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The impact of a medical undergraduate student-selected module in palliative care
  1. Catherine Sweeney1,2,
  2. Gerardine Lynch1,
  3. Ali Khashan2,
  4. Bridget Maher2,
  5. Marie Murphy1,2 and
  6. Tony O'Brien1,2
  1. 1Marymount University Hospice/St Patricks University Hospital, Cork, Ireland
  2. 2School of Medicine, University College Cork, Cork, Ireland
  1. Correspondence to Dr Catherine Sweeney, School of Medicine, University College Cork, Brookfield Health Sciences Complex, College Road, Cork, Ireland; c.sweeney{at}ucc.ie

Abstract

Background The need for undergraduate medical education in palliative care is widely recognised. An optional student-selected module ‘Fundamentals of Palliative Medicine’ was introduced in 2011 and offered to third-year medical students. The overall objective of the module was to develop students’ knowledge, attitudes and skills in palliative care.

Aim To assess impact of the module in terms of qualitative and quantitative measures, and to improve the module design and content for future years.

Methods Students completed validated tools (Self Efficacy in Palliative Care and Thanatophobia Scale (TS)) premodule and postmodule. A Minute Paper was completed at the penultimate session with students identifying areas they had a good understanding of, and issues they still found unclear.

Results Twenty-four of 155 eligible students chose the module. Significant differences were seen in premodule and postmodule Self Efficacy in Palliative Care scores (communication p<0.0001, patient management p=0.0002 and teamwork p=0.03). No difference was seen in TS score. Five main themes emerged from the qualitative analysis of the Minute Paper: changes to attitudes and knowledge, psychological effects, teaching methods, careers in palliative care, and further palliative care learning needs. Several students commented that the module should be core curriculum.

Conclusions The module was a popular choice with students, was well received, and appears to have had a significant educational impact in terms of changing students’ attitudes and perceived knowledge and skills in palliative care.

  • Education and training
  • Undergraduate medical
  • Special study module

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Introduction

The need for palliative care education of medical students has been highlighted by several key organisations including the WHO, the European Association for Palliative Care (EAPC) and the General Medical Council.1–3 Although education in areas relevant to palliative care (eg, medical ethics and communication skills), is usually part of the medical curriculum, there is evidence that lack of a formal palliative care curriculum at undergraduate level impacts negatively on the development of students’ palliative care skills.4 ,5 Undergraduate medical students need to understand the core principles and philosophies of palliative care and be made aware of the important role of palliative care throughout the various stages of the disease trajectory from diagnosis to end-of-life care.2

Forty-eight percent of deaths in Ireland occur in acute hospitals, and 75% of these are expected.6 Junior doctors are actively involved in the care of these patients. As the population ages, it is anticipated that there will be increasing numbers of patients with palliative care needs related to both malignant and non-malignant diseases. Indeed, the patient with palliative care needs will typically present with a multiplicity of pathologies that collectively influence the symptom burden and individual quality of life. Hence, palliative care competencies are vital aspects of junior doctors’ clinical practice, and will be important for many doctors throughout their professional lives.

Currently, University College Cork (UCC) offers two undergraduate medical courses, a school-leaver direct entry course (5 years) and a 4-year graduate entry course.

Both programmes have content relevant to palliative care, but neither has a comprehensive structured approach to palliative care education. A 5-credit student-selected module (SSM), ‘Fundamentals of Palliative Medicine’, was offered to third-year direct entry and second-year graduate entry students in UCC in the 2011/2012 academic year. SSMs (also known as special study modules) offer students choice in their medical education, allow in-depth study of topics of particular interest and facilitate the development of skills, knowledge and attitudes necessary for future lifelong learning.

