Background Palliative care (PC) is a relatively new field in Brazil, but this knowledge is of great importance in medical practice.
Objective To evaluate the degree of confidence among medical students and first-year and second-year internal medicine residents in addressing issues of death and terminal illness with patients and their families.
Method A modified version of the Self-Efficacy in Palliative Care Scale was applied to 293 students in their first year to sixth year at the School of Medicine of São José do Rio Preto and to 43 residents in their first year or second year of medical practice at the same institution in Brazil, in 2015. The questionnaire evaluated students' opinions on the need to include theoretical and practical classes on PC in the medical school.
Results Students in their fifth year of medical school were more confident than the students in their first, second, third and fourth years; there were no statistically significant differences between fifth-year students, sixth-year students and the internal medicine residents.
Conclusion Residents were more confident than all of the medical school students except those in their fifth year (P<0.05) because they have more contact with terminally ill patients than other students do; fifth-year medical students are likely overestimating their abilities.
- end of life care
- education and training
- clinical decisions
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Although palliative care (PC) has been growing in medical practice since the 1960s and has been well defined by WHO in 1990, the status of PC teaching in Brazil is unknown. Training of the Brazilian physician focuses on disease treatment and cure besides caring and relieving suffering, inspite of knowing that 74.7% of deaths in Brazil occurred due to chronic diseases.1 Few Brazilian universities include PC in their curriculum.2
The need to include PC in medical training has been debated in other countries.3 Several studies have been performed to assess the need for this knowledge, the best way to introduce it into the medical school curriculum, and opinions among students and physicians regarding this addition.4 5 Hesselink et al, showed a positive impact of lessons on the fundamentals of PC using the Self-Efficacy in Palliative Care Scale (SEPC) in second-year and third-year medical students in Ireland.6
Our study arose from the need to verify the knowledge and needs in PC issues in medical students and residents in our institution.
To assess medical school students and internal medicine residents to determine the degree of confidence in working with terminally ill patients.
We invited all medical students from the first year to the sixth year and internal medicine residents to fill the questionnaire. We used a modified version of SEPC for evaluation purposes. This scale was created in 1999 as part of a study conducted at the University of Liverpool7 and contains eight items to determine individuals’ anxiety over and confidence in communication with terminally ill patients and their families. A score above 28 points means that the individual is considered confident.
A total of 293 from the 300 medical students and 43 from the 64 residents completed the questionnaires. The first-year and second-year internal medicine residents who had studied here had an average score of 33.38 and 37.05 points on the SEPC, respectively. The average scores for medical school students were 21.66 (first-year students), 22.90 (second-year students), 21.71 (third-year students), 25.13 (fourth-year students), 29.13 (fifth-year students) and 25.63 (sixth-year students). First-year internal residents had an average of 33.38; and second-year internal residents, 37.6.
Comparison of the SEPC Scores between the groups by the analysis of variance resulted in a P value of <0.001. In this way, the post hoc analysis was performed by the Bonferroni test, which identified the effect between first-year and second-year physicians of the residence programme and the first-year, second-year, third-year, fourth-year and sixth-year medical students; and among medical students in the fifth year versus the first year, second year and third year. The data are shown in table 1.
The descriptive portion of the questionnaire included the open-ended question, ‘Do you believe it is important to include a subject about palliative care in the medical school curriculum? If so, how?’. Of the 168 students who answered these open-ended questions, 114 (67.8%) indicated the need for both theoretical and practical classes on the subject. Some interesting answers to the question were the following:
‘I believe that all medical schools should offer, if not a course on palliative care, at least a discussion about it every year, about the issue of death in our profession.’
‘I believe a course needs to be included that addresses the topic of palliative care from the moment we start having contact with patients; that is, from the beginning of symptomatology.’
‘Medical students are not prepared to give bad news to patients or their families. It would be interesting if there were a course that taught techniques for this situation, which is so common in hospital environments and in medical practice.’
The current study also compared the profiles of students from each year of medical school in terms of the situations addressed by the questionnaire. For this comparison, the medical school students were separated into two groups—those who had had previous contact with a PC situation (whether in a theoretical course or in practice) and those who had had no contact. In each of the groups, the frequencies of the students’ answers to each of the questions were compared, but no statistically significant differences were found between the groups (χ2 test). Among the students who had not had contact with PC, the situations in which there was a significant difference in responses were situation 2 (‘Discussing the likely effects of cancer with the patient’s family’), situation 7 (‘Answering the patient’s question, ‘How long have I got to live?’) and situation 8 (‘Answering the question, ‘Will there be much suffering or pain?’). Among the students who had not had contact with PC, the situations in which there were significant differences in the responses were situation 2 (‘Discussing the likely effects of cancer with the patient’s family’), situation 7 (‘Answering the patient’s question, ‘How long have I got to live?’) and situation 8 (‘Answering the question, ‘Will there be much suffering or pain?’).
