Background Palliative care (PC) education has become a priority in many European countries where PC is quickly developing. There remains, however, a lack of information on acceptability and medical students’ experiences in PC education. This kind of information is important because it could encourage universities to adapt their curricula appropriately to the demographic and societal necessity.
Objective To explore medical students’ reactions to an optional PC course using their reflective written comments.
Methods 316 medical students at the University of Navarra, over a period of 4 years, wrote evaluative comments regarding their experience and what they perceived as the course's contribution to their education. With these comments, a qualitative thematic analysis was carried out.
Results With a response ratio of 90%, five main themes were identified: (1) The course helped medical students to become and act as doctors, (2) The benefits of having a holistic view of the patient and taking the family into account, (3) PC opens up a new a field of knowledge, (4) The course makes students think and reflect on their personal development and encourages them to deepen humanistic aspects of their practice, (5) The practical aspect is essential in PC learning. In addition, significantly, students used vigorous and positive expressions when writing about their experiences.
Discussion The subject of PC turns out to be very important to students, who almost unanimously evaluated their experience positively and highlighted the benefits of attending a PC course. Students especially reported being surprised by the humane and holistic features of the course, and they found that what they learned in the course is applicable to all patients and prepares them to work better as doctors. Participants recommend the course for all undergraduate students as a core component of the curricula.
- Education and training
- Supportive care
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International institutions have consistently and for a long time requested the implementation of palliative care (PC) education within the undergraduate medical degree courses.1–3 PC as a subject is slowly being incorporated at the undergraduate level at medical faculties in North America, the UK and other countries.4 ,5 As the EAPC Atlas of Palliative Care shows,6 in 2013, 10 of 52 European countries included palliative care teaching in their medical schools. A review of USA medical school surveys about the teaching of palliative and end-of-life (EoL) care reveals varied and uneven approaches.7 Teaching tends to be fragmented, ad hoc and lacks an overall coordination, while, at the same time, there are difficulties in recruiting appropriate teachers.8
Studies about the effectiveness of PC and EoL care education show positive results. Medical students that receive palliative care courses acquire knowledge and skills related to PC, differences between the palliative and curative approaches, symptom control, pain management, communication9–12 and self-reported competence and self-reported concern.13–15 Attitudes regarding EoL care do not easily change with short courses, but rather require considerable curricular time.16 There is also a lack of validated tools for evaluating the effectiveness of PC education initiatives.17 It is perhaps significant that the Oxford Textbook of Palliative Care's last edition18 still has no chapter on undergraduate education, further proving the need to dedicate more research to the crucial topic of including palliative care in curricula.
As palliative care education expands at the university level, it is worth exploring how students receive this subject. Medical students’ acceptance of PC education has been explored in pilot studies.4 ,19 ,20 Encouraging experiences that promote the value of caring for dying people has been shown through reflective writings (‘I will never forget’)21 and semistructured interviews (‘It's not all doom and gloom’).22 Reactions, experiences, views and self-perceived learning do not predict the results of education, but they do inform us about the transcendence that students give to palliative care and the need to adapt medical curricula to the demographic and societal needs that students perceive. Positive results can eventually encourage academicals authorities. An open approach, that is, asking students to comment by writing openly about their experience, can help uncover some hidden aspects of palliative care self-perceived learning and later can help to design studies on the effectiveness of palliative care education. Our aim is to explore and describe the reactions and self-perceived learning of medical students participating in optional palliative care courses through reflective comments written at the end of the teaching intervention.
An exploratory qualitative study was designed.
Students from the faculty of medicine at the University of Navarra who completed the optional course on palliative care (n=316) between the academic years 2006–2007 and 2009–2010 were included in the study.
Characteristics of the optional course on palliative care
The subject was offered as an optional course in the fourth, fifth and sixth years of medical studies, with a limit of 75–85 students per year. The course was comprised of 45 h of teaching, while the topics were imparted by different professionals from a PC team, one of whom was a professor in the faculty and the course administrator. The topics covered included: the history and evolution of PC; principles of palliative medicine; general principles of symptom management and evaluation; pain treatment, general, digestive, genitourinary, respiratory and neurological problems; emotional problems; the final hours or days of life; ethical aspects of caring for terminally ill patients; suffering and spiritual guidance. Students were evaluated according to the following criteria: obligatory class attendance, a multiple-choice exam and a clinical case, and 2 days of clinical practice (except for the first year the course was given). The implementation of the study was organised in the years following the inclusion of the course in the faculty of medicine's academic curriculum.
In this study, we present a qualitative analysis of the written responses to the open questions asked at the end of the course. The questions included: How has your experience been in this course on palliative care? How has it contributed to your education? Data collection, following the faculty of medicine's standardised evaluation procedure at that time, was undertaken immediately before the final evaluation, written and anonymous. One student designated by the group collected the forms and kept them until the official course grades were released, at which time they were submitted to the professor in charge of the course in a sealed envelope. As such, students’ opinions were not only anonymous, but also were not influenced by the grade students received.
