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Teaching the difficult-to-teach topics
  1. Anna MacPherson1,
  2. Iain Lawrie2,3,
  3. Sarah Collins3 and
  4. Louise Forman3,4
  1. 1East Lancashire Hospitals NHS Trust, Blackburn, UK
  2. 2The Pennine Acute Hospitals NHS Trust, Manchester, UK
  3. 3Manchester Medical School, University of Manchester, Manchester, UK
  4. 4Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
  1. Correspondence to Dr Anna MacPherson, Pendleside Hospice, Colne Road, Reedley, Burnley, Lancashire BB10 2LW, UK; anna_macpherson{at}hotmail.com

Abstract

It is now accepted that teaching in palliative medicine should be integrated throughout the medical undergraduate curriculum. Recommendations suggest the inclusion of knowledge areas such as symptom control, as well as more attitudinal aspects such as teamwork and understanding patient and carer perspectives on illness. These subjects should be taught on a stepwise basis, introducing concepts at an early stage and then be built on throughout training. However, how this is done and how effectively all aspects are taught vary considerably. This article outlines one way of using patient and carer experiences of significant illness, and multi-disciplinary teams, to teach attitudinal concepts behind palliative care to medical students early in their undergraduate careers. Palliative care is considered here in a broad sense, with the relevance to all healthcare professionals emphasised, and specialist palliative care used as an example of holistic care. The sessions consisted of small group discussions with patient and carer representatives as well as discussions with various members of the multi-disciplinary team. These were led by the patient/carer/professionals’ experiences and further explored with facilitated questions by the students. The sessions have been evaluated well by all involved, including patients, carers, multi-disciplinary team members and palliative medicine doctors. The learning objectives (to understand patient perspectives, multi-disciplinary working and holistic care) were achieved, along with discussion of professionalism.

  • Education and training
  • Supportive care
  • Patients
  • Carers
  • Experience
  • Significant illness

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Background

All doctors will see patients with progressive life-limiting conditions at some point during their careers, some as part of their everyday practice. As a result of national strategies and recognition of the impact on healthcare services of an ageing population,1 the relevance of palliative care to every clinician is increasingly recognised and, consequently, the need to embed teaching the principles of palliative care into undergraduate medical student curricula is highlighted.2 The integration of palliative care and its principles within medical student teaching programmes is variable, with broad recommendations as to what should be included,3 ,4 but variability in models used and effectiveness. There exist recognised improvements that are required.5–7

Medical student teaching has evolved considerably over the past 20 years, moving from a focus on attainment of factual knowledge to a broader, more rounded approach to preparation for provision of high quality, holistic care, including development of the skills and attitudes needed to be a doctor. Methods of learning experience employed to this end have expanded to include more clinical experiences and emphasis on reflective practice, and less didactic, lecture-based sessions.8 Simulated patients and direct patient involvement are increasingly employed in the delivery of education to many groups of healthcare professionals.9

The European Association of Palliative Care (EAPC) and Association for Palliative Medicine recommend the inclusion of various aspects of palliative medicine within medical school curricula.3 ,4 Similarly, the Royal College of Physicians and General Medical Council advocate that skills for end of life care be referenced throughout medical undergraduate curricula.10 ,11 This includes ‘factual’ elements of symptom control and medication use, and exposure to patient and carer perspectives on disease, multi-disciplinary teamwork (MDT) and communication skills. The inclusion of palliative medicine at all stages of undergraduate study is seen as key, with vertical integration of key principles throughout teaching programmes and the opportunity to build on foundations introduced at early stages, often before structured clinical experience placements.

The broad knowledge, skills and attitudes essential in palliative medicine lend themselves to being taught in a variety of formats throughout undergraduate training. Symptom control issues and the opportunity to spend clinical attachments with specialist palliative care services seem more suited to later, clinically-focused stages of the undergraduate course. Bedside clinical teaching can pose challenges within palliative care,12 so inclusion at an early stage may not be the most appropriate or effective use of this resource. The concept of holistic care and attitudes towards multi-disciplinary working and patient experience run through all aspects of medicine, and so inclusion from an early stage is important.

With the above in mind, we developed an innovative teaching programme aiming to introduce palliative care concepts to medical undergraduates at an early stage.