The module consisted of 12 weekly 2-hour sessions that were usually delivered in the specialist palliative care unit. Module content was chosen by the authors to complement the existing core curriculum and was informed by European Association of Palliative Care recommendations.2 The seven domains recommended for basic competency in palliative care were addressed (palliative care definitions, etc, pain, neuropsychological symptoms, other symptoms, ethics and law, patient/family/non-clinical caregivers perspectives, and clinical communication skills). Teaching on assessment and management of symptoms was limited to 6 h due to the students’ clinical inexperience and to time constraints. Additional areas identified for specific attention in the module were teamwork, settings of palliative care delivery, palliative care for non-malignant conditions and self-care. The College of Medicine and Health Teaching and Curriculum Committee approved the module. Table 1 summarises the module content. Palliative healthcare professionals from a range of disciplines, palliative care educators and a senior lecturer in healthcare ethics delivered teaching. Teaching methods included lectures, small group discussions, role-play and case studies. A key objective of the SSM was to develop students’ attitudes to palliative care by increasing their awareness of its relevance to care of patients (and their families) with a wide range of life-limiting diseases, and at earlier stages in their illness. Other learning objectives included improvement of students’ knowledge and skills in areas, such as symptom management, communication and teamwork. Formal assessment of students was in the form of a case-based workbook covering physical, psychosocial, spiritual aspects of patient and family care that also contained reflective elements.

Table 1

Module content

Aim

The aim of this study was to

  • Assess the educational impact of a palliative care module for medical students in terms of attitudes and perceived knowledge and skills

  • Inform future development of the module.

Methods

Participants and ethics

Participants were third-year direct entry (5-year course) and second-year graduate entry (4-year course) students enrolled in the SSM (n=24). Ethics approval was obtained from the School of Medicine research ethics committee.

Assessment

Qualitative and quantitative assessments of the module were performed. The Self-Efficacy in Palliative Care (SEPC)7 and Thanatophobia Scale (TS)8 were completed anonymously by students attending the first and final sessions. Completion of the two tools took approximately 10 min. The SEPC and TS are validated instruments for assessment of undergraduate medical education.7–9 The SEPC is a 23-item questionnaire that assesses students’ perceived competence in three key areas of palliative care practice (communication, patient management and team work). A 100 mm visual analogue scale with anchors of ‘very anxious’ and ‘very confident’ is used. The TS is a 7-item scale that assesses attitudes towards caring for patients at the end of life, and uses a 7-point Likert scale for rating. Lower scores represent more favourable attitudes.

In addition, a ‘Minute Paper’ (MP),10 a commonly used classroom assessment technique was completed at the penultimate session. Students were asked to concisely answer two questions (anonymously):

  • 1. What is the most important thing you have learned so far?

  • 2. What is still confusing or unclear for you?

This allowed feedback and clarification of unclear areas at the final session.

Analysis

Fisher's exact test was used to compare numbers enrolled on the module. Paired Student t test in STATA 10.0 was used to compare the mean SEPC and TS scores before and after the module.11 The SEPC analysis was based on three sections;

(1) Communication, (2) Patient Management and (3) Teamwork. All analyses were two-sided, and a p<0.05 was considered statistically significant.

Qualitative information from the Minute Paper was transcribed and independently analysed by two authors (GL and CS). Comments were read and reread to immerse authors in the material. The data were then coded and categorised, and themes were then identified from the categories. Finally, the authors compared and agreed themes.12

Results

Twenty-four of 155 (15%) eligible students chose the module as their first choice, and all of these enrolled in the module. Nineteen were from third-year direct entry, and five from second-year graduate entry classes (representing 17% and 11%, respectively, p=0.3). Eighteen were women and six were men (representing 23% and 8% of the combined classes, respectively, p=0.01).

Quantitative

All participants completed the premodule questionnaires. Nineteen students attended the final session and completed the postmodule SEPC questionnaire. Seventeen students completed the TS (the two attendees who did not complete it may not have seen the questionnaire on the back of the page). Table 2 summarises the results of the analysis of SEPC and TS, respectively. Average total premodule and postmodule TS scores were 23.8 and 21.0, respectively.

Table 2

Comparison of premodule and postmodule self-efficacy in palliative care and Thanatophobia scale scores using paired t test

Qualitative

Eighteen students completed the MP. Five main themes emerged from the qualitative analysis: changes to attitudes and knowledge, psychological effects, teaching methods, careers in palliative care, and further palliative care learning needs. Students frequently mentioned material covered in two specific sessions as having been particularly important: Breaking Bad News and Total Pain.

