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What Is the “Right” Intensity of Care at the End of Life and How Do We Get There?

J. Randall Curtis, MD, MPH; and Ruth A. Engelberg, PhD
[+] Article, Author, and Disclosure Information

From Harborview Medical Center, University of Washington, Seattle, WA 98104

Grant Support: By the National Institute of Nursing Research grants R01 NR005226 and R01 NR009987 and the National Heart, Lung, and Blood Institute grant K24 HL68593 (Drs. Curtis and Engelberg).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2909.

Requests for Single Reprints: J. Randall Curtis, MD, MPH, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, Box 359762, University of Washington, 325 Ninth Avenue, Seattle, WA 98104-2499; e-mail, jrc@u.washington.edu.

Current Author Addresses: Dr. Curtis: Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, Box 359762, University of Washington, 325 Ninth Avenue, Seattle, WA 98104-2499.

Dr. Engelberg: Division of Pulmonary and Critical Care, University of Washington, Box 359765, 325 Ninth Avenue, Seattle, WA 98104-2499.

Ann Intern Med. 2011;154(4):283-284. doi:10.7326/0003-4819-154-4-201102150-00009
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In this issue, Kelley and colleagues report that the intensity of end-of-life care is associated with several patient-level as well as regional factors. The editorialists discuss how the study extends what we know and highlights the challenges of identifying the “right” intensity of care for individual patients.

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Need to get back to the basics
Posted on March 2, 2011
John L. Friedman
No Affiliation
Conflict of Interest: None Declared

To the Editor:

I found the above article interesting and the subject challenging and important.

But I do not see how our medical schools and post-graduate training programs can make any headway in managing the very complicated and daunting medical problems of life and the end of life if our medical schools and post-graduate training programs cannot teach our medical students, residents and fellows how to do a basic medical history and and physical examination and how to choose the appropriate medical workup on an ill human being.

When I was in medical school in the early fifties, thorough history and physical examinations were taught and emphasized through repeated teaching, and medical workups were practiced over and over again.

I have contact with third year Internal Medicine Residents. None know how to use a stethoscope or palpate an abdomen, nor do they spend more than a few minutes on a cursory initial history and a superficial physical examination.

My wife and I have not had to take our upper garments off to have our lungs and heart examined or our abdomens palpated in many years, and we usually have our blood pressure taken with a cuff placed over a long- sleeved shirt and a sweater. The medical care we receive, except from one or two senior physicians, is really of low quality.

Before we try to tackle the difficult and complex problems our educational institutions have to back up and start all over again teaching the basics of internal medicine. Once we make headway here we can then start trying to deal with the complex problems of the modern medical world.

Conflict of Interest:

None declared

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