Improving medical graduates’ training in palliative care: advancing education and practice

Figures & data

Figure 1 Flowchart of literature search procedure for eligible studies.

Abbreviation: PC, palliative care.

Table 1 Summary of palliative medical education efforts outside the US published in the English literature (January 2005–June 2015)

Author (date)	Country	Number of students involved	Teaching methodologies Required or elective	Student time	Level of evaluation (Kirkpatrick)	Results
Auret and Starmer (2008)^Citation1	Australia	91	Palliative care structured clinical instruction modules Required	2 hours	2, 3	Increase in student perceptions of knowledge and skill from pre- to post-test with a sustained increase in a subsample in long-term follow-up
Borgstrom et al (2013)^Citation2	UK	123	Students complete a PC course including lectures, assigned readings, and written observations of interactions with two patients approaching the EOL – one in the hospital and one in the community Required	NR	2, 3	Qualitative analysis of the essays revealed that the students’ understanding of clinical care was challenged when they were unable to treat or cure the disease. Students viewed patient denial as a disease-like object that should be diagnosed and treated
Bridge and Bennett (2014)^Citation3	Australia	36	Placement in a hospital-based PC unit plus educational DVDs, readings, journaling, and small group sessions with a PC physician facilitator Required	2 weeks	1, 2, and 3	Qualitative reflection indicated high satisfaction, increased knowledge, and student perception of skill
Centeno et al (2014)^Citation4	Spain	316	45 hours of teaching (predominantly lecture) by different professionals experienced in PC; two clinical days Elective	60 hours	1, 2, and 3	Qualitative analysis of evaluative comments revealed: the course helped students become and act as doctors; the benefits of having a holistic view of patient and family; the course makes students think and reflect on their personal development and encourages them to deepen the humanistic aspect of their practice; the practical (clinical) aspect is essential in PC learning
Hall et al (2011)^Citation5	Canada	141	Team Observed Structured Clinical Encounter (TOSCE) stations using PC case scenarios Required	4 hours	1	Learners were satisfied and TOSCE was found to be feasible
Jahan et al (2013)^Citation6	Oman	73	Lectures, demonstrations, and group teachings Required	NR	2	Deficiency in post-test knowledge and perception related to the following: symptom control, interdisciplinary team members, and communicating problems to patient and family
Kaufert et al (2010)^Citation7	Canada	6	Classroom-based learning Elective	2 hours	1, 2	Qualitative data on student perception of satisfaction and knowledge had mixed results
Loh et al (2006)^Citation8	Malaysia	50	One week each of lectures, ward rounds, and a hospice attachment Elective	3 weeks	1, 2	Increase in PC knowledge from pre- to post-test
Mason and Ellershaw (2008)^Citation9	UK	216	Problem-based learning approach employed to integrate PC vertically and horizontally across the curriculum. Two-week PC module offered during fourth year to consolidate and further develop learning integrated throughout the curriculum Required	2 weeks for module	2, 3	Pre- and postsurveys using the Self-efficacy in Palliative Care Scale (SEPC) and the Thanatophobia Scale (TS) Statistically significant differences pre- and postsurveys were found for both scales. Qualitative analysis of focus group feedback found increased understanding of the nature and structure of PC, changes anticipated in future practice, and realization of communication challenges
Mason and Ellershaw (2010)^Citation10	UK	660	Cohort 1 spent 8 days (two classroom, 6 clinical) while cohort 2 had an additional 3 days of clinical placement, 3 days of advanced communication skill training, and a 2-day group ethics project Required	8 days (Cohort 1) 16 days (Cohort 2)	2, 3	Both cohorts showed statistically significant improvement on the SEPC and TS given before and after the education. Cohort 2 showed a statistically significant greater improvement in self-efficacy across all subscales of the SEPC when compared to Cohort 1 with the largest effect between cohorts being in communication
