only half received feedback from residents or attendings ; nearly all residents had talked with patients about wishes for end-of-life care , and 33 % received no feedback . CONCLUSIONS : Students and residents in the United States feel unprepared to provide , and faculty and residents unprepared to teach , many key components of good care for the dying . Current educational practice s and institutional culture in U.S. medical schools do not support adequate end-of-life care , and attention to both curricular and cultural change are needed to improve end-of-life care education Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more BACKGROUND : Although opioids are central to acute pain management , numerous studies have shown that many physicians prescribe them incorrectly , result ing in inadequate pain management and side effects . We assessed whether a case-based palliative medicine curriculum could improve medical house staff opioid prescribing practice s. DESIGN : Prospect i ve chart review of consecutive pharmacy and billing records of patients who received an opioid during hospitalization before and after the implementation of a curricular intervention , consisting of 10 one-hour case-based modules , including 2 pain management seminars . MEASUREMENTS : Consecutive pharmacy and billing records of patients who were cared for by medical residents ( n=733 ) and a comparison group of neurology and rehabilitative medicine patients ( n=273 ) that received an opioid during hospitalization in 8-month periods before ( 1/1/97 to 4/30/97 ) and after ( 1/1/99 to 4/30/99 ) the implementation of the curriculum on the medical service were review ed . Three outcomes were measured : 1 ) percent of opioid orders for meperidine ; 2 ) percent of opioid orders with concomminant bowel regimen ; and 3 ) percent of opioid orders using adjuvant nonsteroidal anti-inflammatory drugs (NSAIDs).MAIN RESULTS : The percentage of patients receiving meperidine decreased in the study group , but not in the comparison group . The percentages receiving NSAIDs and bowel medications increased in both groups . In multivariate logistic models controlling for age and race , the odds of an experimental group patient receiving meperidine in the post-period decreased to 0.55 ( 95 % confidence interval [ 95 % CI ] , 0.32 to 0.96 ) , while the odds of receiving a bowel medication or NSAID increased to 1.48 ( 95 % CI , 1.07 to 2.03 ) and 1.53 ( 95 % CI , 1.01 to 2.32 ) , respectively . In the comparison group models , the odds of receiving a NSAID in the post-period increased significantly to 2.27 ( 95 % CI , 1.10 to 4.67 ) , but the odds of receiving a bowel medication ( 0.45 ; 95 % CI , 0.74 to 2.00 ) or meperidine ( 0.85 ; 95 % CI , 0.51 to 2.30 ) were not significantly different from baseline . CONCLUSIONS : This palliative care curriculum was associated with a sustained ( > 6 months ) improvement in medical residents ’ opioid prescribing practice s. Further research is needed to underst and the changes that occurred and how they can be translated into improved patient outcomes Non-r and omised studies of the effects of interventions are critical to many areas of healthcare evaluation , but their results may be biased . It is therefore important to underst and and appraise their strengths and weaknesses . We developed ROBINS-I ( “ Risk Of Bias In Non-r and omised Studies - of Interventions ” ) , a new tool for evaluating risk of bias in estimates of the comparative effectiveness ( harm or benefit ) of interventions from studies that did not use r and omisation  to allocate units ( individuals or clusters of individuals ) to comparison groups . The tool will be particularly useful to those undertaking systematic review s that include non-r and omised studies Inadequate physician knowledge , particularly in areas of pain assessment and use of analgesics , has been identified as a major factor contributing to poor pain management in cancer patients . In most medical schools , teaching in Palliative Care at both the undergraduate and postgraduate levels is limited or nonexistent . Baseline knowledge and changes in knowledge in areas relevant to Palliative Care were assessed by the use of 2 16- question examinations ( Exams A and B ) in 78 second-year Family Medicine Residents from the University of Alberta Family Medicine Residency Program . The residents participated in a two-week rotation on the Acute Palliative Care Unit at the Edmonton General Hospital or Grey Nuns Community Health Centre between September 1991 and February 1996 . The residents were r and omly assigned on their first day ( Time 1 ) to complete either Exam A or B and were subsequently crossed over on their final day of the rotation to complete the alternate Exam ( Time 2 ) . Six domains were represented in the Exams as follows : pain assessment , opioid use , adjuvant medications , delirium , urinary catheterization , and hydration . Improvements were noted in the mean percentage results in Time 2 compared with Time 1 for Exams A , B , and A and B combined . Mean global percentage results were 53 + /- 15 versus 73 + /- 13 ( p < 0.001 ) at Times 1 and 2 , respectively . There were significant improvements for domains in Time 2 compared to Time 1 ( p < or = 0.05 ) for combined A and B Exam except for urinary catheterization . Despite these documented improvements in scores , serious deficiencies were identified particularly in the areas of pain assessment and opioid use , namely opioid sude effects and issues involving dependence , addiction , and tolerance . Examinations , such as the two used in this study , can be a useful aid in assessing physician knowledge in addition to structuring teaching in Palliative Care . Examination content will require updating as knowledge in Palliative Care evolves BACKGROUND Previous end-of-life and palliative care curricula for surgical residents have shown improved learner confidence , but have not measured cognitive knowledge or skill acquisition . METHODS A nonr and omized trial evaluated a structured palliative care curriculum for  7 postgraduate year 2 surgical residents ( intervention group ) compared with 6 postgraduate year 5 surgical residents ( comparison group ) . Outcomes were measured using an 18-item knowledge test , a 20-minute objective structured clinical examination simulating an intensive care unit family conference , and a survey measuring self-confidence . RESULTS The mean knowledge test scores for the intervention group , both before and after undergoing the structured palliative care curriculum , were no