An international survey of undergraduate medical education in palliative medicine

"This Project Helped Me to Grow": Experiences of Teaching Palliative Care Using the EDUPALL Project Medical Undergraduate Curriculum

Background: The WHO has proclaimed that palliative care (PC) should be integrated as a routine element of all undergraduate medical and nursing education. The EDUPALL Erasmus+project produced a PC curriculum for undergraduate medical education based on the European Association for Palliative Care (EAPC) recommendations for undergraduate training. This was tested in four Romanian Faculties of Medicine: Universities of Transilvania, Iasi, Targu Mures, and Timisoara. The aim of this study is to describe teachers' satisfaction and views on the effectiveness of the EDUPALL curriculum and supporting learning materials. Methods: We conducted nine semistructured interviews with teachers involved in EDUPALL implementation in their universities. Interviews were transcribed and collected data underwent thematic analysis. Kirkpatrick's four-level evaluation model of training was employed to synthesize the outcomes into final categories of reaction, learning, behavior, and results. Results: Data were categorized against Kirkpatrick's four levels as follows: Level 1 (Reaction) EDUPALL curriculum-a good standard with achievable goals; Level 2 (Learning) Personal appraisal and development needs of the teaching faculty; Level 3 (Behavior) Application of competencies and student feedback; and Level 4 (Results): Faculty- and country-level Impact of the EDUPALL project. Conclusion: EDUPALL curriculum is a good and adaptive model to teach PC at Faculties of Medicine, considered by teachers as a way of bridging an existing training gap for medical students in building essential competencies in symptom management, communication, spirituality, and self-awareness.

Improving the Management of Terminal Delirium at the End of Life

Objective:

Terminal delirium is a distressing process that occurs in the dying phase, often misdiagnosed and undertreated. A hospital developed the “comfort measures order set” for dying patients receiving comfort care in the final 72 h of life. A chart review of patients experiencing terminal delirium revealed that the current medication option initially included in the order set was suboptimally effective and patients with terminal delirium were consistently undertreated. The purpose of this pilot study was to highlight an in-service intervention educating nurses on the management of terminal delirium at the end of life and to assess its effect on their knowledge of the management of patients with terminal delirium.

Methods:

A before-and-after survey design was used to assess the effect of the in-service training on nurses' knowledge of terminal delirium.

Results:

We describe the results from a small sample of nurses at a large urban tertiary care center in Canada. Of the twenty nurses who attended the in-services, 60% had cared for a patient with terminal delirium; however, 50% felt that their knowledge of the topic was inadequate. Despite no statistical significance between the pre- and posttest scores for both the oncology and the medicine unit nurses, all participants who completed posttest survey found the in-services useful.

Conclusions:

The findings from this study provide initial insights into the importance of in-service trainings to improve the end-of-life care and nursing practice. Future research will include expanding this pilot project with sufficient power to assess the significance of these types of interventions.

Facing Death in Medical Training

This study explores how medical students feel about caring for terminally ill patients as well as how their medical courses prepare them for addressing end-of-life (EOL) issues with patients. Four hundred and five Mexican medical students were surveyed through the Student Views on Death questionnaire. The vast majority of students (94%) felt that physicians should inform patients of their impending death. Most students said they felt comfortable talking with (61%) or examining (76%) terminally ill patients. However, only half the students actually talked with patients about death. Participants in our study were interested in learning about EOL medical attention, yet most considered themselves poorly prepared to offer this type of care to terminally ill patients. The study provides objective data on a topic that has scarcely been explored in Mexico, data that will be useful in designing educational activities to improve EOL medical training.

Improving end-of-life care through quality improvement

Although end of life (EoL) care has been identified as an area for quality improvement in hospitals, the quality of care Canadian patients receive at the end of life is not well-evidenced. National statistics indicate that Canadians would prefer to die at home, yet more than 50% die in acute care hospital settings. Busy and often highly specialised acute care units may be perceived as a distressing place of death for both patients and their families. Furthermore, many clinicians are not trained in diagnosing imminent dying, managing symptoms at the end of life or supporting dying patients and their families. As such, to improve the experience of EoL care, a corporate, institution-wide strategy entitled the Quality Dying Initiative was introduced and implemented across a tertiary care academic teaching hospital. A primary focus of this initiative was the implementation of a comprehensive Comfort Measures Strategy. This strategy involved the development of an evidence-based order set, which included elements of symptom assessment and management, patient and family education, and spiritual and emotional support. Staff education and mentoring was also a critical element of the larger Comfort Measures Strategy, as well as an evaluative component.