Mutto et al (2014)^Citation11	Argentina	146	Classroom-based learning, small group problem-based learning and 2 clinical rotations in a PC unit Elective	7 weeks	1, 2, and 3	Increases in students’ self-perceived attitudes toward suffering and knowledge in addition to improvements in comfort levels in evaluation and treatment of pain. High satisfaction indicated
Ozcakir et al (2014)^Citation12	Turkey	518	First-year medical students watched the movie, Wit, after which they completed an evaluation survey Not specified	2 hours	1	88% rated the film as excellent, very good, or good. 80.5% stated the film made them think about the emotional and spiritual suffering of dying patients. 65.3% thought that caring for dying patients would be very or fairly personally satisfying
Philip and Remlabeevi (2010)^Citation13	India	124	Comprehensive community-based PC course using lecture, video, and group discussions, followed by a clinical rotation Not specified	3 days	1, 2, and 3	High quantitative satisfaction and knowledge ratings postcourse and qualitative feedback indicated motivation to change practice
Pinheiro et al (2010)^Citation14	Brazil	NR	Lecture, readings, daylong clinical rotation in an ambulatory PC clinic, followed by a reflective writing session Not specified	1 week	1, 2, and 3	Qualitative data on student perception of satisfaction, knowledge, and skill not completely reported. Themes included keeping the focus on the patient, students went from fearing EOL to feeling confident they could provide comfort, and narrative medicine approach was helpful
Romotzky et al (2014)^Citation15	Germany	17	Use of simulated patients for EOL communication training; case vignettes in five different settings concerning atypical communication situations developed by a multidisciplinary panel of PC experts Elective	Five sessions	1, 2	Qualitative results indicate urgent need for better communication training for medical students. Training with standardized, simulated patients may generate an authentic learning situation for development of student skills
Schulz et al (2015)^Citation16	Germany	556	Interdisciplinary, longitudinal curriculum employing innovative teaching methods (virtual standardized/simulated patient contacts, e-learning courses, interdisciplinary teaching, and group sessions for reflective self-development) aimed at teaching PC core competencies Required	60 teaching units	1	Unpublished (manuscript submitted). Components rated highly by pilot students.
Srisawat and Phungrassami (2012)^Citation17	Thailand	110	Lecture, group discussion, role playing, site visits, and ward rounds Required	4 weeks	2, 3	At least 80% of participants were confident to manage cases independently or under supervision in holistic care and communication but less than 80% were confident in common symptom management and ethical aspects
Stecho et al (2012)^Citation18	Canada	126	Classroom training, small group discussion, didactics, and a clinical rotation with a hospice volunteer on home visits Elective	6 months	1, 2	Significant decreases in participants’ anxiety regarding death and communicating with dying patients, and high quantitative and qualitative satisfaction
Tai et al (2014)^Citation19	Australia	84	Placement in a hospital-based PC unit Elective	1 week	1, 2	High satisfaction ratings and palliative care knowledge increases for most learners
Tan et al (2013)^Citation20	Canada	130	Online “virtual” patient clinical case Required	1 hour on average	1, 2, and 3	High satisfaction and increases in student perceptions of knowledge and level of preparedness managing EOL clinical situations
Yardley et al (2013)^Citation21	UK	79	Integrated undergraduate curriculum using a hybrid model of learning opportunities (problem-based learning, experiential learning, laboratory sessions, lectures, and clinical placements); one study day in EOL care consisting of a plenary, role play using simulated patients followed by feedback and debriefing Required	8-hour study day	1, 2	96% agreed that the study day helped them understand issues related to dying; 91% agreed they were able to apply their learning in other parts of the course including clinical practice, communication skills (88%), and prescribing skills (92%)

