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Medical undergraduate palliative care education (UPCE)
  1. Des McMahon1 and
  2. Bee Wee2
  1. 1 Academic Department of Palliative Medicine, Our Lady's Hospice and Care Services, Dublin, Ireland
  2. 2 Palliative Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
  1. Correspondence to Dr Des McMahon, Academic Department of Palliative Medicine, Our Lady's Hospice and Care Services, Dublin D6W RY72, Ireland; Des.McMahon{at}hse.ie

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Introduction

As interns, new doctors care for the dying or others who have palliative care (PC) needs.1 Undergraduate medical students need to learn about PC.2 Up to half of newly qualified doctors are underprepared for end of life issues and many feel it is a source of distress.3 4 Medical students value palliative education5 but many feel training is deficient.6 7

Undergraduate palliative care education (UPCE) for medical students shows wide variation throughout Europe and internationally.8 In 2015, PC was compulsory in only 14% of countries; only 30% of European medical schools taught PC.9 Medical curricula did not include PC in 14 countries (33%).

In the UK, the General Medical Council requires that newly qualified doctors: ‘Contribute to the care of patients and their families at the end of life, including management of symptoms, practical issues of law and certification, and effective communication and team working.’10

Current UPCE-related literature gives guidance on effective delivery of PC education for medical students (box 1).

Box 1

Effective Delivery of PC Education for Medical Students.

Palliative care education for medical students should:

  • Be mandatory and based on a nationally agreed curriculum.

  • Be introduced early and integrated in the wider curriculum.

  • Involve clinical exposure.

  • Include objective assessment.

  • Be delivered by a multidisciplinary team.

  • Be competence based.

Recommendations

UPCE should be mandatory and based on a nationally agreed curriculum

In the past, UPCE was often voluntary. Students recommended a course for all undergraduates as a medical curriculum core component.11 They agreed PC training is essential.12

Optional PC teaching suggests PC is unimportant13 and is a barrier to discipline development.9 PC teaching improves PC attitudes.14 Australia, Canada and the UK have adopted nationally agreed curricula which reduces the degree of variation in the UPCE delivery.3 15

UPCE should be introduced early and integrated in the wider curriculum

Undergraduate education needs to create an environment in which students develop the attitudes, knowledge and skills necessary for compassionate and effective PC.2 Direct exposure should occur early in medical school curricula.16 It is important to teach attitudinal concepts.17 Junior doctors with early PC training have enhanced communication, patient-centred medicine, professionalism, self-awareness skills and teamwork.18

UPCE is no longer a stand-alone subject and integration into undergraduate medical curricula is important.17 PC should be included in cardiology, neurology, nephrology, oncology and respiratory medicine (horizontal integration), and throughout undergraduate education (vertical integration). Training must include recognising and addressing PC needs in practice.

UPCE should involve clinical exposure

Despite resource challenges, an educationally rich PC curriculum should include both didactic elements and clinical experience.19 This provides compassionate and competent PC role modelling and supervised experience. Clinical experience exposure during undergraduate clinical years increases significant learning.19 Students regard PC teaching as important and essential.11 In the UK, increased medical student time includes time with hospice patients.20

UPCE should involve objective assessment

PC assessment involves more than self-assessment.13 Objective assessments are increasingly used rather than self-report of satisfaction or perceived skill level.7 Medical education typically focuses on knowledge and skills but attitudinal aspects are equally important. PC spans many medical specialties and evaluation should be longitudinal.21

UPCE should be delivered by a multidisciplinary team

Traditionally, physicians teach medicine but an interprofessional team delivers patient care.22 Interprofessional PC education is a rewarding professional experience22 and an educational design strength.21

UPCE should be competence based

The medical education challenge is to increase and apply knowledge that will be reflected in clinical performance and enhanced patient care.19 The European Association for Palliative Care has advocated such training to promote leadership and enlightened change.23 A curriculum should achieve requisite competencies. Such competencies should encompass behaviour and attitudes, as well as knowledge and skills.24 Competence-based questionnaires and assessments which reliably examine knowledge, behaviour and attitudes are being developed.24

Challenges

These recommendations are to equip future doctors with complex medical and psychosocial skills for life-limiting illness. However, they pose significant challenges. There are resource and curriculum time pressures in busy medical undergraduate curricula.25 Current medical school curricula are already overstrained.5 In addition, there are concerns about insufficient funding, placements and teachers.15 More innovative teaching methods, including online teaching and actors as simulated patients, help overcome resource limitations.26 New teaching and evaluation methods, including online and virtual, help in environments with limited clinical access.27 eLearning is promising and well accepted by medical students but as a supplement rather than substitute.28

Conclusions

Appropriate training is essential for PC safe practice.7 PC undergraduate education increases confidence and control to interact with dying patients and families.18 Learning the PC approach helps address terminal illness and general patient care.18 Palliative medicine academic departments play a key role in supporting and strengthening undergraduate PC teaching and learning.29

References

Footnotes

  • Contributors DM carried out the relevant literature review and wrote the first draft of this article. BW contributed to the design of the work and to revising it critically for important intellectual content. Both authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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