Teaching methods

Session development

The sessions discussed here are part of an overall programme for palliative medicine inclusion in the undergraduate curriculum at the University of Manchester Medical School, UK. Current provision of palliative care teaching within the undergraduate programme was reviewed, and gaps were identified, principally in years 1 and 2, where there was passing reference to palliative care concepts, but no specific structured learning outcomes. Priorities for student learning during each year of the medical student curriculum were identified, in accordance with the priorities identified by the EAPC. The priorities for years 1 and 2 were principles of palliative care, holistic care and MDT working, as well as the patient perspective. The EAPC outlines patient and caregivers’ perspectives of illness as one of the key components of undergraduate curricula, alongside communication skills.3

An opportunity arose fortuitously to deliver a stand-alone, half-day teaching session for half of the second year of the undergraduate course (ie, 17 established problem-based learning (PBL) groups of second year medical students) as the result of a gap created by revision of the timetable. These sessions linked to the semester's science and PBL content, to address the priorities mentioned above. Small group sessions were designed to offer the greatest potential to be interactive and memorable for students.

Session structure and content

Each of the 17 sessions (ie, one session for each student PBL group, with 10–12 students in each) began with a whole group introduction to palliative care, followed by small group discussions (with the students allocating themselves into groups of five or six). The main part of the session was divided into two parts, one consisting of an hour-long discussion with a patient or relative, and the other comprising two half-hour discussions with different members of the extended multi-disciplinary team. Two palliative care physicians facilitated the sessions, along with a communication specialist member of the medical school to provide support and manage any problems, as it was identified that some students might find the topics discussed upsetting. The discussions were described to all as informal, and were an opportunity for students to hear the perspectives of patients, relatives and professionals from various parts of the multi-disciplinary team, in the context of significant illness, to interact with them and to reflect on and discuss issues that arose.

The patients and carers represented various patient groups, including patients who had experienced potentially curative cancer treatment, patients with dementia and progressive neurological conditions, and their relatives. The multi-disciplinary team member participants were also varied, including chaplains, social workers, pharmacists, physicians, nurses, allied health professionals, cancer information officers and welfare rights association representatives. There was widespread interest among staff in taking part in the sessions and, although the individual experiences and accounts varied considerably, the same learning objectives and themes emerged. The patient or carers’ stories highlighted issues such as the impact of significant illness on all aspects of a person's life and their family, and the importance of good communication skills and seeing the person behind the illness. The discussions with professionals tended to be centred around the roles of individual team members, how teams work together and the impact of working with patients with serious illnesses on the healthcare professionals themselves.

Evaluation

Feedback was collected from participants in the sessions via invitations to give open comments by email or verbally. Students are asked to complete evaluations for numerous course components on a regular basis; therefore, the medical school has to manage evaluation carefully so that students are not overloaded. Because the sessions were positively received, it was decided to conduct evaluation with a sample of the groups (eight out of 17) for this new area of the curriculum. All comments received were documented and analysed thematically. The major themes identified from this qualitative analysis are outlined below.

In all, 180 students and 48 patients/carers/professionals participated in the programme over 13 weeks. A total of 57 responses (31.6%) were received from students, and 15 (31.2%) from patients/carers/professionals.

Student evaluations

Student evaluations were very positive overall, with a variety of comments about the session structure and the learning points.

The sessions were structured to offer a new learning experience for students. The elements that were rated highly were the value of being allowed patient contact, the opportunity to talk to different healthcare professionals and the ability to discuss the points raised in small groups. …a first hand experience of understanding patients’ feelings and through health professionals working in this field vastly broadened my views on patients’ feelings during diseases and that caring is very much greatly varied on an individual basis. Medical student, session 6

The learning objectives given to the students prior to the session were deliberately broad, focusing on how the sessions made the students reflect on medical care and how they would care for patients in the future. The patient experiences particularly, and the reflections on those, brought out the importance of good communication and seeing the patient's point of view. …her story made me realise how important it is to be a good communicator Medical student, session 1 The session really helped me to see the person behind an illness. Medical student, session 14

Other common learning points included aiding understanding of the psychological impact of illness, building on prior theoretical teaching during the course. It's been really useful to hear from a patient (and a family member of a patient) about how the illness impacted different people in the family and first hand. The session was extremely useful and thought-provoking. Medical student, session 13