Notes: ¹ Auret K, Starmer DL. Using Structured Clinical Instruction Modules (SCIM) in teaching palliative care to undergraduate medical students. J Cancer Educ. 2008;23(3):149–155.² Borgstrom E, Barclay S, Cohn S. Constructing denial as a disease object: accounts by medical students meeting dying patients. Sociol Health Illn. 2013;35(3):391–404.³ Bridge DT, Bennett KS. “Spirituality, suffering, and healing”: a learning option for Australian medical students. J Pain Symptom Manage. 2014;47(3):659–665.⁴ Centeno C, Ballesteros M, Carrasco J, Arantzamendi M. Does palliative care education matter to medical students? The experience of attending an undergraduate course in palliative care. BMJ Support Paliat Care. 2014.⁵ Hall P, Marshall D, Weaver L, Boyle A, Taniguchi A. A method to enhance student teams in palliative care: Piloting the McMaster-Ottawa team observed structured clinical encounter. J Palliat Med. 2011;14(6):744–750.⁶ Jahan F, Al Shibli HS, Qatan RS, Al Kharusi AA. Perception of undergraduate medical students in clinical years regarding palliative care. Middle East J Age and Ageing. 2013;10(2):22–31.⁷ Kaufert J, R, Schwartz K,Labine L, Lutfiyya Z, Pearse C. End-of-life ethics and disability: differing perspectives on case-based learning. Med Health Care Philos. 2010;12(2):115–126.⁸ Loh KY, Kwa SK, Nurjahan MI. Palliative medicine as an elective posting for undergraduates. Med Educ. 2006;40:1131–1132.⁹ Mason SR, Ellershaw JE. Preparing for palliative medicine; evaluation of an education programme for fourth year medical undergraduates. Palliat Med. 2008;22(6):687–692.¹⁰ Mason SR, Ellershaw JE. Undergraduate training in palliative medicine: is more necessarily better? Palliat Med. 2010;24(3):306–309.¹¹ Mutto EM, Bunge S, Vignaroli E, Bertolino M, Villar MJ, Wenk R. Medical students’ palliative care education in a Latin American university: a three-year experience at Austral University in Buenos Aires, Argentina. J Palliat Med. 2014;17(10):1137–1142.¹² Ozcakir A, Bilgel N. Educating medical students about the personal meaning of terminal illness using the film, “Wit”; J Palliat Med. 2014;17(8):913–917.¹³ Philip S, Remlabeevi A. Teaching community-based palliative care to medical students. Med Educ. 2010;44(11):1136–1137.¹⁴ Pinheiro TR, De Benedetto MA, Levites MR, Giglio AD, Blasco PG. Teaching palliative care to residents and medical students. Fam Med. 2010;42(8):580–582.¹⁵ Romotzky V, Galushko M, Dusterdiek A, et al. “It’s Not that Easy”-Medical Students’ Fears and Barriers in End-of-Life Communication. J Cancer Educ. 2015;30:333–339.¹⁶ Schulz C, Wenzel-Meyburg U, Karger A, et al. Implementation of palliative care as a mandatory cross-disciplinary subject (QB13) at the Medical Faculty of the Heinrich-Heine-University Dusseldorf, Germany. GMS Z Med Ausbild. 2015;32(1):Doc6.¹⁷ Srisawat S, Phungrassami T. Thai medical students’ self assessment of palliative care competencies. Palliat Care: Res Treat. 2012(6):1–8.¹⁸ Stecho Khalaf R, Prendergast P, Geerlinks A, Lingard L, Schulz V. Being a hospice volunteer influenced medical students’ comfort with dying and death: a pilot study. J Palliat Care. 2012;28(3):149–156.¹⁹ Tai V, Cameron-Taylor E, Clark K. A mixed methodology retrospective analysis of the learning experience of final year medical students attached to a 1-week intensive palliative care course based at an Australian university. Am J Hosp Palliat Care. 2014;31(6):636–640.²⁰ Tan A. Medical students and dying patients. Virtual Mentor. 2013;15(12):1027–1033.²¹ Yardley S, Hookey C, Lefroy J. Designing whole-task learning opportunities for integrated end-of-life care: a practitioner-derived enquiry. Educ Prim Care. 2013;24(6):436–443.

