Graduating medical students' competencies and educational experiences in palliative care

280 Journal of Pain and Symptom Management

Vol. 14 No. 5 November 1997

Original Article

Graduating Medical Students' Competencies and Educational Experiences in Palliative Care K a r e n S. Ogle, MD, Brian Mavis, PhD, a n d J o n Rohrer, P h D Department of Family Practice (K.S.O.), Medical Education, Research, and Development Office (B.M.), College of Human Medicine, and College of Osteopathic Medicine (].R.), Academic Affairs, Michigan State University, East Lansing, Michigan, USA

Abstract

Palliative care involves an interdisciplinary approach to patient care and specific clinical skills. Little prior research on palliative care education has involved medical students, and the J~v reported studies focus mainly on student attitudes. This stud), describes a needs assessment of senior medical students based on a newly developed competenc~-based palliative care curriculum. Prior to graduation, 102 senior students were mailed an anonymous survey with four parts: a self-assessment of attitudes, knowledge, and skills; adequa O, of instruction; exposure to specific clinical experiences; and demographic information. The response rate was 4 7 %. While attitudinal goals were strongly endorsed by, students, they were less confident with regards to knowledge and skills. Ratings varied across the five content areas of the curriculum. The results suggest a need for educational efforts more focused on specific clinical competencies as well as systematic evaluation of student competencies. J Pain Symptom Manage 1997;14:280-285. © L~S. Cancer Pain Relief Committee, 1997. Key Words Palliative care curriculum, medical student education, survey research

Introduction Medical schools have b e g u n to confront the necessi~" of including palliative care issues in the curriculum. T h e literature to date 1-4 suggests that the m e t h o d s used to provide palliative care education in the United States have largely relied on elective a n d / o r freestanding courses within the existing medical school cur-

Address reprint requests to: Karen S. Ogle, MD, Department of Family Practice, College of Human Medicine, Michigan State University, B110 Clinical Center, East Lansing, MI 48824. Accepted for publication: February 10, 1997. Cancer Pain Relief Committee, 1997 Published by Elsevier, New York, New York

© U.S.

riculum. In practice, however, palliative care is an interdisciplinary a p p r o a c h to patient care involving highly specific clinical skills, and as such, m i g h t best be taught as part of a comp r e h e n s i v e p r o g r a m i n t e g r a t e d across the existing medical school curriculum. Limited previous work has e x a m i n e d the views of medical students themselves a b o u t this aspect of their training. H o l l e m a n et al. 2 surveyed senior class presidents (response rate 80%), but were not able to relate their questions to specific curricular goals. They f o u n d that 37% indicated that their training was ineffective in p r e p a r i n g t h e m to deal with dying

0885-3924/97/$17.00 PII S0885-3924(97)00223-6

Vol. 14 No. 5 November 1997

Students Assess Palliative Care Curriculum

patients. A l t h o u g h they asked a b o u t " t h e d y i n g or g r i e v i n g p r o c e s s , " they did n o t inquire a b o u t any specific clinical experiences. R a p p a p o r t a n d Witzke 5 s u r v e y e d s t u d e n t s completing their third year clerkships (response rate 59%) and f o u n d that 57% felt that they were not well p r e p a r e d to deal with terminally ill patients. They also assessed specific clinical experiences: 59% of students had b e e n p r e s e n t w h e n an a t t e n d i n g physician talked to a dying patient, and 83% had discussed a t e r m i n a l diagnosis with a p a t i e n t themselves. Palliative care curricular objectives were developed for the Michigan State University College of H u m a n Medicine based on (a) review of existing curricular ~-9 (b) research reports, 4A°A1 (c) conceptual articles 12 about palliative care education, and (d) qualitative interviews with students and interdisciplinary facul~: A complete listing of objectives is found in Appendix A. Based on these newly developed objectives, we conducted a curricular needs assessment by surveying graduating medical students regarding their selfassessed competencies and related educational experiences.

Methods T h e subjects for this study i n c l u d e d all graduating fourth year medical students at the six c o m m u n i t y campuses of the College of H u m a n Medicine. Surveys were mailed to students at their h o m e addresses prior to graduation. A total of 48 c o m p l e t e d surveys were r e c e i v e d f r o m a total of 102 d i s t r i b u t e d (response rate, 47%). Respondents were comp a r e d on the basis of age, gender, and clerkship c o m m u n i t y to the graduating class as a whole. No significant differences were found, suggesting that the survey respondents were representative of the whole class with respect to these three indices. T h e survey was a n o n y m o u s and comprised four parts. T h e first section included questions derived from the attitude, knowledge and skill competencies of the p r o p o s e d palliative care curriculum. Students rated each c o m p e t e n c y s t a t e m e n t on a six-point scale, w h e r e 1 = strongly disagree and 6 = strongly agree. In the second p a r t of the survey, students were asked to assess the a d e q u a c y o f the a m o u n t o f instructional time devoted to the five major