Learning to care: medical students' reported value and evaluation of palliative care teaching involving meeting patients and reflective writing

BACKGROUND

Over recent years there has been an increase in teaching of both palliative care and reflective practice in UK medical schools. The palliative care teaching at the University of Cambridge School of Clinical Medicine is multi-faceted and involves students writing reflective essays after individually meeting patients approaching the end of life during their final year general practice and hospital medicine placements. This paper draws on two studies examining this teaching element to analyse what the students found valuable about it and to comment on the practice of meeting patients and subsequent reflective writing.

METHODS

Two studies have explored students' perceptions of these course components. The first was a thematic analysis of 234 reflective essays from 123 students written in 2007-2008, including examining what students wrote about the exercise itself. The second project involved a semi-structured questionnaire that students completed anonymously; this paper reports on the free text elements of that study [sample size =107]. Since similar themes were found in both studies, the coding structures from each project were compared and combined, enabling triangulation of the findings around what the students found valuable from the palliative care teaching involving meeting patients and reflective writing.

RESULTS

Overall, students reported that these components of the palliative care teaching are valuable. Four main themes were identified as aspects that students valued: (1) dedicated time with patients, (2) learning about wider elements of treatment and holistic care, (3) practicing communication skills, and (4) learning about themselves through reflective writing. Some students expressed a dislike for having to formally write a reflective essay.

CONCLUSION

It is possible to arrange for all of the medical students to individually meet at least two patients receiving palliative or end of life care. Students found these encounters valuable and many wrote about the benefit of formally writing about these experiences. Students reported finding this model useful in widening their skill-set and understanding of palliative care.

Palliative Care Medical Education in European Universities: A Descriptive Study and Numerical Scoring System Proposal for Assessing Educational Development

CONTEXT

The lack of palliative medicine (PM) education has been identified as a barrier to the development of the discipline. A number of international institutions have called for its implementation within undergraduate medical curricula.

OBJECTIVES

The objectives are to describe the situation of undergraduate PM education in Europe and to propose a scoring system to evaluate its status.

METHODS

This descriptive study was conducted with data provided by key experts from countries of the World Health Organization European Region (n = 53). A numerical scoring system was developed through consensus techniques.

RESULTS

Forty-three countries (81%) provided the requested information. In 13 countries (30%), a PM course is taught in all medical schools, being compulsory in six of them (14%). In 15 countries (35%), PM is taught in at least one university. In 14 countries (33%), PM is not taught within medical curricula. A full professor of PM was identified in 40% of countries. Three indicators were developed to construct a scale (rank 0-100) of educational development: 1) proportion of medical schools that teach PM (weight = 32%); 2) proportion of medical schools that offer PM as a compulsory subject (weight = 40%); 3) total number of PM professors (weight = 28%). The highest level of PM educational development was found in Israel, Norway, the U.K., Belgium, France, Austria, Germany, and Ireland.

CONCLUSION

PM is taught in a substantial number of undergraduate medical programs at European universities, and a qualified teaching structure is emerging; however, there is a wide variation in the level of PM educational development between individual countries.

An important but stressful part of their future work: medical students' attitudes to palliative care throughout their course

CONTEXT

Palliative care (PC) education for medical students is important. Knowledge concerning drugs and services can be readily taught, and skills of communicating with terminally ill patients and their families are increasingly being addressed. Developing positive attitudes toward caring for patients near the end of life is more challenging.

OBJECTIVES

To examine medical students' attitudes toward PC in each year of their course, investigate changes in these attitudes over time during their course, and identify gender differences in attitudes and attitudinal change.

METHODS

Questionnaires administered to four cohorts of preclinical core science and clinical medical students at the University of Cambridge Medical School from 2007 to 2010, with annual longitudinal follow-up in subsequent years; 1027 participants in total.

