An International Survey of Undergraduate Medical Education in Palliative Medicine

Transcription

1 174 Journal of Pain and Symptom Management Vol. 20 No. 3 September 2000 Original Article An International Survey of Undergraduate Medical Education in Palliative Medicine Doreen Oneschuk, MD, John Hanson, MSc, and Eduardo Bruera, MD Regional Palliative Care Program (D.O.), Grey Nuns Community Hospital; Department of Epidemiology (J.H.), Cross Cancer Institute, Edmonton, Alberta, Canada; and Department of Symptom Control and Palliative Care (E.B.), University of Texas, MD AndersonCancer Center, Houston, Texas, USA Abstract A 9-item mail survey dealing with availability and characteristics of undergraduate medical education programs in palliative medicine was sent to all medical schools in Canada (16) and the United Kingdom (UK) (30), and 129 randomly selected medical schools in the United States (US) and Western Europe. The overall response rate was 117/175 (67%). The highest percentage of mandatory (required by the university) rotations in palliative medicine was in the UK medical schools (14/22, 64%). Considerably lower numbers were obtained from the other countries: US; 4/37, 11%, Canada; 2/14, 14%, and Western Europe; 8/43, 19% (P 0.001). Elective rotations in palliative medicine were more readily available in the UK; 18/22, 82% and Canada; 10/14, 71%, compared with the US; 23/37, 62%, and Western Europe; 13/43, 30% (P 0.001). Seventy-two percent (13/18) of UK, 70% (7/10) of Canadian, 59% (16/27) of US, and 9/30 (30%) of Western European medical schools provide educational reading material in palliative medicine (P 0.014). Case-based learning in small groups and small group discussion were favored by the UK, 14/22 (63%) and 17/22 (77%), respectively, and Canadian medical schools, 8/14 (57%) and 8/14 (57%), respectively (P 0.176). The number of universities with academic faculty positions for palliative medicine and the median number of positions for the countries were as follows Canada 8/13 (62%) and 2; UK 12/22 (55%) and 1; US 5/36 (14%) and 1; and Western Europe 9/24 (21%) and 1, respectively (P 0.001). Besides the UK, mandatory (required) rotations in undergraduate palliative medicine education are lacking in Canadian, US, and Western European medical schools. The median number of 1 academic faculty member per responding medical school is discouraging. In order for undergraduate and postgraduate medical education in palliative medicine to improve, the number of both educational programs and faculty members will need to be increased. J Pain Symptom Manage 2000;20: U.S. Cancer Pain Relief Committee, Key Words Education, undergraduate, international, academic, palliative care Address reprint requests to: Doreen Oneschuk, MD, Regional Palliative Care Program, Grey Nuns Community Hospital, Room 5211, 1100 Youville Drive West, Edmonton, Alberta, T6L 5X8 Canada. Accepted for publication: October 25, Introduction Practicing physicians acknowledge uneasiness in caring for patients with terminal illness. This stems partially from a lack of knowledge in areas and topics pertaining to end-of-life care, such as cancer pain management. 1 5 U.S. Cancer Pain Relief Committee, /00/$ see front matter Published by Elsevier, New York, New York PII S (00)00172-X

2 Vol. 20 No. 3 September 2000 Undergraduate Medical Education Survey 175 Many physicians and educators attribute this, at least in part, to limited exposure to palliative care education during medical school. 3 Medical educators note that medical students attitudes, behavior, and clinical knowledge in the area of palliative care can be positively influenced by education Despite this optimistic finding, deficiencies continue to exist in the area of undergraduate palliative care education as this relates to program availability, content, and structure The purpose of this survey was to identify the availability and characteristics of undergraduate palliative medicine education in all Canadian, all United Kingdom, and randomly selected United States and Western European medical schools. Methods A 9-item survey dealing with undergraduate medical education in palliative medicine was mailed to the Deans of Medicine for all 16 Canadian medical schools, all 30 United Kingdom medical schools, 58 randomly selected United States medical schools, and 71 randomly selected medical schools in Western Europe (France, Germany, Italy, Greece, Spain, Portugal, and Scandinavian countries). The Faculties of Medicine for the respective countries were obtained from a Worldwide