Analysis and rigour
The anonymous forms and manuscripts collected were numbered and scanned, presenting an identical copy to each of the participating researchers. The response rate in the study was calculated from the proportion of students that responded to the study question.
We aimed to derive concepts and meanings from the data, and therefore, we analysed it in order to look for themes related to the written reactions or material that students studied. Connections were made between the codes to identify categories and connections among categories were made to derive themes. Three researchers independently read each document and coded the text and they then met at intervals to compare and refine the codes. Saturation of information was achieved. The principal investigator was a professor of nursing studies from a different university, whereas the second researcher, who was also a professor of nursing studies, was affiliated with the participating university. The third member of the team was the medical professor in charge of the course. All of them received specific training in the qualitative research methodology and have previous experience in it.
We illustrate the results with quotations (with a number assigned consecutively to each student) since the relevance of the findings does not come from the frequency of repetition of themes or categories, but rather from the formulation of meaningful expressions. As additional contextual information, we also provide the number of students that mention specific themes in their reflective writings.
During this 4-year study, 316 students attended the PC course, reflecting maximum attendance of the course each year. Nearly half the students who graduated from the faculty within these 4 years completed the elective course in palliative medicine. All participants (n=316) submitted their completed evaluation form, but 32 failed to respond to the study questions. We did not ask why, but suppose that non-response was related to disagreement or negative experiences with the teaching. Hence, 284 responses were analysed (response rate=90%). The students were between 20 and 23 years old and 72% were female. Age and gender distributions were in the range of similar populations in the faculty. Around 25% were in their fourth or sixth year of the degree course, and 50% were in their fifth year. Students’ evaluations varied in content, extension (70–100 words on average) and style, as everyone stated what they believed to be most relevant in their own words.
From the analysis of the data, five main themes were identified: (1) the course helped medical students to become and act as a doctor, (2) the benefits of having a holistic view of the patient taking the family into account, (3) palliative care opens up a new a field of knowledge for students, (4) the course makes students think and reflect on their personal development and encourages them to deepen humanistic aspects of their practice, and (5) the practical aspect is essential in palliative care learning. When speaking about the meaning of the experience, students used vigorous and positive expressions in referring to the subject. In the documents analysed, there were also a few negative comments, but they always regarded practical issues, a concrete lesson, or technical methods, and did not refer to the learning experience in itself. As we consider these points to be beyond the focus of our research, they will not be considered here.
The palliative care course better prepares students to become and act as doctors
Students (n=92) stated that the course helped them to learn something new, something that not included in any other course (table 1) and that is in some ways essential for the future of any doctor because it provides a global vision of medicine, helping to integrated other medical subjects.
I think that the knowledge I acquired is necessary to be a good doctor in any speciality (M44)
This course gives one a different view of the patient and it will help me to develop my professional career in whichever direction I choose to go (M270)
As the previous statement indicates, what students learned regarding palliative care would serve them in any branch of medicine, regardless of the speciality they intended to follow. Some students went further, indicating that it should be a mandatory course for all students and, in any case, they would recommend it to their peers.
It is fundamental for a medical student as not only the theory and practice of palliative care is taught, but one also learns how to handle difficult situations, to give bad news and to work in a team …all of which is useful to all types of doctors (M98)
This course is necessary to obtain a degree in medicine (M163)
This is a really interesting course that I would recommend to any medical student (M110)
Concretely, this course was considered so important for all medical students because they felt that the ability to deal with EoL care situations is an essential capacity of any doctor. They considered that it is fundamental to understand terminal patients, to support them and to handle their problems.
All future doctors will have to learn to deal with the terminal patient (M64)
This course has helped me a lot to understand that although it is clear that the patient will die, you can make their last days more tolerable for them and their family (M278)
Learning that a holistic approach and family care is also part of medicine
Nineteen of the students stated that in this course they learned the humanistic aspect of medicine for the first time, including whole-person care and family care as part of medicine:
Through the lecturers and seeing the doctors in the practical sessions, I have seen a very different way to conceive of medicine and to treat the patient, which is very different from what I had seen until now (M64)
I have seen how important the family is, something that I had disregarded and isolated (M264)
Our curriculum lacks the holistic touch that palliative care makes you consider (M131)
Opening a new field of knowledge
Students especially perceived that they learned about pain and other symptoms, as well as issues related to medication, especially opioids (table 2). They also reported learning about spirituality, interdisciplinarity, communication and ethics, although less frequently. We found 31 students that mentioned having found some of these new topics in their curricula.