RESULTS

Students started their medical course with broadly positive attitudes toward PC, which largely persisted into the final years. During the core science component, some attitudes became more negative, whereas during the clinical component, some attitudes became more positive. Over the whole course, there was evidence of increasingly positive attitudes. No significant effect of gender on attitudes or attitudinal change was found. Although statistically significant, all these changes were small.

CONCLUSION

Medical students' attitudes toward their future role in caring for people with PC needs were broadly positive. Core science was associated with increasingly negative attitudes and clinical studies with increasingly positive attitudes. For teaching faculty, the challenge remains to address negative and foster positive attitudes toward PC during medical school.

Development, implementation and evaluation of a pain management and palliative care educational seminar for medical students

BACKGROUND

Despite calls for the development and evaluation of pain education programs during early medical student training, little research has been dedicated to this initiative.

OBJECTIVES

To develop a pain management and palliative care seminar for medical students during their surgical clerkship and evaluate its impact on knowledge over time.

METHODS

A multidisciplinary team of palliative care and pain experts worked collaboratively and developed the seminar over one year. Teaching methods included didactic and case-based instruction, as well as small and large group discussions. A total of 292 medical students attended a seminar during their third- or fourth-year surgical rotation. A 10-item test on knowledge regarding pain and palliative care topics was administered before the seminar, immediately following the seminar and up to one year following the seminar. Ninety-five percent (n=277) of students completed the post-test and 31% (n=90) completed the follow-up test.

RESULTS

The mean pretest, post-test and one-year follow-up test scores were 51%, 75% and 73%, respectively. Mean test scores at post-test and follow-up were significantly higher than pretest scores (all P<0.001). No significant difference was observed in mean test scores between follow-up and post-test (P=0.559), indicating that students retained knowledge gained from the seminar.

CONCLUSIONS

A high-quality educational seminar using interactive and case-based instruction can enhance students' knowledge of pain management and palliative care. These findings highlight the feasibility of developing and implementing pain education material for medical students during their training.

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

AIMS

To assess the experiences in an established 1-week palliative care placement for final year medical students attending the University of Newcastle, New South Wales, Australia.

DESIGN

A retrospective, mixed methodology, consecutive cohort. Student data collected included satisfaction feedback scores, open-ended questions and palliative medicine multiple-choice results before and after their 1-week placement.

RESULTS

Although there were high satisfaction ratings and objective improvements (P < .001) seen in multiple-choice quiz scores, a subset did not improve. Practical issues such as prescribing, opioid use, and conversions were particularly valued by students. More teaching time and practical experience were requested.

DISCUSSION

Given the importance of palliative care teaching within a medical degree, the results suggest continued development and review of palliative medical education are essential.

Development of a nationwide consensus syllabus of palliative medicine for undergraduate medical education in Japan: a modified Delphi method

BACKGROUND

There is currently no consensus syllabus of palliative medicine for undergraduate medical education in Japan, although the Cancer Control Act proposed in 2007 covers the dissemination of palliative care.

AIM

To develop a nationwide consensus syllabus of palliative medicine for undergraduate medical education in Japan using a modified Delphi method.

DESIGN

We adopted the following three-step method: (1) a workshop to produce the draft syllabus; (2) a survey-based provisional syllabus; (3) Delphi rounds and a panel meeting (modified Delphi method) to produce the working syllabus. Educators in charge of palliative medicine from 63% of the medical schools in Japan collaborated to develop a survey-based provisional syllabus before the Delphi rounds. A panel of 32 people was then formed for the modified Delphi rounds comprising 28 educators and experts in palliative medicine, one cancer survivor, one bereaved family member, and two medical students.

RESULTS

The final consensus syllabus consists of 115 learning objectives across seven sections as follows: basic principles; disease process and comprehensive assessment; symptom management; psychosocial care; cultural, religious, and spiritual issues; ethical issues; and legal frameworks. Learning objectives were categorized as essential or desirable (essential: 66; desirable: 49).

CONCLUSIONS

A consensus syllabus of palliative medicine for undergraduate medical education was developed using a clear and innovative methodology. The final consensus syllabus will be made available for further dissemination of palliative care education throughout the country.