Directory of Medical and Dental Schools Directory of Medicine and Dental Schools, 6 th ed., U.S. Directory Service, New Providence, NJ: Reed Elsevier Inc., A first mailing occurred in March 1997 and a second mailing in January Demographic inquiries included the name of the medical school/university, the average size of the graduating class during the last 2 3 years, whether the university is privately or publicly owned, religious denomination(s) if privately owned, and the length of the undergraduate medical program. The survey is displayed in Appendix 1. Data Analysis The Statistical Analysis System software package (Version 6.12, 1996) was used to perform the analysis. Descriptive statements were employed including medians and percentages. Chi-square tests were used to compare proportions with the level of statistical significance established as P The random allocation of medical schools for the United States and Western Europe was obtained from computer generated numbers. Results A total of 117 of 175 (67%) completed questionnaires were returned, 73 with the first mailing, and 44 with the second mailing. Three other questionnaires were returned uncompleted with the following reasons cited: one university was undergoing dissolution of the medical program because of a planned merger of 4 medical schools with a total curriculum renewal program planned (a United States medical school), one United Kingdom university was involved in teaching preclinical basic medical sciences only (i.e. BSc Medical Science degree), and one university provided only general comments on single issue questionnaires (United Kingdom medical school). Fourteen of the 16 (87.5%) Canadian medical schools, 22 of the 30 (73.3%) United Kingdom medical schools, 38 of the 58 (65.5%) of the United States medical schools, and 43 of the 71 (60.6%) of the Western European medical schools responded. The median class size for the medical schools were: Canada 98 students, United Kingdom 160 students, United States 145 students, and Western Europe 118 students. The majority of universities 95/112 (85%) were publicly owned. Of the 17 privately owned universities, 10 (59%), were non- or multidenominational. The median length of the undergraduate medical programs were as follows: Canada 4 years, United Kingdom 5 years, United States 4 years, and Western Europe 6 years. Table 1 depicts the availability of mandatory (required) and elective palliative medicine rotations by country. There was a statistically significant difference between the countries for both (P 0.001). The median percentages of students who participated in an elective rotation in palliative care for each country were as follows: Canada 1.0%, United Kingdom 1.5%, United States 1.0%, and Western Europe 2.5%. The number and percentage of sites offering formal lectures and the median number of lecture hours, respectively, per site were as fol-

3 176 Oneschuk et al. Vol. 20 No. 3 September 2000 Table 1 Mandatory and Elective Rotations in Palliative Medicine for Medical Students, by Country Number and frequency Canada (n 14) United Kingdom (n 22) a United States (n 37) Western (n 43) Mandatory Rotation b 2 (14.3%) 14 (63.6%) 4 (10.8%) 8 (18.6%) Median rotation duration in days Elective rotation b 10 (71.4%) 18 (81.8%) 23 (62.2%) 13 (30.2%) Median rotation duration in days a One response missing. b P lows: Canada 10/13 (76.9%), 6 hours; United Kingdom 17/22 (77.3%), 4 hours; United States 23/38 (60.5%), 4 hours; and Western Europe 27/42 (64.3%), 5.5 hours (P 0.478). Besides formal lectures, various other teaching formats used for palliative medicine education for each country are depicted in Table 2. Table 3 illustrates the various clinical settings in which palliative teaching occurred for each country. The number and percentage of medical schools per country that provide educational reading material in palliative medicine were as follows: Canada 7/10 (70%), United Kingdom 13/18 (72.2%), United States 16/27 (59.3%), and Western Europe 9/30 (30.0%) (P 0.014%). The number of universities with academic faculty positions for palliative medicine and the median number of positions for those countries were as follows: Canada 8/13 (61.5%), 2 faculty positions; United Kingdom 12/22 (54.6%), 1 faculty position; United States 5/36 (13.9%), 1 faculty position; and Western Europe 9/42 (21.4%), 1 faculty position (P 0.001). With respect to medical student evaluation following a clinical rotation, no university identified a specific evaluation form for their palliative medicine rotation. Thirty-two