I thought it was a very useful course, particularly to learn how to handle opioids and morphine without fear (M91)
The course is important from both the medical point of view, as well as from the spiritual point of view (M303)
I believe that it is the best option to understand how teamwork really works (M18)
We must all confront ethical questions and situations that are difficult to resolve without this knowledge (M96)
The palliative care course makes one reflect and grow, it gives you humanity
The students mentioned that the PC course made them reflect and grow, and that as such, made them more humble (n=35). They stated that it brought them down to earth and that they saw and understood the true purpose of a doctor, which is always being at the patient's side. They believed that this field is necessary in medicine given that it brought out their more humane side and that it helped them to envisage future situations.
The study of palliative care brings a doctor down to the ground and makes one understand a doctor's true purpose: to be at the patient's side, always (M65)
In my opinion it is a very necessary course in medicine, given that it brings out ones more humane side, and it helps one to come face to face with sad situations that we will inevitably have to confront in the future (M128)
The practical sessions are essential for learning palliative care
If practical sessions can be considered to be important in all subjects, here 162 students mentioned that they are essential (box 1). They specified that they were important, that more practical sessions are necessary, that they added more value to the course and that all students should perform practical studies in palliative care. They thought that despite being short they ‘offered a lot’ and served to come into contact with PC and to analyse what they considered to be the ‘battle field’, as well as to convert theory into practice.
The practical sessions are necessary to fully capture the value of this speciality and its effect; spending time in the unit was very worthwhile (M21)
The practical sessions are the best way to understand how teamwork really takes effect (M18)
Despite being short, the practical sessions served perfectly to come into contact with the speciality and to analyse it on the battle field (M272)
Box 1 Practical sessions are essential to learn about palliative care (Categories identified in the text)
The practical sessions are the most important part of the course
The more practical sessions the better
They help a lot
All students should attend practical sessions for palliative care
Expressions regarding the palliative care course convey a deeper meaning
A noteworthy theme that emerged in the analysis of 162 students’ spontaneous expressions was the deeper meaning that the course offered (box 2). Some said, ‘It was stimulating’. Others also referred to the course as ‘useful’. Students who were about to qualify as doctors considered the course beneficial. According to them, PC is rarely referred to in other courses, and moreover, they were taught different things that are sometimes virtually overlooked in other subjects.
I think that the course is very useful for students who are about to qualify as doctors, since palliative medicine is rarely dealt with in the rest of the courses, except in oncology (M131)
Box 2 Other meaningful comments or expressions to refer to the experience (Categories identified in the text)
They stated that the course ‘was revealing’, meaning that they discovered things that they previously ignored or that weren't discussed. They believed that PC is an important subject and they were happy to have chosen the course because otherwise they would not have addressed the issues dealt with.
I consider palliative care to be an important subject that is not given enough consideration and at least I am happy to have chosen this subject because otherwise, I would have hardly heard of this topic (M99)
An important number of students offered their ‘thanks’ and recognised that they were grateful to the lecturers for their interest, for the scientific value of the course and its practical approach.
I'm not sure, but in the end I felt very happy and I just wish to say THANKS (M156)
This work adopted a novel approach to the study of palliative care teaching for medical students. Students were asked to give their opinion as to what the PC course offered them. The qualitative analysis subsequently carried out revealed interesting insights into their perceptions, including: the relevance of the subject to become and act as a doctor, the benefits of having a holistic view of the patient, the discovery of new fields of knowledge, the importance of humane values and the determinant role of practical sessions in PC learning.
Given that we were mainly interested in reaction—what participants thought and felt about their training—and self-perceived learning (knowledge and/or skills, and change in attitudes), our findings could be associated with the initials levels of Kirkpatrick's evaluation model.23 It is clear that this is an initial exploratory study using documentary sources. A complete evaluation of PC learning would require a longer-term study that should also include other complementary data collection methods, such as focus groups or personal interviews, and a longer evaluation of behaviour, and conduct after the conclusion of the PC course that includes more than immediate reactions.
We used a novel approach, based on qualitative research techniques, to study a new subject in the medical curriculum. To date, most studies have focused on closed or specific questions or have used validated quantitative measures. By contrast, we were looking to identify new reactions and a wider range of thoughts about PC. For this reason we asked a very general and open question and we analysed a large number of respondents. The students responded to our questionnaire spontaneously and anonymously, in the knowledge that their replies would not affect their course grades. The triangulation and complementarity of the research team gave the study additional rigour and depth.
Some methodological aspects of our study call for comment. Because the course was optional, our sample could reflect the opinions of students that are particularly interested in the topic and thus, it is reasonable to suspect that the opinions offered do not represent a balanced account. It would therefore be interesting to repeat the study and compare the results in the light of this new premise. Soliciting the opinions of students in isolated courses in a single centre represents a good beginning to evaluate PC learning, but the reactions attributed to the optional course on palliative care within the context of a medical degree cannot be disentangled from the results found at a specific university or the teachers that taught the course. It should be noted that the written statements from the students are most likely shorter than if the information had been obtained in the context of an interview or a focus group, but it should also be noted that students were given one side of an A4 sheet to respond and the answers they offered were long enough and content rich.