Teaching dying patient care in three universities in Argentina, Spain, and Italy

We performed a multicenter comparative survey on undergraduate medical education regarding the care of dying patients at medical schools in three countries. We enrolled 380 first- and sixth-year medical students from Universidad Austral (Argentina), Universidad de Navarra (Spain), and Università Campus Biomedico di Roma (Italy). Answers to the questions were similar among the three universities. Students acknowledged interacting directly with dying patients in all cases. Attitudes toward dying patients were highly positive. Students spontaneously requested more training in end-of-life care. Some attitudes and wishes varied significantly from course to course. Students perceived that this issue received more attention in humanistic rather than in clinical subjects. Ninety-eight percent of students considered that death and helping patients to have a good death should be included in their training. Students' attitudes revealed high interest and poor training in end-of-life issues. Medical curricula should be improved to adequately address these issues.

U.S. medical students' perceptions of the adequacy of their schools' curricular attention to care at the end of life: 1998-2006

BACKGROUND

Little is known about the long-term effectiveness of recent efforts to improve end-of-life care education at U.S. medical schools.

OBJECTIVE AND DESIGN

Longitudinal, observational study using national data from the Graduation Questionnaire of the Association of American Medical Colleges from 1998-2006, comparing national trends with those at New York Medical College (NYMC), where a required 1-day clinical rotation to a palliative care hospital began in 1998.

RESULTS

The fraction of graduating U.S. students reporting that their instruction time on death and dying was at least adequate rose from 70.8% in 1998 to 79.5% in 2006 (p < 0.001); instruction time in pain management rated as at least adequate rose from 34.3% in 1998 to 55.3% in 2005 (p < 0.001); training in palliative care rated as at least adequate rose from 59.9% in 2000 to 74.8% in 2006 (p < 0.001). Improvement began earlier at NYMC compared with national trends, but by 2004 NYMC was no longer significantly different. In multivariate analyses, women, Asians, and older students gave lower ratings of the quality of their end-of-life care education.

CONCLUSION

While much remains to be done, there have been significant improvements since 1998 in graduating U.S. medical students' ratings of the adequacy of their instruction time in end-of-life care.

Paediatric palliative care: challenges and emerging ideas

Paediatric palliative care is an emerging subspecialty that focuses on achieving the best possible quality of life for children with life-threatening conditions and their families. To achieve this goal, the individuals working in this field need to: clearly define the population served; better understand the needs of children with life-threatening conditions and their families; develop an approach that will be appropriate across different communities; provide care that responds adequately to suffering; advance strategies that support caregivers and health-care providers; and promote needed change by cultivating educational programmes. Despite these challenges, advances in paediatric palliative care have been achieved in a short period of time; we expect far greater progress as the field becomes more formalised and research networks are established.

Knowledge toward Cancer Pain and the Use of Opioid Analgesics among Medical Students in their Integrated Clinical Clerkship

Introduction

Among the focal issues of barriers to pain management include the physicians’ lack of knowledge about cancer pain and negative attitudes towards opioids. Many physicians and educators attribute this, at least in part, to limited exposure to pain and palliative care education during medical school.

Aim

The researcher investigated the medical students’ knowledge about cancer pain and the use of opioid analgesics.

Methods

The subjects were a sample of 50 students of the University of the Philippines College of Medicine in their integrated clinical clerkship year. Descriptive statistics (frequencies, means, standard deviation, rating scales) were used to determine mean knowledge score and level of confidence with opioid use. The study also identified specific areas where students exhibited good or poor knowledge of opioids.

Results

Approximately sixty-nine (69%) of the study respondents mentioned that pain management was given to them during their Anesthesiology lectures while a few recalled that they had these lectures during their Family Medicine rotation in Supportive, Palliative and Hospice Care. More than a third (35%) of the respondents admitted to not being confident with morphine use at present. The top three reasons cited as limitations in choice of opioids for cancer pain include fear of addiction, lack of adequate knowledge and experience and fear of side effects and complications. Out of a maximum of 13 correct answers, the mean knowledge score of the medical students was 6.6 ± 2.9. Less than 16% of the respondents had adequate knowledge on cancer pain and opioid use.