In situation 1, most first-year medical students were found to be anxious over providing PC (56.86% reported values lower than 4), while the majority of students in the fifth year and sixth year (68.75% and 56.25%, respectively) reported scores reflecting confidence (P=0.007). In situation 7, most of the first-year and sixth-year students were found to be anxious (84.31% and 62.5%, respectively), while most of the fifth-year students were found to be confident (56.25%; P=0.001).
In situation 8, most of the first-year and fifth-year students were found to be anxious (56.86% and 56.25%, respectively), while the majority of the sixth-year students reported scores that reflected confidence (62.5%; P=0.008).
The apparent confidence that the fifth-year students expressed is likely due to their limited contact with difficult situations involving patients and death and probably involves a case of the Dunning-Kruger effect—a cognitive bias in which people with limited experience and training overestimate their abilities more so than people with more experience and training8—but this evaluation goes beyond the objectives of the study.
The main difficulty in the preparation of this study was the limited access to students and resident physicians, a factor which reduced the study population. Even so, with 293 students plus 43 residents, there was a higher number of participants than in a similar study: Mason et al 9 considered a sample of 216 students for a study comparing student responses on the questionnaire before and after a PC training programme, and the same authors, in a multicentre study comparing results obtained in France, Italy, Ireland, Spain and the UK, noticed that the variation in exposure to the teaching of palliative medicine is likely to be the result of training at different universities and it may be useful for those looking for support to increase the number of hours of palliative medicine within undergraduate curricula.10 11
SEPC was formally validated in 2004 in order to assess the effectiveness of the PC training programme.9 It was originally used to evaluate a PC education programme for fourth-year medical students. Significant differences were found in students’ responses before and after the programme, reflecting the effectiveness of practical classes on the subject among medical school students.10 There seem to be no studies in the literature comparing students in different years of medical school.
Our results of SEPC showed that internal medicine residents are more confident overall than medical school students in communicating with terminally ill patients and their families (P<0.05). This is probably due to the residents’ prolonged contact with their patients, since they go through several rotating clerkships during the medical residency that puts them in contact with terminally and seriously ill patients. Students spend less time in the different departments and don’t have contact with patients until the third year, which hinders the development of doctor-patient and doctor-family relationships, and which also explains students’ major communication difficulties.
The literature reinforces the need for physician education reform so that students can obtain the basic skills required for the practice of PC, because many doctors currently leave medical school without the necessary skills and emotional support to care for terminally ill patients.11 12 Camargo et al wrote a review article about the teaching of death and dying in Brazilian medical graduation, where they found that there are very few discussions about death and dying, usually in a superficial and theoretical form.13
This also happens in the USA, as most medical schools still do not include PC training as a requirement for graduation.13 Unfortunately, implementing such training has a number of constraints. In order to instil greater confidence and prepare them to handle problems involved in terminal illness it is very important to prepare medical students thoroughly for situations as delicate as the end of life.
The authors thank Danielle Deremo Cosimo for the English review, and Patricia Fucuta for the statistical analysis review.
Contributors Conception and design of study: ACMS, GDdC, PMC. Acquisition of data ACMS, GDdC, PMC. Analysis and/or interpretation of data ACMS, GDdC, LC, PMC. Drafting the manuscript ACMS, PMC. Revising the manuscript critically for important intellectual content ACMS, PMC. Approval of the version of the manuscript to be published ACMS, GDdC, LC, PMC.
Funding Fundaçãode Amparo à Pesquisa do Estado de São Paulo (FAPESP) (PROCESSO 2013/24533-8).
Competing interests None declared.
Ethics approval Faculdade de Medicina de São José do Rio Preto, Brazil, Institutional Research Ethics Committee, reference numbers 27457314.9.0000.5415 and 27343614.2.0000.5415.
Provenance and peer review Not commissioned; externally peer reviewed.
Presented at Poster presentation at the 22th International Congress of Palliative Montreal, Canada, October 2016.