Abbreviations: DVD, digital video disc; EOL, end-of-life; NR, not reported; PC, palliative care.

Table 2 Summary of notable innovative educational efforts in palliative care (January 2005–June 2015)

Author (date)	Country	Number of students involved	Teaching methodologies Required/elective	Student time	Level of evaluation (Kirkpatrick)	Results
Alt-Epping et al (2014)^Citation1	Germany	224	Lecture and seminar Required	NR	1, 2	93.9% “felt not only stimulated to think about the subject of death and dying, but also felt prepared better for the handling of deceased persons”
Burke and Smith (2005)^Citation2	USA	70	Lectures, case studies, and bedside teaching/role modeling by NP Required	4 days	1	97% of students rated the curriculum “very good” or “excellent,” and >90% of students rated NP faculty as “very good” or “excellent” on teaching, attitude, role modeling, and sparking interest/participation
Ellman et al (2012)^Citation3	USA	211	Online case-based module; reflection exercise; small group problem-based learning workshop Required	155 minutes	1, 2	Both qualitative analysis of reflections and student self-report reflected positive interdisciplinary learning and meeting of course objectives
Green and Levi(2011)^Citation4	USA	133	Lectures, small group discussion Required	NR	2, 3	Students self-report of greater knowledge of advance care planning and greater confidence in assisting patients; patients’ satisfaction with advanced care planning method greater in intervention group (8.1) vs control group (6.6)
Hall et al (2006)^Citation5	Canada	8	Lectures, reflection exercise, and large group discussion Elective	12 weeks	1, 2	Authors stated that students’ assignments showed deepening of their reflective skills and attitudinal changes toward other disciplines
Head et al (2015)^Citation6	USA	352	Online case-based modules, reflection exercise, small group interdisciplinary case management exercise Required	12–48 hours	1, 2	Students demonstrated a significant difference in EOL skills and self-efficacy for interprofessional experiential learning. Student evaluations of the curriculum were positive
Jeffrey et al (2012)^Citation7	Ireland	9	Workshop, group discussion, reflection exercise, and theatrical performance Elective	2 weeks	1	Students reported they had achieved the learning outcomes for the module. Desired learning outcomes were not specified, but authors stated intent of curriculum to help students “develop a creative approach to problem-solving and to gain a better understanding of the patient’s experience” at the end of life”
Kitzes et al (2009)^Citation8	USA	63	Facilitated small group discussion Required	2 hours	1, 2 and 3	Student self-assessment of EOL knowledge and skills pre- and postintervention revealed effect sizes ranging from 0.9 to 1.9 in five skill categories. Faculty coding of student dialogue reflected student demonstration of six core competencies
Morrison and Forbes (2012)^Citation9	USA	157	Lecture, role-modeling, and online module with corresponding examination Required	8 hours	2, 3	Students demonstrated statistically significant improvement in basic opioid knowledge based on examination and improved EOL attitudes as measured on the Thanatophobia Scale
Radwany et al (2011)^Citation10	USA	Not specified	Lectures, standardized patients, observation of interdisciplinary team meetings and patient encounters, case-based learning experience, reflective essays, and small group discussions Required	NR	1, 3	Evaluation data limited to subjective feedback from faculty, students, and patients, except for examination questions in preclinical years (results not reported). Student self-evaluation and evaluation of the Clinical Epilogue experience were included and favorable
Schillerstrom et al (2012)^Citation11	USA	222	Facilitated small group discussion Required	NR	1, 2	Increased comfort levels (77%) and improved knowledge on EOL issues (85%) were noted
Stevens et al (2009)^Citation12	USA	134	Lectures, small group seminars, and Objective structured clinical exam Required	8 hours	2, 3	Intervention cohort outperformed the control cohort in acute pain basic (82.8% vs. 66.5%) and terminal pain advanced pain management skills (54.3% vs. 28.8%)

Abbreviations: NP, nurse practitioner; EOL, end-of-life; NR, not reported.

Table 3 Comprehensive and Essential Palliative Care Competencies for Medical Students and Internal Medicine/Family Medicine Residents, Developed from a Survey of 71 Palliative Care Experts, 2012a