Changes in palliative care attitudes and knowledge:

The students noted that their attitudes to, and knowledge of, palliative care changed during the course of the module. Before starting the module I thought that palliative care was based on patients who are actually dying (e.g. in the last few days of life). However I now understand that palliative care begins much earlier in a patients illness… S09

Appreciation of a number of palliative care principles were highlighted by students, including the patient as an individual and the need for holistic care, multidimensional aspects of pain, communication, the inclusion of the family, multidisciplinary team work, and the importance of early palliative care referral.

Learning about the individuality of each patient was seen as an important part of palliative care. The patient was seen as a unique person with their own needs and experiences, and everyone had their own individual story. The module taught me that every patient is an individual with a unique story of their life S11 Palliative care is about more than treating a patient who is terminally ill...….. Seeing a patient as a whole picture approach. Not just the medical perspective S15

Pain was viewed as more than physical with the concept of total pain seen as important. ‘Pain is not only a sensory or emotional reaction to tissue damage or potential tissue damage but includes social and spiritual pain S02 ….. the concept of ‘total pain’. Prior to this module I did not consider the impact of pain that is not physical to the degree that it should be emphasized S01

Several students identified communication skills as a key aspect of the module. Breaking bad news was identified as having been particularly important and helpful. My understanding of the role of a doctor has been seriously reshaped, particularly in the context of bad news S18

Other aspects of communication specifically highlighted included the importance of empathic skills, listening and being with the patient. The idea that sometimes there is nothing to say to a patient and that sitting in silence is ok (no correct answers to some questions) S09

The students also reported learning about the importance of caring for the patient's family and using a team approach. I enjoyed learning about how the team try to incorporate the patient's family in their care as well and I feel this was an important part S04 I've also learnt about the importance of a functioning multidisciplinary team S06

Psychological effects on students:

As well as gaining knowledge, students commented that what they learned would remain with them and affect their clinical practice. I know it is something that I will carry with me throughout my career! S13 … I believe this module helped me to become a more understanding medical student S17

It appears that the module also stimulated self-reflection and increased students’ awareness of their own needs. Doctors seem to be emotionally detached from their patients. …I still find it hard to maintain a balance between being a professional and sharing a closer relationship with patients S17 How to cope with dealing with sadness and bad news outside of hospital setting—is it that the practitioner becomes desensitised or is it an active behavioural modification to leave that behind S13

Other themes emerging included teaching methods (in particular, the understanding of key issues facilitated by the inclusion of case studies), postgraduate career pathways, and further learning needs in palliative care (in particular, clinical exposure to patients).

Discussion

The module was a popular choice with medical students, with 15% of those eligible choosing it as their first choice. Twelve different SSMs are offered to this group of students (including sports medicine, mountain and wilderness medicine, writing skills for medicine, etc…) and the level of interest in the module was encouraging, particularly as this was the first time that this option was available.

The SEPC and TS instruments have been well validated in assessing the impact of palliative care educational initiatives in undergraduate medical education.7 ,9 The theory underpinning the use of the SEPC and TS tools is based on Bandura's Social Cognitive Theory,13 and is described in more detail elsewhere.7 If students perceive that they have efficacy in doing something and that its outcome is worthwhile, they are more likely to put it into practice. The SEPC measures students’ perceptions of their knowledge and ability to perform tasks (self-efficacy). The TS assesses attitudes towards caring for palliative care patients and is considered a measure of outcome expectancies.9 Significant changes were found in all three areas covered by the SEPC. No changes were found between pre-TS and post-TS scores. Other studies have found significant changes in SEPC and TS scores before and after educational initiatives.9 ,14 However, in one of these studies, there were irregularities in TS scores, with no change, or negative changes, in scores in a substantial number of students.9 The authors postulated that these might have been due to students initially overestimating their competencies, but following education, being more aware and realistic about their limitations. Other possible reasons for this finding in our study include the small numbers, the lack of a clinical component in the module, deficiencies in module content or the level of clinical inexperience of our medical students. Previously published studies using both tools have assessed courses that have both theoretical and clinical components, and students have been in their penultimate year.9 ,14 Future research should seek to look at this issue in more detail.