Conclusions

The results show that basic knowledge of the role of opioids in cancer pain management among medical students in their integrated clinical clerkship year at the University of the Philippines is poor. The findings imply a need to look into making revisions in the medical curriculum to include a training program that will enable all students to graduate with basic competency in pain management and palliative care.

Palliative medicine teaching program at the University of Cape Town: integrating palliative care principles into practice

The article describes the development of the postgraduate palliative medicine programs at the University of Cape Town (UCT) through collaboration with the Palliative Medicine Division from the University of Wales College of Medicine in Cardiff, United Kingdom. The course is presented as a distance-learning program supported by web-based learning with three face-to-face teaching sessions during the course. UCT recognized the urgent need to assist African doctors in developing the medical skills required to care for an ever-increasing population of patients and their families who are faced with terminal illness and the physical, emotional, psychosocial, and spiritual distress associated with end-of-life issues. Since 2001, 139 postgraduate students have registered for the course, 10% of whom are from African countries other than South Africa. Using the experience from UCT in distance-learning programs, the Hospice Palliative Care Association developed an interdisciplinary course, "Introduction to Palliative Care." This course recognizes that, although improvement in patient care and palliative care will come as undergraduate training in palliative care is established, it is essential that previously qualified health care professionals are able to enhance their palliative care knowledge, skills, and attitudes. Trainers provide support to participants over a six-month period and assist in the transference of knowledge and skills into the workplace.

Impact of a postgraduate six-month rotation in palliative care on knowledge and attitudes of junior residents

Fifty junior residents completed a six-month training period. An anonymous postal questionnaire was sent to collect the residents' opinions on improvements in their knowledge, perception of priorities and usefulness of training. Responses were rated from 5 (a great deal) to 1 (not at all improved). A total of 33 (66%) questionnaires were returned. A mean score of 4.48 was obtained on general improvement of knowledge, 4.91 +/- 0.29 on pain control, 4.17 +/- 0.58 on neurological symptoms, 4.09 +/- 0.77 on psychological symptoms, 4.64 +/- 0.60 on communication skills and 4.4 +/- 0.91 on physician attitudes. Some 58% of residents began the training with apprehension, 85% outlined their priorities and 76% reached these objectives. A total of 70% were fully satisfied with the tuition and support received and 98% recommended such clinical rotation. Data suggest that a six-month rotation in palliative care results in high levels of perception of improvement in knowledge and satisfaction. Exposure to palliative care patients during clinical rotations in specialized centres must be encouraged.

Detecting attitudinal changes about death and dying as a result of end-of-life care curricula for medical undergraduates

BACKGROUND

There is heightened emphasis on teaching end-of-life (EOL) care in the medical school curriculum, but a relative paucity of tools focused on assessing key attitudinal changes due to curricula.

OBJECTIVE

We sought to evaluate the responsiveness of two validated measures of relevant attitudes to changes caused by two EOL curricula: a year-long Elective and a day-long Inter-Clerkship for medical undergraduates.

DESIGN

A case control design (n = 100) and a one group pretest-posttest design (n = 98) were used to ask: (1) Are these two attitudinal measures responsive to changes induced by two undergraduate EOL curricula? (2) Do these two curricula have an additive effect (i.e., taking both yields a stronger attitudinal change than taking only one)? (3) Are there attitudinal and sociodemographic differences between students who took the year-long elective EOL course and those who did not?

SUBJECTS

Undergraduate medical students.

MEASUREMENTS

Two self-report measures: Concept of a Good Death and Concerns about Dying.

RESULTS

Compared to nonelective participants, Elective participants reported less concern about working with dying patients at the end of the course and increased their valuation of clinical criteria in thinking about a "good death." There were trends suggesting decreased general concern about dying and increased valuation of closure, and an interaction suggesting a larger impact on those with higher precourse concern scores. There were no differences between elective and nonelective participants at baseline. The Interclerkship increased students' valuation of personal control aspects of death, and there was a trend in reducing concerns about working with dying patients. We did not find an additive effect of taking both curricula.

CONCLUSIONS

We conclude that both measures were responsive to the relatively large effects this study would have been able to detect, and may be useful in future research to substantiate the effectiveness of EOL curricula in influencing attitudes and level of comfort with death and dying.