of 70 (45.7%) universities acknowledged the use of a similar format of assessment for other rotations. Twenty-five of 70 (35.7%) medical schools from all sites identified other assessment formats, including Objective Structured Clinical Examinations (OSCE), case presentation and case report, and inclusion of questions in an oncology, internal medicine, family medicine, or surgery post rotation assessment. The following number and percentage of medical schools per country acknowledged use of written examinations in palliative care: Canada 3/14 (21.4%), United Kingdom 5/22 (22.7%), United States 2/38 (5.3%), Western Europe 8/43 (18.6%) (P 0.200). For all countries combined, the total number and percentage of specific palliative medicine examinations following formal lectures and/or post rotation exposure to patients was 29/117 (24.8%). There was no statistically significant difference Table 2 Teaching Formats of Palliative Medicine for Medical Students Other than Formal Lectures, by Country Frequency and collective percentage Canada (n 14) United Kingdom (n 22) United States (n 38) Western Europe (n 43) P-Value Case-based learning Small groups (57.1%) (63.6%) (55.3%) (48.8%) Large group (2.3%) Both (28.6%) (18.2%) (5.3%) (2.3%) Question & answer (14.3%) (45.5%) (34.2%) (11.6%) Small group discussion (57.1%) (77.3%) (55.3%) (37.2%) Computer-based learning (9.1%) For all countries, one or more teaching formats could be selected

4 Vol. 20 No. 3 September 2000 Undergraduate Medical Education Survey 177 Table 3 Clinical Settings Where Palliative Medicine Teaching Occurs for Medical Students, by Country Frequency and collective percentage Canada (n 14) United Kingdom (n 22) United States (n 38) Western Europe (n 43) P-Value Acute Care Hospital Team (64.3%) (59.1%) (65.8%) (41.9%) Acute Palliative Care Unit (35.7%) (36.4%) (10.5%) (16.3%) Hospice setting (42.3%) (81.8%) (52.6%) (20.9%) Cancer Center (50.0%) (50.0%) (29.0%) (39.5%) Community/Outpatient (42.9%) (59.1%) (52.6%) (23.3%) Other (7.1%) (4.6%) (10.5%) (18.6%) For all countries, one or more teaching setting could be selected. among the 4 regions with respect to the use of written palliative medicine examinations. For inclusion of palliative medicine questions in the final examination required by the Licensing Body or Government for each respective state/country, the numbers were as follows: Canada 4/14 (28.6%), United Kingdom 10/22 (45.5%), United States 4/38 (10.5%), and Western Europe 10/43 (23.3%) (P 0.023). Numbers and percentages of oral examinations in palliative care taken by medical students per country were as follows: Canada 7/14 (50.0%), United Kingdom 6/22 (27.3%), United States 26/38 (68.4%), and Western Europe 18/43 (41.9%) (P 0.013). Discussion Our survey is the first to explore the availability and characteristics of undergraduate palliative education at the international level. The survey revealed both similarities and variability among countries with respect to both availability and operation of palliative medicine education. Given the maturity of palliative medicine in the United Kingdom, the country where the modern hospice movement originated, 16 it was not surprising to find this country having the highest percentage of mandatory or required rotations in palliative care. In contrast, mandatory rotations in Canada, United States, and Western Europe in this area are strikingly low. Elective time is considerably more generous for these countries, apart from Western Europe. One would have anticipated a more positive influence from the United Kingdom s palliative medicine education system on the surveyed Western European countries given proximity alone. However, language and historical differences in medical school curricula may be some of the reasons why Western European palliative medicine education is overall slightly less than in North America. More than half of all universities in each of the 3 groups (North America, United Kingdom, and Western Europe) have formal lectures in palliative care for their medical students, although the hours devoted to these sessions are not plentiful (range of median hours 4 6). More than half of responding North American and British universities provide educational reading material on palliative care. With respect to teaching strategies for palliative medicine education, case-based learning, an increasingly popular teaching format, is more highly favored by United Kingdom and Canadian medical schools, although all this appears to be the predominant teaching format utilized by all countries. Only the United Kingdom indicated the use of computer-based learning. This may change in the not too distant future, as the Internet and CD- ROM programs are developed for educational and other purposes in palliative care. 17 It was not unexpected to discover the majority of palliative medicine education occurring in the hospice setting in the United Kingdom versus acute care hospital teams as in Canada, the United States, and Western Europe. The United Kingdom alone now has well over 200 hospices. 18 Acute palliative care units appear to be underutilized although one could assume that academic and community hospitals affili-