Comprehensive Palliative Care Competencies for Medical Students Caring for Seriously Ill Patients	Comprehensive Palliative Care Competencies for Internal and Family Medicine Residents Caring for Seriously Ill Patients
Pain and symptom management	Pain and symptom management
1. Assesses pain systematically and distinguishes nociceptive from neuropathic pain syndromes.	1. Assesses pain systematically and treats pain effectively with opioids, non-opioid analgesics, and non-pharmacologic interventions.
2. Describes key issues and principles of pain management with opioids, including equianalgesic dosing, common side effects, addiction, tolerance, and dependence.	2. Defines and applies principles of opioid prescription, including equianalgesic dosing and common side effects, and an understanding that appropriate use of opioids rarely leads to respiratory depression or addiction when treating cancer-related pain.
3. Assesses non-pain symptoms and outlines a differential diagnosis,initial work-up and treatment plan.	3. Assesses and manages non-pain symptoms and conditions, including but not limited to, dyspnea, nausea, bowel obstruction, and cord compression using current best practices.
4. Describes an approach to the diagnosis of anxiety, depression anddelirium.	4. Assesses and diagnoses anxiety, depression and delirium and provides appropriate initial treatment and referral.
Communication	Communication
5. Explores patient and family understanding of illness, concerns, goals, and values that inform the plan of care.	5. Explores patient and family understanding of illness, concerns, goals, and values, and identifies treatment plans that respect and align with these priorities.
6. Demonstrates patient-centered communication techniques whengiving bad news and discussing resuscitation preferences.	6. Demonstrates effective patient-centered communication when giving bad news or prognostic information, discussing resuscitation preferences, and coaching patients and families through the dying process.
7. Demonstrates basic approaches to handling emotion in patients and families facing serious illness.	7. Demonstrates effective approaches to exploring and handling strong emotions in patients and families facing serious illness.
Psychosocial, spiritual, and cultural aspects of care	Psychosocial, spiritual, and cultural aspects of care
8. Identifies psychosocial distress in patients and families.	8. Identifies psychosocial distress in individual patients and families, and provides support and appropriate referral.
9. Identifies spiritual and existential suffering in patients and families.	9. Evaluates spiritual and existential distress in individual patients and families, and provides support and appropriate referral.
10. Identifies patients’ and families’ cultural values, beliefs, and practicesrelated to serious illness and end-of-life care.	10. Identifies patients’ and families’ values, cultural beliefs and practices related to serious illness and end-of-life care, and integrates these into the treatment plan.
Terminal care and bereavement	Terminal care and bereavement
11. Identifies common signs of the dying process and describes treatments for common symptoms at the end of life.	11. Identifies and manages common signs and symptoms at the end of life.
12. Describes the communication tasks of a physician when a patient dies, such as pronouncement, family notification and support, and request for autopsy.	12. Describes and performs communication tasks effectively at the time of death, including pronouncement, family notification and support, and request for autopsy.
13. Describes normal grief and bereavement, and risk factors for prolonged grief disorder.	13. Differentiates normal grief from prolonged grief disorder, and makes appropriate referrals.
14. Describes ethical principles that inform decision-making in seriousillness, including the right to forgo or withdraw life-sustaining treatment and the rationale for obtaining a surrogate decision maker.	14. Describes and applies ethical principles that inform decision-making in serious illness including: 1) the right to forgo or withdraw life-sustaining treatment, 2) decision-making capacity and substituted judgment, and 3) physician-assisted death.
Palliative care principles and practice	Palliative care principles and practice
15. Defines the philosophy and role of palliative care across the life cycle and differentiates hospice from palliative care.	15. Defines and explains the philosophy and roles of palliative care and hospice, and refers appropriate patients.
16. Describes disease trajectories for common serious illnesses in adult and pediatric patients.	16. Applies the evidence base and knowledge of disease trajectories to estimate prognosis in individual patients.
17. Describes the roles of members of an interdisciplinary palliative care team, including nurses, social workers, case managers, chaplains, and pharmacists.	17. Describes the roles of and collaborates with members of an interdisciplinary care team when creating a palliative patient care plan.
18. Reflects on personal emotional reactions to patients’ dying and deaths.	18. Reflects on one’s own emotional reactions, models self-reflection, and acknowledges team distress when caring for dying patients and their families.

Notes:

a Essential graduation competencies in grey. Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents. Academic Medicine. Volume 89/Edition 7 by Schaefer KG, Chittenden EH, Sullivan AM, et al. Copyright 2014 by the Association of American Medical Colleges. Reproduced with permission of the Association of American Medical Colleges via Copyright Clearance Center.⁵⁸

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