different from the comparison group . There was also no difference in objective structured clinical examination scores between the 2 groups . The intervention group felt less comfortable managing pain , breaking bad news , or addressing ethical issues . CONCLUSIONS Junior surgical residents have similar palliative care knowledge to senior residents without a palliative care curriculum . After participating in a palliative care curriculum , they have simulated skills that are similar to chief residents . However , self-confidence is lower among junior residents despite undergoing a palliative care curriculum Little attention has been paid to the symptom management needs of patients with life-threatening diseases other than cancer . In this study , we aim ed to determine to what extent patients with progressive chronic diseases have similar symptom profiles . A systematic search of medical data bases ( MEDLINE , EMBASE , and PsycINFO ) and textbooks identified 64 original studies reporting the prevalence of 11 common symptoms among end-stage patients with cancer , acquired immunodeficiency syndrome ( AIDS ) , heart disease , chronic obstructive pulmonary disease , or renal disease . Analyzing the data in a comparative table ( a grid ) , we found that the prevalence of the 11 symptoms was often widely but homogeneously spread across the five diseases . Three symptoms-pain , breathlessness , and fatigue-were found among more than 50 % of patients , for all five diseases . There appears to be a common pathway toward death for malignant and nonmalignant diseases . The design s of symptom prevalence studies need to be improved because of method ological disparities in symptom assessment and design PURPOSE To investigate the strength of association between trainees ' self- assessment s of the quality of their end-of-life communication skills and the assessment s of their patients , patients ' families , and clinician-evaluators . METHODS As part of a r and omized trial , pre-intervention survey data were collected at two sites from internal medicine trainees and their patients , patients ' families , and clinician-evaluators . In this observational analysis , comparisons using regression analysis were made between ( 1 ) trainees ' scores on a scale of perceived competence at communication about end-of-life care and ( 2 ) patients ' , families ' , and clinician-evaluators ' scores on a question naire on the quality of end-of-life communication ( QOC ) . Secondary analyses were performed using topic-focused subscales of these measures . RESULTS Internal medicine trainees ( 143 ) were studied with both self- assessment and external assessment s. No significant associations were found between trainee perceived competence scores and primary outcome measures ( p>0.05 ) . Of the 12 secondary subscale analyses , trainees ' self-ratings were significantly associated with external assessment s for only one comparison , but the association was in the opposite direction with increased trainee ratings being significantly associated with decreased family ratings on " treatment discussion s. " We also examined the correlation between ratings by patients , family , and clinician-evaluators , which showed significant correlations ( p<0.05 ) for 7 of 18 comparisons ( 38.9 % ) . CONCLUSIONS Trainee self-evaluations do not predict assessment s by their patients , patients ' families , or their clinician-evaluators regarding the quality of end-of-life communication . Although these results should be confirmed using the same measures across all raters , in the meantime efforts to improve communication about end-of-life care should consider outcomes other than physician self- assessment to determine intervention success BACKGROUND House officers frequently lack basic competency in end-of-life care . Few studies have evaluated educational interventions deliberately utilizing physicians ' learning strategies , particularly in the context of a concomitant effort at modification of practice patterns . STUDY DESIGN Prospect i ve controlled trial utilizing pre-intervention and post-intervention cross-sectional surveys . PARTICIPANTS Internal medicine residents at a university hospital in their first , second , and third years of training . SURVEY A 25-item survey modified from previously published instruments . INTERVENTION Residents in the intervention group utilized an experiential learning intervention ( integrated , end-of-life clinical pathway : PEACE Tool ) . The control group delivered care in a st and ard fashion . DATA ANALYSIS SURVEY item and test responses were tabulated and pair-wise comparisons between group means evaluated statistically using two- sample t tests . RESULTS Fifty-four internal medicine residents ( n = 24 , first-year ; n = 17 , second-year ; and n = 13 , third-year ) completed the survey . Pre-intervention mean scores on a 16-item knowledge scale were 7.4 ( 46 % correct ) for first-year , 8.1 ( 51 % ) for second-year , and 9.2 ( 58 % ) for third-year residents . Eighteen first-year residents participated in the intervention phase ( 8 in the intervention , 10 in the control ) . Mean overall knowledge scores were 46 % higher in the intervention group compared to the control group ( 11.8 versus 8.1 p < 0.001 ) . CONCLUSIONS A time-effective , practice -based strategy led to a significant improvement in knowledge of end-of-life care . Prior to implementation of this strategy competency in end-of-life care was suboptimal among internal medicine residents , in spite of desirable attitudes . Factual knowledge improved slightly with st and ard , pre-intervention training and experience Background : Health-care costs are growing , with little population -based data about people ’s priorities for end-of-life care , to guide service development and aid discussion s. Aim : We examined variations in people ’s priorities for treatment , care and information across seven European countries . Design : Telephone survey of a r and om sample of households ; we asked respondents their priorities if ‘ faced with a serious illness , like cancer , with limited time to live ’ and used multivariable logistic regressions to identify associated factors . Setting / participants : Members of the general public aged  
    Output:
    
Despite method ological considerations , all educational methods improved trainees ' learning outcomes .
Current educational training programs in symptom management appear to improve trainees ' comfort , preparedness , and knowledge in assessing and managing patients ' symptoms at the end of life .