Qualitative data shows that the subject of palliative care matters very much to students who have taken the subject and they highlighted the benefits of attending a palliative care course, showing almost unanimous support for it. In the sample studied, students were surprised by the humane and holistic features of a palliative care course. We found that the students felt that what they learned in their palliative care course was not just applicable to terminally ill patients. Students thoroughly supported the combined clinical, humanistic and holistic vision of medicine, and they perhaps perceived it as closer to their vocational idea of medicine, which they had not found until they came across the PC course. The future clinicians in the study go even further when they say that this course prepared them to become and act as clinicians. They thought that it was not only valuable for attending to terminal patients, but rather was useful for attending to any kind of patient. They maintained that what they learned was useful to them as clinicians in order to take better care of any patient. They claimed to have learned essential things that will help them to take care of any patient and, for this reason, they insist PC should be a mandatory course. This is consistent with previously issued training recommendations for both clinicians and nurses, as well as for other professionals.16 ,24 At the same time, the students recognised that the training received was essential to handle EoL situations in their future professional careers. This was to be expected given that PC covers this phase.
They also indicated that the course provided them with a different way of conceiving medicine, emphasising the importance of a family based and holistic treatment. The course prompted them to reflect and helped them to develop, making them more humanitarian, and thus, in addition to a professional effect, it also had an influence on the personal level. To them, it felt as though they had rediscovered medicine, the way of caring for the patient and dealing with their family. The course helped them to reflect and express a more humane side of the profession and to come down to earth and face the reality of caring and supporting their patients until the very end.
As expected, they also indicated that the course taught them something new, as mentioned in previous studies. 9 ,12 ,25 Students indicated that the course taught them something new about symptom management, pain treatment, medication and opioids, as indicated elsewhere,9 ,11 despite the previous assertion that improvement in general knowledge was low. As in other studies, the students referred to an improvement in their communication skills, as well as in their approach to difficult situations.9 ,14 Furthermore, they also mentioned that they learned more about spirituality and teamwork. The students attributed particular importance to the practical sessions, which they considered essential for better understanding the theoretical concepts they had learned in the classroom. Such practical sessions have already been mentioned as important in learning and the inclusion of a practical rotation has been suggested.26
The course on PC represented an important discovery for students, which surprised them and led them to offer statements such as: ‘it's stimulating’, ‘it's useful’, ‘it's revealing’, ‘it's enjoyable’. At the same time they demonstrated gratitude for the education they had received, making clear that it will have an impact far beyond the subject of the course.
This study identifies some novel contributions a PC course offers to students and, to our knowledge, it is one of the first times that undergraduate medical students express themselves, in their own words, about PC teaching programmes. Knowing what students think about PC's whole-person model, and not just about symptoms or pain control, is the first necessary step toward performing studies designed to obtain empirical information about how to intervene and address PC programmes and to reach the objective of changing behaviours. It would be interesting to consider these aspects in future evaluations to assess the repercussion of such teaching and its potential effects on other areas other than those related to patients in advanced stages of a disease.
Qualitative data highlighted the benefits of attending a palliative care course showing almost unanimous support. In the sample studied, the humane and holistic features of a palliative care course surprised them. The students perceived that their vision of medicine improved because they learned that it is applicable to all types of patients and prepares them to work better as professionals, regardless of their speciality, and to deal with difficult situations faced by patients and their families. Participants recommend that the palliative care course be mandatory for all undergraduate students.
It is time to develop the undergraduate curricula in palliative medicine in medical schools.27 In fact, students’ experiences reached our faculty's academic authorities and, in 2013 during a general review and update of the medical curriculum, after 6 years of optional palliative care teaching, the course became mandatory for all medical students at our university.
We would first like to acknowledge and thank our students for sharing their learning experiences with us. Special thanks also go to the professionals of the Department of Palliative Medicine of Clinica Universidad de Navarra and to the Palliative Care Services of Hospital San Juan de Dios-Pamplona, which supports the practical training of University of Navarra medical students each year.
Contributors CC, MB and MA participated in the design, collection of data, qualitative analysis of results, discussion, redaction and final approval of the manuscript. JMC participated in the discussion, redaction and final approval of the manuscript.
Funding Institute for Culture and Society University of Navarra.
Competing interests The medical professor in charge of the course, CC, was also one of the three researchers who participated in this analysis.
Ethics approval The Ethical Research Committee of the Clínica Universidad de Navarra approved the study.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Unpublished data of this research as the documents analysed (scanned in pdf format) and a relation of all quotation of the documents extracted are available under written request.