The role of palliative care, although often not specifically covered during the sessions, was a frequent area of learning, with students reflecting that this was an example of multi-disciplinary working and holistic care. The role of the MDT in patient care was an area students felt they had not been exposed to before. Speaking to professionals in less familiar roles certainly opened my eyes to the scope of services available and dispelled a few myths/misinterpretations I had before. Medical student, session 16

A vital part of evaluating teaching is how it impacts on future practice and, although early to tell, this was referenced in student evaluations, and the inclusion of this topic at an early stage of the undergraduate medical course was praised. It is very valuable to be learning about such care at such an early stage as it will definitely affect the way I approach learning in the medical school. Medical student, session 6

These sessions were an addition to the usual elements of the undergraduate course, and so areas for improvement were elicited. There were few comments on this; the students generally asked for further opportunities to talk to more patients, relatives and health professionals. Some found the sessions to be lengthy with a lot to take in, and others would have preferred more time with the patient and MDT representatives to talk more in depth. These views are being considered.

Evaluations from patient representatives and MDT members

The MDT member participants were mainly positive about the inclusion of these issues in the medical student curriculum at an early stage. It was felt that it was useful to give an early insight into how different professionals work together to provide overall care to the patient, and that having an appreciation of the patient's view on illness was extremely valuable. Idea is to sow the seeds of what is on offer so that it can be there for the future. Allied health professional, session 14 …view of the whole person and their needs and that there is a team to address these, that it is not one person (i.e. the doctor) to do everything Support volunteer, session 15

Several patient representatives have asked to take part in these sessions again, having found the experience interesting and enjoyable. There has also been an interest in participation from other patient groups after having heard about the sessions. This supports the view that palliative care patients wish to be involved in the education of future doctors.12

Doctor evaluations

There was an excellent response from palliative medicine specialty trainees and consultants in the North West region to support these sessions. Each session was supported by one or two doctors. Their roles were to facilitate the patient interview, and to link the themes discussed to palliative care and palliative care approaches.

Overall, the doctors were positive about the session structure and content, and the concept of exposing students to patient perspectives and different aspects of holistic care. The sessions required no preparation by the doctor facilitators, which was seen as positive, and overall the doctors enjoyed taking part. Very heart warming and motivational—reminds me why I'm doing medicine. Palliative medicine consultant, session 15

There were concerns that the sessions did not specifically cover palliative care, particularly if the patient representative had not need to come into contact with specialist palliative care services. I'm not sure this provided a good introduction to palliative care—but provided a good insight into how it feels to be a patient and the importance of good communication skills etc Palliative medicine specialty trainee, session 9

Related to this issue, some doctors found the learning objectives too general and so faltered a little during the sessions. The aims of the session were deliberately not specific to palliative care per se; the priority was to cover concepts of holistic care and multi-disciplinary working as a background topic in order to build on this in future sessions, and to ensure the students recognised the relevance of these issues to everyone, rather than it being a specialty-specific session. The information given to future medical participants will be reviewed to reflect this.

The cost-efficiency of two doctors attending 17 half-day sessions was questioned, and several attendees felt that the same outcomes could potentially be achieved with less senior medical input, or one doctor. Most palliative medicine physicians who took part said they would be happy to do so again. The main positive evaluations from the students came from discussions with the patients and various members of the MDT including, but not restricted to, doctors. As future sessions are planned this will be taken into account.

Discussion

Palliative care is now a recommended core part of undergraduate medical curricula. It is recognised that issues such as symptom control, holistic care and team working are core aspects of most clinicians’ roles, and so an understanding of various aspects of palliative care is mandatory, as well as an understanding of end of life care specifically.10 It has been shown that horizontally and vertically integrating palliative medicine into undergraduate training improves outcomes for students.13 To enable this, aspects of palliative care appropriate to each stage of training need to be included throughout the undergraduate curriculum, and need to be built upon while remaining relevant to other topics being reviewed.

When planning how to integrate different aspects of palliative care into medical school curricula, it is essential to consider how each topic area can best be taught. Some aspects of palliative care are easier to teach than others; symptom management can be taught using patient examples in various settings, and opioid conversion can be taught in tutorials. Other, more attitudinal aspects of patient care and an understanding of the ethos of palliative care can be more challenging to convey in teaching sessions, and have often been missed out of undergraduate curricula in the past.