Long-Term Evaluation of Required Coursework in Palliative and End-of-Life Care for Medical Students

BACKGROUND

In response to the nationwide need for improved care of patients at end of life, our medical school implemented approximately 20 hours of mandatory coursework on the care of dying patients for all students, with satisfactory completion required for graduation.

OBJECTIVE

We now report a long-term evaluation of this coursework. DESIGN/SUBJECTS/MEASUREMENTS: A 74-item questionnaire concerning attainment of palliative care and other medical school course objectives, postgraduate practice encounters with patients at end of life, and postgraduate behaviors in palliative care was mailed to all students who graduated from our medical school in 2000, 2001, and 2002. Responses were graded by a Likert-type scale. Additionally, the Association of American Medical Colleges Medical School Graduation Questionnaire (AAMC/GQ) reports for all schools and for our medical school were queried for data regarding palliative care.

RESULTS

The return rate of the questionnaire was 54%. The respondents perceived the training to be valuable and effective. They displayed good postgraduate palliative care practices such as choosing to use opiates other than meperidine for pain in the end-of-life setting. Fifty-three percent of the respondents reported that dying patients were often or frequently under their care since graduation. Despite evidence for the efficacy of the training, the respondents perceived that preparedness in certain palliative care domains was somewhat below preparedness in benchmark medical school competencies such as assessment/management of hypertension and diabetes. The AAMC/GQ surveys indicated that for the years 2000-2002, at least 20% more of our graduates perceived that their training in pain management and palliative care was adequate than did all other medical students graduating nationwide.

CONCLUSIONS

The evaluation provides support for the conclusion that mandatory training in palliative and end-of-life care is effective, perceived to be valuable, and contributes to good palliative and end-of-life care practices in our graduates. Furthermore, the training meets a significant demand in our graduates' clinical practice: end-of-life care. However, expanded medical school emphasis and curriculum hours are still needed for palliative care topics, because preparedness in palliative care skills was perceived to be inferior to benchmark medical skills. To our knowledge, this is the first report of a rigorous summative evaluation of the efficacy of required coursework in palliative and end-of-life care in a U.S. medical school curriculum.

The outcome of pain related undergraduate teaching in Finnish medical faculties

Little is known about how other than cancer pain related issues are represented in medical education. A standardised questionnaire was mailed to all medical students who graduated from the five Finnish medical schools in 2001. A total of 387 students received the questionnaire and 41% responded. The students had to evaluate the quantity and the quality of pain teaching. The availability and the participation in the advanced courses or research in pain medicine were asked. The students reported how the IASP curriculum on pain had been covered during the studies. Two clinical cases were presented for diagnosis and treatment. In addition to integrated pain teaching, specific pain education was received by 27% of the students. The departments of anaesthesiology were reported as the major deliverers of teaching of pain. The overall ratings of the pain-related teaching of the faculties varied from 3.4 to 4.6 on a scale of 10. Anatomy, biochemistry, physiology and pharmacology of pain were covered well. The definitions of pain, pain research, sociological issues, paediatric, geriatric and mentally retarded patients' pain were taught most poorly. Only 34% of the students had been offered advanced studies and 15% had been offered research projects in pain medicine. The lack of teaching about the concept of a multidisciplinary pain clinic was recognised by almost all students. The clinical problems were excellently solved. In conclusion, the IASP curriculum is well covered in the present programmes in the Finnish medical faculties. However, the quality and the methods of teaching still need improvement.

Palliative care for end-stage dementia: a discussion of the implications for education of health care professionals

The increasing burden of chronic disease demands that palliative care clinicians address the needs of patients with non-malignant disease. This discussion document seeks to address some of the challenges to providing palliative care for end-stage dementia (ESD) and the need for skill enhancement in key providers of care. In spite of the intent, there is an apparent lack of appropriate, co-ordinated and comprehensive palliative care available for these individuals and their families. There is an absence of well-articulated models to assist health care providers of ESD clients. It would appear that the development and evaluation of guidelines, implementation of education programs and collaborative associations between palliative and aged-care providers of care are key strategies to facilitate palliative care for ESD clients.

Attitudes of preclinical medical students towards caring for chronically ill and dying patients: does palliative care teaching make a difference?