5 178 Oneschuk et al. Vol. 20 No. 3 September 2000 ated with their respective local medical school may not operate an acute palliative care unit. While no university identified a specific evaluation form for their respective palliative rotation and close to half (32/70, 46%) utilize a similar format of assessment for other rotations, it is reassuring to see that more than one-third of the surveyed medical schools from all sites implemented other teaching assessment formats such as the Objective Structured Clinical Examinations (OSCE), case reports, and presentations. The use of written examinations exclusive to palliative medicine occurring after formal lectures and/or exposure to patients was limited, and oral examinations were utilized more frequently in Canada and the United States. Although United States medical schools indicated minimal inclusion of palliative medicine questions on final exams required by a licensing body, this also may change with the implementation of the American Board of Internal Medicine End-of-Life Patient Care Project. 19,20 Perhaps what is most concerning is the limited number of universities with academic faculty positions. This ranged from 14% in the United States to 62% in Canada, coupled with a median number for all surveyed universities of 1 position. In order for palliative medicine education to prosper at this level, a critical mass of teachers must exist, particularly for the creation and practice of mandatory (required) rotations that are already having difficulty finding their way into an already crowded undergraduate curriculum. Despite reasonable availability of elective time for palliative medicine, very few students (median percentage of less than 5 for all surveyed medical schools) choose to pursue this elective. The reasons for this may include limited academic faculty, a low profile of palliative medicine compared to other medical fields such as cardiology or plastic surgery, a top-down message from the Dean s office that palliative care and end-of-life issues are not worthy subjects, and/or students reluctance to confront apprehensions and fears of the dying process and death itself. Future research should focus on this area with the objective of substantiating or negating these possibilities. There are several limitations of this survey. Although the survey was addressed to the deans of the medical schools, the deans may not have been aware of the entire medical curricula of their respective medical schools. The department s chairperson involved with palliative medicine education may have been the appropriate person to complete the survey. The authors did not request and, therefore, do not know the identity of the individual who completed the survey. Given that the survey is approximately 3 years old and many medical schools may have expanded or improved upon their palliative medicine curriculum since then, some of the survey results will be outdated. Our results suggest that, at an international level, medical educators are not ensuring that the future generation of physicians will do a better job than ours in caring for terminally ill patients and their families. Increased availability of palliative care education should become a major priority for medical schools. References 1. Cleeland CS, Cleeland LM, Dar R, Rinehardt L. Factors influencing physician management of cancer pain. Cancer 1986;58: MacDonald N, Findlay HP, Bruera E, et al. A Canadian survey of issues in cancer pain management. J Pain Symptom Manage 1997;14: Von Roenn J, Cleeland CS, Gonin R, et al. Physician attitudes and practice in cancer pain management. A Survey from the Easter Cooperative Oncology Group. Ann Intern Med 1993;119: Sloan PA, Donnelly MB, Vanderveer B, et al. Cancer Pain Education Among Family Physicians. J Pain Symptom Manage 1997;14: Levin ML, Berry JI, Leiter J. Management of pain in terminally ill patients: physician reports of