281

c o n t e n t areas of the c u r r i c u l u m . For each statement, the a m o u n t of instructional time was rated on a three-point scale: 1 = inadequate, 2 = adequate, or 3 = excessive. T h e third section of the survey assessed whether the students e x p e r i e n c e d any of five specific clinical experiences: b e i n g p r e s e n t when a patient was told they were terminally ill; having any contact with a hospice; following a terminally ill patient for longer than 2 weeks; being present when the family was notified of the d e a t h o f a patient; a n d b e i n g p r e s e n t when a patient was p r o n o u n c e d dead. Students indicated whether or not they had had each of the experiences at least once during the course of their medical education. T h e last section consisted of four questions that focused on respondent demographic information: age, gender, clinical communiW, and any clinical experience prior to entering medical school. C o m p a r a b l e self-assessments of clinical competencies have not b e e n perf o r m e d for any other area of clinical skills at o u r institution. T h e students surveyed had c o m p l e t e d a curriculum that offered little consistent formal education in palliative care. T h e only scheduled instruction in related issues was pro~4ded in the h u m a n d e v e l o p m e n t course at the e n d of the first year in a 1-week segment on d}fing a n d death. I n s t r u c t i o n there took place in large g r o u p a n d small g r o u p formats, and focused largely on psychosocial and spiritual issues in the care of patients and families. Although multiple opportunities for attention to this area existed during the clinical years, such education was not formalized and thus n o t systematic. T h e r e are n o o t h e r f o r m a l c o m p o n e n t s in the curriculum that deal with palliative care, although the entire curriculum is quite strong in the psychosocial areas.

Results

Mean ratings across the 30 specific competency items ranged from 2.71 (knowledge of the hospice insurance benefit and eligibility criteria) to 5.75 (ability to i m p l e m e n t collaborative care with other health-care professionals). T h e m e a n rating for each c o m p e t e n c y is identified in A p p e n d i x A. Items were g r o u p e d as attitudes, knowledge, or skills. In addition, subgroups were created

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,e

f

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clinical experiences) were examined for differences related to respondent age, gender, clinical community, and prior clinical experience. Age, clinical community, and prior clinical experience did not reveal any significant differences in perceptions. For only two of the 30 competen W items, male students were more likely to agree with the c o m p e t e n w statement than female students. The two items were (a) ability to communicate effectively with patients a n d families r e g a r d i n g psychosocial, d e v e l o p m e n t a l , a n d spiritual issues, and (b) confidence in fulfilling the physician's role in legal issues.

g

Fig. 1. Student ratings of competencies in palliative care.

D/scuss/on

to reflect core clinical competencies and competencies specific to pain m a n a g e m e n t . T h e m e a n ratings for each of these groups of competencies are presented in Figure 1. Students rated themselves considerably higher on attitudes than on specific clinical competencies. Student evaluation of the adequacy of the a m o u n t of instruction in each of the m a j o r c o n t e n t areas of the curriculum is shown in Table 1. T h e only areas in which even a minority of students r e p o r t e d excessive instruction were those related to psychosocial domains. Less than one-half of the students r e p o r t e d having h a d a d e q u a t e instruction r e g a r d i n g specific c o m p e t e n c i e s in i m p l e m e n t i n g care plans and m a n a g i n g symptoms. A majority of students indicated that they had e n c o u n t e r e d each of the key clinical experiences listed in the survey in their medical education. Frequencies for each e x p e r i e n c e are shown in Figure 2. Thirty-three p e r c e n t of the students r e p o r t e d exposure to all of the key clinical experiences. Each of the above items (the 30 specific competencies, the five c o m p e t e n c y groups, the adequacy of instruction, and frequency of key

This study is limited by the fact that only onehalf of the class responded, suggesting the possibility of selection factors that might bias the findings. In addition, its generalizability is limited in that the findings were based on a single graduating class at one institution. Finally, the assessm e n t of student competency is based on curricular goals established for our curriculum. These goals may vary across institutions. A l t h o u g h the evaluation of the palliative care c o m p e t e n c i e s and educational expectations of these students was based on a set of p r o p o s e d c o m p e t e n c i e s for a required integrated longitudinal curriculum, the students w h o p a r t i c i p a t e d in this e v a l u a t i o n w e r e exposed to an educational p r o g r a m that did not include a formal palliative care curriculum. O u r results support the n e e d for a m o r e formalized palliative care curriculum. Overall, o u r students' assessment of their attitudinal c o m p e t e n c i e s was quite high. As the competencies b e c a m e m o r e specific and clinical in n a t u r e , s t u d e n t self-assessments b e c a m e less confident. A majority of students rated the a m o u n t of instruction as inadequate Table I

Goal task la. lb. 2. 3. 4. 5.