Traditional lectures and tutorials continue to have their place. Likewise, bedside teaching and clinical attachments can be extremely valuable to understand palliative care. However, exposing medical students to palliative patients in clinical settings at each stage of their training would be difficult. In Manchester Medical School there are over 2000 students across the 5 years, and this would quickly swamp local palliative services. The challenges of bedside teaching within palliative settings are recognised,12 and this certainly has its role, but is likely to be more appropriate later in training. The teaching approach described here showed that patients and carers can still be involved in teaching, without it needing to be within a clinical setting. There have been increasing reports of patients acting as educators with good results in other aspects of healthcare professional teaching.9 This has clear advantages in palliative medicine settings where patients can be relatively vulnerable when receiving clinical care, and existing palliative medicine services can struggle to provide educational experiences for large numbers of students.

The sessions described above provide a way of teaching the ‘more difficult-to-teach’ aspects of palliative care, with patient and multi-disciplinary team contact, but in a non-clinical setting. This is an example of how alternative learning methods can be useful in providing different perspectives on medical student learning, giving opportunities to shape and develop attitudes at an early stage. The student feedback gathered in this project validated the aims of the session: students obtained from sessions exactly what was intended, and students’ comments about the impact of these encounters with patients and health professionals on their learning showed that this format was worthwhile. This will provide these students with a foundation for future learning about palliative care in later, more clinically-focused phases of the undergraduate career.

In addition to providing an introduction to aspects of palliative care, the format of these sessions provided insights into broader attitudes on providing good care and professionalism. It has been recognised elsewhere that palliative medicine teaching provides opportunities to develop attitudinal aspects of learning often not covered elsewhere.14 Early clinical contact has been found to play an important part in teaching professionalism, particularly patient contact,15 and this links to the feedback received that highlighted various aspects of professionalism as learning points. Again, this is a difficult-to-teach area in which integrated learning is desirable,16 and so it is very positive that these sessions provided an opportunity for effective early learning experiences.

The sessions were labour intensive. Two palliative medicine doctors, a patient representative often with a relative and two other healthcare professionals were present for each session, as well as a communication lecturer from the medical school. Despite the amount of people required for these sessions, there were plenty of volunteers to help deliver them. The facilitators and visitors commented on having enjoyed the experience, and felt they had been able to contribute to the medical students’ learning. The patient representatives agreed with these positive comments, and no patient or relative participant reported being upset by the sessions, or provided any negative comments.

This was the first time these sessions had been delivered, and the format will be developed in light of the experiences and feedback obtained. There were concerns when designing the sessions that students or participants may be upset by the topics discussed, but generally this was not the case, and so the extra precautions of having additional professionals present was not wholly necessary. In addition, the sessions generally did not need complex active facilitation as long as the students had considered their objectives beforehand and the visitors had been well briefed, and so future sessions will not be as fully staffed. This will allow expansion of the sessions to the whole of year 2 of Manchester Medical School which, given the positive feedback, the medical school are keen to support.

Conclusions

There are ways of teaching the more nebulous aspects of palliative care in a way that is interesting, useful and enjoyable for students and participants. By thinking broadly about the aspects of palliative care most relevant to medical students at different stages of their learning, and considering different ways of teaching them, sessions can be devised which can have a real impact on students’ ways of thinking about medicine at an early stage.

Acknowledgments

The authors would like to acknowledge the significant and valuable contributions of both time and experience provided by the patients, carers, volunteers and professionals who were involved in this project.

References

Footnotes

  • Contributors AM drafted this manuscript in cooperation with IL, SC and LF. SC was responsible for data collection and thematic analysis. All authors were involved in design and delivery of the programme and interpretation of the data. All authors read and approved the manuscript.

  • Funding Funding for expenses for volunteer participants was provided from the Medical School budget as part of the introduction of the new series of workshops.

  • Competing interests None.

  • Patient consent All participants provided written consent for comments provided as part of the course evaluation to be used for analysis and publication.

  • Ethics approval This was an evaluation of student feedback for a new pilot teaching programme. All feedback was gathered as part of established, approved University of Manchester guidelines on gathering and using feedback.

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

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