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Coaching supports academic goals, professional development and wellbeing in medical education. Scant literature exists on training and assessing coaches and evaluating coaching programs. To begin filling this gap, we created a set of coach competencies for medical education using a modified Delphi approach.An expert team assembled, comprised of seven experts in the field of coaching. A modified Delphi approach was utilized to develop competencies.Fifteen competencies in five domains resulted: coaching process and structure, relational skills, coaching skills, coaching theories and models, and coach development.These competencies delineate essential features of a coach in medical education. Next steps include creating faculty development and assessment tools for coaching.

Coaching is rapidly advancing in medical education as a relational process of facilitating sustainable change and growth. Coaching can support learners in emergency medicine at any stage by improving self-reflection, motivation, psychological capital, and goal creation and attainment. Different from the traditional models of advising and mentoring, coaching may be a new model for many educators. An introduction to key coaching concepts and ways they may be implemented in emergency medicine is provided. Experienced coaches employ a diverse array of models and techniques that may be new to novice coaches. This article summarizes a variety of coaching models, theories, and content areas that can be adapted to a coachee's needs and the situational context-be it the fast-paced emergency department or the faculty member's office.

Dr. Gail Gazelle writes that hospice care is now considered part of mainstream medicine, as evidenced by growing patient enrollment and Medicare expenditures. But despite its increased use, many aspects of hospice care are still misunderstood by both physicians and patients. Timothy Quill discusses U.S. hospice programs, patients' and physicians' attitudes toward such care, and the “open-access” option for combining disease-directed treatment with hospice services. Dr. Quill is director of the Center for Ethics, Humanities, and Palliative Care at the University of Rochester.

The past two decades have witnessed dramatic changes in professional values and social expectations regarding medical care and decision making at the end of life. Increased emphasis on patients' autonomy and participation have made open discussion, both in the medical and popular literature and at the bedside, the new norm. The seemingly final taboo, euthanasia, is now the topic of frank public, intellectual, and legal debate. Although Wanzer et al., in their 1989 second look at “The Physician's Responsibility toward Hopelessly Ill Patients,” wrote that the “entire subject is now discussed openly,”1 there remains a practice that has received little . . .

Background: We examined deaths of Medicare beneficiaries in Massachusetts and California to evaluate the effect of managed care on the use of hospice and site of death and to determine how hospice affects the expenditures for the last year of life. Methods: Medicare data for beneficiaries in Massachusetts (n=37 933) and California (n=27 685) who died in 1996 were merged with each state’s death certificate files to determine site and cause of death. Expenditure data were Health Care Financing Administration payments and were divided into 30-day periods from the date of death back 12 months. Results: In Massachusetts, only 7% of decedents were enrolled in managed care organizations (MCOs); in California, 28%. More than 60% of hospice users had cancer. Hospice use was much lower in Massachusetts than in California (12% vs 18%). In both states, decedents enrolled in MCOs used hospice care much more than those enrolled in fee-for-service plans (17% vs 11% in Massachusetts and 25% vs 15% in California). This pattern persisted for those with cancer and younger (aged 65-74 years) decedents. Decedents receiving hospice care were significantly (P.001 for both) less likely to die in the hospital (11% vs 43% in Massachusetts and 5% vs 43% in California). Enrollment in MCOs did not affect the proportion of in-hospital deaths (those enrolled in fee-forservice plans vs MCOs: 40% vs 39% in Massachusetts; and 37% vs 34% in California). Expenditures in the last year of life were $28 588 in Massachusetts and $27 814 in California; about one third of the expenditures occurred in the last month before death. Hospital services accounted for more than 50% of all expenditures in both states, despite 77% of decedents being hospitalized in Massachusetts and just 55% being hospitalized in California. Among patients with cancer, expenditures were 13% to 20% lower for those in hospice. Conclusions: Medicare-insured decedents in California were more than 4 times more likely to be enrolled in MCOs, were 50% more likely to use a hospice, and had a 30% lower hospitalization rate than decedents in Massachusetts, yet there are few differences in out-of-hospital deaths or expenditures in the last year of life. However, patients with cancer using hospice did have significant savings. Arch Intern Med. 2002;162:1722-1728