Student Ratings of Adeqtmcy of Instruction Related to Specific Tasks Inadequate Appropriate Excessive

Understand the physician's role in palliative care Practice the physician's role in palliative care Assesssynptoms in the terminally ill Understand the full range of psychosocial, developmental, and spiritual issues of terminal patients and their families Implement palliative care plans Formulate personal strategies for dealing with death and d~ing

33% 50% 46% 19%

67% 50% 54% 62%

0% 0% 0% 19%

60% 31%

40% 65%

0% 4%

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Students Assess Palliative Care Curriculum

283

m e n t in palliative care to a n a p p r o a c h m o r e g r o u n d e d in l e a r n e r a n d c u r r i c u l a r assessment strategies.

Present when patient pronounced dead Present when family notified of patient's death

Followed a terminally ill patient for two weeks

/•,ference$

Had contact with hospice

1. Dickson GE. Death education in U.S. medical schools: 1975-1980. J Med Educ 1981 ;56:111-114.

Present when patient told of terminal illness 20

40 60 Percentage of Students

80

100

Fig. 2. Percentage of students reporting specific educational experiences.

2. Holleman WL, Holleman MC, Gershenhorn S. Death education in U.S. medical schools. Teaching Learning Med 1994;6:260-263. 3. Kitchen, AD. Potentials and pitfalls in death education in medical schools. In: DeBellis R, ed. T h a n a t o l o g y c u r r i c u l u m - - m e d i c i n e . New York: Haworth, 1988.

in t h e specific clinical a r e a s o f p r a c t i c i n g t h e physician's role, managing symptoms, and implementing palliative care plans. Threequarters of the students reported having had at least f o u r o f t h e five key clinical e x p e r i e n c e s during their medical education. T h o u g h s t u d e n t assessments o f themselves as c o m p e t e n t with r e g a r d s to palliative care attit u d e s m a y n o t necessarily b e r e f l e c t e d in an e x t e r n a l p e r f o r m a n c e - b a s e d assessment, it seems quite likely that those items that received low ratings d o reflect areas o f true weakness. Unlike p r i o r studies, 4'5'1~ which suggest that a focus o n attitudes is necessary for i m p l e m e n t i n g palliative care curricula, o u r work suggests the n e e d for a focus o n core clinical c o m p e t e n c i e s , particularly s}naaptom m a n a g e m e n t . This is in a c c o r d a n c e with studies that show that p r a c t i c i n g physicians a r e ineffective at d e l i v e r i n g quality s y m p t o m m a n a g e m e n t , particularly r e l a t e d to p a i n m a n agement.a 1,14,15

4. Mermann AC, Gunn DB, Dickinson GE. Learning to care for the dying: a survey of medical schools and a model course. Acad Med 1991;66:35-38.

Most a u t h o r s writing a b o u t palliative care education a g r e e that t h e r e is a n e e d for m o r e attention to the a r e a o f evaluation. O u r work affirms the importance of greater focus on student evaluation, using not only student selfassessment as we have d o n e , b u t also d e v e l o p i n g external performance-based evaluation measures that assess palliative care c o m p e t e n c i e s . This study provides a l i m i t e d e m p i r i c a l basis for progress in palliative care c u r r i c u l u m develo p m e n t . F u r t h e r r e s e a r c h is n e e d e d to test the generalizability o f o u r findings a m o n g a l a r g e r s a m p l e o f m e d i c a l students. I n addition, attention m u s t be given to t h e study o f the m o s t effective m e a n s for d e v e l o p i n g the d e s i r e d clinical c o m p e t e n c i e s as l e a r n e r s p r o g r e s s t h r o u g h m e d i c a l training. T h e r e is a striking n e e d to move beyond "armchair" curricular develop-

10. Schonwetter RS, Robinson BE. Educational objectives for medical training in the care of the terminally ill. Acad Med 1994;69:688-690.

5. Rappaport W, Witzke D. Education about death and dying d u r i n g the clinical years of medical school. Surgery 1993;113:163-165. 6. O'Donnell JF, Bakemeier RF, Chamberlain RM, G a l l a g h e r RE, et al. C h a n g i n g t h e c a n c e r curriculum: a curriculum committee's response to the results of the AACE Cancer Education Survey II. J Cancer Educ 1992;7:115-124. 7. Working Part}, of the Association for Palliative Medicine. Association for Palliative Medicine of Great Britain and Ireland Palliative Medicine Curriculum for: Medical Students, General Professional Training, H i g h e r Specialist T r a i n i n g . S o u t h H a m p t o m , England: Association for Palliative Medicine, 1992. 8. 8.The Canadian Palliative Care Curriculum. Report of the Canadian Comminee on Palliative Care Education, 1991. 9. Fields HL. Core Curriculum for Professional Education in Pain. Seattle: International Association for the Study of Pain, 1991.