Formal assessment of student learning through workbooks at the end of the module indicated improved knowledge in key areas of palliative care consistent with their self-report in the qualitative and quantitative instruments. Formal assessment of how attitudinal changes potentially translate into behavioural modification is highly desirable, and is in keeping with EAPC recommendations on the need for palliative care content in undergraduate medical examinationss.2 One possibility would be inclusion of palliative care scenarios in objective structured clinical examination content.

Findings from the study have highlighted areas that warrant further attention in the undergraduate curricula. The three areas assessed by the SEPC (communication, teamwork and patient management) were all identified in the Minute Paper. However, the Minute Paper also identified areas not specifically highlighted in either of the quantitative tools, the most notable of these being the importance of seeing the patient as a unique person and the non-physical dimensions of pain. The former is a fundamental aspect of all medical practice and raises the question of whether or not it is receiving adequate or effective educational focus in our preclinical years. The assessment of the dimensions of physical pain is covered vertically in the curriculum and frequently features in examinations, however, the non-physical dimensions may similarly require attention to improve student understanding. Student rating of communication on the SEPC was lowest of the three areas covered by the tool at the initial assessment and showed the greatest improvement. A significant amount of time is dedicated to generic communication education in the core curriculum, with the addition of a limited amount of selected practical palliative care-related material, this appears to have translated into improved student confidence in the area.

The lack of students’ prior clinical experience was one of the concerns when the module was developed, and something that was shared with the students in a discussion at the final session. Interestingly, the students commented that they thought the timing was very good and that it would help them with other aspects of the curriculum as they progressed through their training and careers.

The Minute Paper was easy to perform, provided useful information in terms of the educational impact and benefits of the module, and highlighted areas that needed additional clarification and attention. It proved to be a rich source of information and provided very useful feedback to the teachers. Despite the lack of significant change in TS scores, this qualitative aspect of our study indicates that the module impacted on students’ attitudes towards caring for palliative care patients and their families, and that students saw the importance of providing palliative care. The addition of this qualitative element to the assessment of the module provided evidence of student understanding of key palliative care concepts. In addition, it has provided valuable information for planning of future module content.

Limitations include the small number of students in the study. Another limitation is that this was a self-selected group of students, and the educational impact of a similar module delivered across an entire year of students is likely to be different. The module lacked a clinical component, and this inevitably impacted on the students’ experiential learning. Practical exposure in a clinical setting may have addressed some of the further learning needs identified by students.

It would require a considerable increase in staff time and resources to deliver the module in its present form to all undergraduate medical students in our university. However, we are currently developing a complementary e-learning tool, so that will make it possible to deliver some of the content to a greater number of students.

Student feedback was very positive and enthusiastic, and several students commented at the final session that they thought the module should be part of the core curriculum. This is in keeping with other studies that have found that palliative care education is well received by students. The suggestion that the module should be core curriculum is likely to reflect the relative lack of palliative care content in the core curriculum, but may also be influenced by the fact that this is a self-selected cohort of students. It has been previously reported that optional modules in palliative care have variable uptake.15 In this study, the module was found to be a popular choice, and those who took the module were very appreciative of the opportunity to obtain further education in this area. In addition, key generic personal and professional skills have been identified that can be covered by an SSM (eg, personal and professional development, teamwork, communication, medical ethics, legal and professional responsibilities).16 Palliative care education complements these core learning outcomes in undergraduate medical education. The authors would encourage other institutions to consider offering optional modules in palliative care, particularly where there is a deficit in the core curriculum, as elective palliative care modules have the potential to raise the profile of palliative care education, and afford interested students the opportunity for further education in the area.

Conclusion

The module was a popular choice with students, was well received, and appears to have had a significant educational impact in terms of changing students’ attitudes and perceived knowledge and skills.

Acknowledgments

The authors would like to thank the students of MX3008 who provided valuable feedback for this study, and the teachers and palliative healthcare professionals who willingly gave of their time and expertise to teach on the module.

References

Footnotes

  • Competing interests None.

  • Ethics approval UCC School of Medicine Research Ethics Committee.

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

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