knowledge, attitudes, and behavior. J Pain Symptom Manage 1998;15: Wilson JF, Brockopp GW, Kryst S, et al. Medical students attitudes toward pain before and after a brief course on pain. Pain 1992;50: Haley HB, Huynh H, Paiva RE, Juan IR. Students attitudes toward cancer: changes in medical school. Med Educ 1977;56: Blanchard CG, Ruckdeschel JC, Cohen RE, et al. Attitudes toward cancer: the impact of a comprehensive oncology course on second-year medical students. Cancer 1981;47: Stedeford A, Twycross RG. Care of the patient with advanced cancer: a course for clinical medical students at Oxford. Journal Cancer Educ 1989;4: Buss MK, Marx ES, Sulmasy DP. The preparedness of students to discuss end-of-life issues with patients. Acad Med 1998;73: Seely J, Scott JF, Mount BM. The need for specialized training programs in palliative medicine. CMAJ 1997;157:

6 Vol. 20 No. 3 September 2000 Undergraduate Medical Education Survey Billings JA, Block S. Palliative care in undergraduate medical education. JAMA 1997;278: Kitchen AD. The medical curriculum: status and direction of thanatology. potential and pitfalls in death education in medical schools. In: DeBellis R, Marcus ER, Kutscher AH, Klagsbrun SC, Seeland IB, Preven DW, eds. Thanatology curriculum medicine. New York: The Haworth Press, 1998: Hill TP. Treating the dying patient. The challenge for medical education. Arch Intern Med 1995; 155: Scott JF, MacDonald N, Mount BM, et al. Palliative medicine education. In: Doyle D, Hanks G, Mac- Donald N, eds. Oxford textbook of palliative medicine, 2nd ed. Oxford: Oxford University Press, 1998; Doyle D, Hanks G, MacDonald N. Introduction. In: Doyle D, Hanks G, MacDonald N, eds. Oxford textbook of palliative medicine, 2nd ed. Oxford: Oxford University Press, 1998; Pereira J, Bruera E. The internet as a resource for palliative care and hospices: a review and proposals. J Pain Symptom Manage 1998;16: Doyle D. Palliative medicine training for physicians. J Neurol 1997;244(Suppl 4):S26 S The American Board of Internal Medicine Endof-Life Care Project Committee. Caring for the dying: identification and promotion of physician competency. Philadelphia, PA: American College of Physicians, Field MJ, Cassell CK. Educating clinicians and other professionals. In: Field MJ, Cassell CK, eds. Approaching death: improving care at the end of life. Washington, DC: National Academy Press, 1997; Appendix 1 Questionnaire 1. Do your medical students participate in a mandatory rotation in palliative care during their training? If yes, what is the length of rotation in days, weeks, or months? 2. Do you offer elective time in palliative care for your medical students? If so, approximately what percentage of medical students participate in an elective rotation? What is the approximate length of an elective rotation in days, weeks, or months? 3. Are your medical students given formal lectures in palliative care? 4. Besides formal lectures, please indicate below other teaching formats used for palliative medicine education for medical students. Please check more than one if appropriate. case-based learning small groups large groups question and answer sessions use of small-group discussion computer-based learning 5. Is educational reading material provided as part of the medical students palliative medicine evaluation? N/A 6. What are the clinical settings in which palliative care teaching occur? Please check more than one if apropriate. acute care hospital team acute palliative care unit hospice setting cancer center community/outpatient environment other N/A 7. Does your university have academic faculty positions for palliative medicine? If yes, how many faculty positions? 8. How are the medical students evaluated? Do you have a specific evaluation form for their palliative medicine rotation or are they evaluated in a similar format of assessment for other rotations? 9. Are your medical students evaluated by means of a written examination? If yes, please check the appropriate box(s) below to indicate the format of their written evaluation. specific palliative medicine examination following exclusively formal lectures multiple choice questions short answer questions other specific palliative medicine examination post-rotation where medical students are exposed to patients multiple choice questions short answer questions other palliative medicine questions included in the final exam required by Licensing Body or Government for your state/country other Please elaborate if desired. If no, do your medical students undergo oral examination?