11. Haines CS, Thomas Z. Assessing needs for palliative care education of primary care physicians: Results of a mail survey. J Palliat Care 1993;9:23-26. 12. J a m e s CR, M a c L e o d RC. T h e p r o b l e m a t i c nature of education in palliative care. J Palliat Care 1993;9:5-10. 13. Linn BS, Moravec J, Zeppa R. The impact of clinical experience on attitudes of j u n i o r medical students about death and dying. J Med Educ 1982; 57:684-691. 14. Max MB. Improving outcomes of analgesic treatments: is education enough? Ann Intern Med 1990; 113:885-889. 15. Wilson JF, Brockopp K, Steger, et al. Medical students attitudes toward pain before and after a brief course on pain. Pain 1992;50:251-256.

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Appendix A A REQUIRED CURRICULUM IN PALLIATIVE CARE: Learning objectives from which survey was composed. (Student rating on a six-point scale: 1 = "strongly disagree," 6 -- "strongly agree") Overall goal: Students will be able to provide an integrated biopsychosocial approach to the care o f the patient needing palliative care. Students will: Mean rating Standard deviation g o a l 1" Understand and practice the physician's role in palliative care Attitudes: a) Value active symptom management b) Value participation in the care of the dying Knowledge: a) Distinguish palliative care from curative care Skills: a) Develop goals for treatment in order to preserve the quality of life with patient/family input b) Evaluate the effectiveness of care Goal 2: Assess and manage symptoms in the terminally ill Attitudes: a) Recognize the full range of psychosocial factors influencing pain and the necessa D' inte~-entions to address these factors b) Value symptom management that emphasizes prevention and control rather than crisis intervention Knowledge: a) State the differences between acute and chronic pain b) Describe common pain syndromes including bone pain and neuropathic pain c) Describe common symptoms in terminal patients and the appropriate techniques to treat these symptoms Skills: a) Assess and manage pain through the use of opioids, adjuvant analgesics, and nonpharmacologic therapies b) ,assess and manage nausea and vomiting c) Assess and manage dyspnea d) .assess and manage bowel problems e) ,assess and manage common psychiatric symptoms of terminal care f) Identify and use resources for consultation in the management of symptoms Goal 3: Understand the full range of psychosocial, developmental, and spiritual issues of patients/families. Attitudes: a) Recognize the psychosocial, developmental, and spiritual issues for patients/families b) Value diverse interventions to address the full range of psychosocial, developmental, and spiritual issues of patients/families Knowledge: a) Know the psychosocial, developmental, and spiritual issues that arise in the treatment of the terminally ill and the appropriate treatments b) Distinguish between quacke D' and valid nontraditional interventions Skills: a) Practice effective communication with patients and families regarding the full range of psychosocial, developmental, and spiritual issues b) Practice necessary interventions for therapeutic outcomes Goal 4" Implement palliative care plans Attitudes: a) Recognize the value of professional caregivers in other disciplines and hospice services in the treatment of the terminally ill Fmowledge: a) Understand hospice philosophy and approach to care b) Understand the hospice insurance benefit and eligibility, along with other third payer issues Skills: a) Implement collaborative care (team work with nurses, social workers, pastoral care, etc.) b) Fulfill the physician's role in legal issues (certify, death and issue death certificates. Advise on advance directives and living wills).

5.15 4.98

(1.11) (1.13)

5.31

(0.80)

5.50

(0.80)

N/A

N/A

4.00

(1.05)

4.85

(1.30)

4.44 3.29

(1.07) (1.29)

3.63

(1.25)

3.56 3.67 3.58 4.00 4.54

(1.18) (1.10) (1.15) (1.07) (0.97)

5.40

(0.89)

5.40

(0.71)

5.40

(0.89)

4.40

(1.03)

4.48

(1.10)

3.83

(1.21)

5.65

(0.84)

4.52 2.71

(1.29) (1.29)

5.75

(0.53)

4.08

(1.35)

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Students Assess Palliative Care Curriculum

Students ~vill: Goal 5: Formulate a personal strategy for dealing with death and dying as a health-care professional Attitudes: a) Recognize that their attitude about death influences the medical therapies offered to the patient Knowledge: a) Understand personal individual world view about death and dying Skills: a) Identify individual challenges in working with death and dying b) ldenti~" systems barriers to effective treatment of the terminally ill c) Create support systems for self

285

Mean rating

Standard deviation

4.65

(1.18)

4.40

(1.23)

4.77 4.42 4.25

(0.97) (0.94) (1.23)