Expenditures for Medicare beneficiaries in the last year of life decrease with increasing age. The cause of this phenomenon is uncertain.To examine this pattern in detail and evaluate whether decreases in aggressiveness of medical care explain the phenomenon.Analysis of sample Medicare data for beneficiaries aged 65 years or older from Massachusetts (n = 34 131) and California (n = 19 064) who died in 1996.Medical expenditures during the last year of life, analyzed by age group, sex, race, place and cause of death, comorbidity, and use of hospital services.For Massachusetts and California, respectively, Medicare expenditures per beneficiary were $35 300 and $27 800 among those aged 65 through 74 years vs $22 000 and $21 600 for those aged 85 years or older. The pattern of decreasing Medicare expenditures with age is pervasive, persisting throughout the last year of life in both states for both sexes, for black and white beneficiaries, for persons with varying levels of comorbidity, and for those receiving hospice vs conventional care, regardless of cause and site of death. The aggressiveness of medical care in both Massachusetts and California also decreased with age, as judged by less frequent hospital and intensive care unit admissions and by markedly decreasing use of cardiac catheterization, dialysis, ventilators, and pulmonary artery monitors, regardless of cause of death. Decrease in the cost of hospital services accounts for approximately 80% of the decrease in Medicare expenditures with age in both states.Medicare expenditures in the last year of life decrease with age, especially for those aged 85 years or older. This is in large part because the aggressiveness of medical care in the last year of life decreases with increasing age.

Palliative care is emerging as an important new field. Although programs are developing in hospital environments, little is known about development of programs in outpatient practices or those serving large managed care populations. This article provides a framework for the development of a comprehensive palliative care program in a large multispecialty group practice that serves managed care patients. The article addresses guiding principles, the need for obtaining baseline data, how the clinical consultation service was established, development of outcomes measures, and information on current program status. Five themes emerged as key to successful program development, most importantly the close collaboration between administrative and clinical staff in all aspects of program development.

303 METHADONE, a potent opioid agonist, has characteristics that make it useful for the treatment of pain when continuous opioid analgesia is indicated. Although available for decades, its use has gained renewed interest because of its low cost and potential activity in neuropathic pain syndromes. Unlike morphine, methadone is a racemic mix; one stereoisomer acts as a N-methyl-D-aspartate (NMDA) receptor antagonist, the other is a mu opioid receptor agonist. The NMDA mechanism appears to play an important role in decreasing opioid tolerance and attenuating neuropathic pain. Any clinician with a Schedule II DEA license can prescribe methadone for pain; a special license is only required to prescribe methadone for the treatment of addiction. In some jurisdictions, it is necessary to write “for pain” on the prescription. Methadone is highly lipophilic with rapid gastrointestinal absorption and onset of action. It has a large initial volume of distribution with slow tissue release. Oral bioavailability is high, approximately 80%. Unlike morphine, there are no active metabolites obviating dose adjustment in renal insufficiency; biotransformation to an active drug is not required. The major route of metabolism is hepatic with significant fecal excretion; renal excretion can be enhanced by urine acidification (pH , 6.0). Methadone is available in tablet, liquid, and injectable forms for oral, rectal, SL, or intravenous use; subcutaneous use is limited because of tissue inflammation. Methadone has an extended terminal half-life, up to 190 hours. This half-life does not match the observed duration of analgesia (6–12 hours) after steady state is reached. This long half-life can lead to drug accumulation and an increased risk for sedation and respiratory depression, especially in the elderly or with rapid dose adjustments; rapid titration guidelines for other opioids do not apply to methadone. Caution must be used when converting from another opioid to methadone Recent work has demonstrated that the dose conversion ratio varies markedly depending on current opioid exposure. Well-established conversion protocols should be used when converting to methadone.2,3 Equianalgesic ratios to convert from methadone to other opioids remain unknown.

Twenty-five to sixty percent of physicians report burnout across all specialties. Changes in the healthcare environment have created marked and growing external pressures. In addition, physicians are predisposed to burnout due to internal traits such as compulsiveness, guilt, and self-denial, and a medical culture that emphasizes perfectionism, denial of personal vulnerability, and delayed gratification. Professional coaching, long utilized in the business world, provides a results-oriented and stigma-free method to address burnout, primarily by increasing one’s internal locus of control. Coaching enhances self-awareness, drawing on individual strengths, questioning self-defeating thoughts and beliefs, examining new perspectives, and aligning personal values with professional duties. Coaching utilizes established techniques to increase one’s sense of accomplishment, purpose, and engagement, all critical in ameliorating burnout. Coaching presumes that the client already possesses strengths and skills to handle life’s challenges, but is not accessing them maximally. Although an evidence base is not yet established, the theoretical basis of coaching’s efficacy derives from the fields of positive psychology, mindfulness, and self-determination theory. Using a case example, this article demonstrates the potential of professional coaching to address physician burnout.