INTRODUCTION

Students entering medical school today will encounter an ageing population and a higher incidence of diseases affecting the elderly-for example, chronic respiratory and cardiac disease and malignancy.

PURPOSE

This study was carried out to determine the attitudes of preclinical medical students towards the care of patients for whom a cure is not possible.

METHODS

All students were invited to complete a 23 item questionnaire prior to initial teaching and again following the second teaching session in palliative care.

RESULTS

Overall, 149 of the 186 students (80%) completed the pre-teaching questionnaire (59 males and 90 females; median age 20 years, range 19-27 years), and 66 students (35%) completed the post-teaching questionnaire. Attitudes towards chronically ill and dying patients were generally positive. It was found that increasing age was associated with a more positive view of caring for patients with chronic or terminal illness, a more positive view of listening to patients reminisce, and a more positive view of patients dying at home (p = 0.014). The only notable result was that after palliative care teaching students had a significantly more positive view of hospices.

CONCLUSION

Caring for patients at the end of life can be one of the most rewarding aspects of being a doctor. This study suggests that the majority of medical students have a positive attitude towards patients with chronic incurable illness, and the trend for encouraging older students to enter medicine may be an influencing factor.

Education and training in palliative care

The growing demand for palliative care means that health professionals are expected to provide palliative care as a core part of their practice. Training in the practice of palliative care is a recent addition to undergraduate and postgraduate medical and other healthcare curricula, and several initiatives are under way to promote palliative care principles and practice in healthcare training. The challenge that we all face is how to develop these skills in the face of multiple demands on our time. Strategies for improving palliative care education include a national undergraduate curriculum for palliative care, expanded training opportunities for generalist practitioners, and further recognition for the role of practitioners of specialist palliative care and associated curriculum development.

A pilot survey of medical students' perspectives on their educational exposure to palliative care in two Canadian universities

BACKGROUND

Graduating medical students from the class of 1999 from McGill University and the University of Alberta completed a self-administered, anonymous, pilot survey to determine students' perspectives on how their educational experience in common palliative care topics contrasted with their educational experience in the diagnosis and management of hypertension, non palliative aspects of breast cancer, and patients dying of acquired immune deficiency syndrome (AIDS).

METHODS

A Likert scale ranging from "excellent," scored 1, "very poor," scored 5, was used. Students also estimated the number of hours they spent, during their training, in operating rooms, on home visits to terminally ill patients, and in interprofessional teaching.

RESULTS

Sixty of 114 (53%) students from McGill University, and 53 of 110 (48%) students from the University of Alberta responded to the survey. The mean ratings of education experience in the various topics for both universities combined were as follows: hypertension, 2.03; breast cancer, 2.33; cancer pain, 3.42; communicating with dying patients, 3.32; and caring for patients with AIDS, 4.15. The average number of hours spent in the operating room, on home visits to terminally patients, and in interprofessional teaching for both universities combined were 155 hours, 4.2 hours, and 16 hours, respectively. Of the responding students from both universities 83% favored increased palliative care teaching.

CONCLUSION

Despite the disproportionate number of hours spent in operating rooms compared to palliative care community exposure, only two students, one from each university, favored shortening surgical rotations to allow for increased time for palliative care education. Recommendations, including increasing palliative care education during clinical clerkships, are provided to improve medical students' perceptions of their educational experiences in palliative care education.

Teaching end-of-life issues: current status in United Kingdom and United States medical schools

Our objective was to determine how broadly end-of-life issues are represented in the undergraduate medical school curricula of the United Kingdom (UK) and the United States (US). Mailed surveys yielded response rates of 100 percent in the UK and 92 percent in the US. With one exception, all medical schools in the survey offered some exposure to dying, death, and bereavement and most addressed the topic of palliative care. Hospice involvement was found in 96 percent of UK medical schools but in only 50 percent of US schools. Overall, the UK appears to provide more exposure to end-of-life issues in medical schools, although the US appears to be moving in that direction.

Palliative care models: international perspective

The delivery of palliative care can vary greatly between countries depending on socioeconomic conditions and cultural issues. The evolution and development of palliative care varies greatly and influences the development of palliative care models. Models of palliative care in three different countries are discussed and suggestions are made for the future development of palliative care in developing and developed countries.