Unmet Learning Needs of Physicians in Specialty Training in Palliative Care: A Japanese Nationwide Study

Abstract

Background:

Despite the urgent need for a quality training system in palliative care, learning needs among physicians in palliative care specialty training have not been systematically explored in Japan.

Aim:

To clarify unmet learning needs among Japanese physicians in specialty training in palliative care and the potential solutions they favor to meet those needs.

Design:

A Japanese nationwide survey.

Setting/Participants:

Participants were physicians in specialty training in palliative care. The questionnaire included unmet learning needs and potential solutions. Factor analysis was performed to identify underlying subscales of unmet needs.

Results:

In total, 253 of 735 institutions (34%) responded; of 284 physicians, 253 (89%) responded and 229 were eligible. The most prevalent unmet needs included the following: “to learn areas other than medicine” (89%), “to obtain research support from a data center” (87%), and “to learn ways to educate students and residents about palliative medicine” (87%). The potential solutions most participants favored to meet those needs included the following: “to develop a comprehensive training program” (74%), “to develop systems which reflect trainees' opinions on the improvement of training programs” (71%), and “to increase the number of training institutions” (69%).

Conclusion:

Physicians in palliative care specialty training had markedly unmet needs regarding training on comprehensive contents, education, and research support; they considered increasing the number of comprehensive quality training programs as a potential solution. Our findings may help physicians in palliative care training, faculty physicians, training programs, academic societies, and the government to develop collaborative efforts to fulfill the unmet needs of trainees.

Introduction

Palliative care has increasingly been recognized as a critical part of medicine. It improves the symptoms, quality of life, satisfaction, and quality of care of patients with advanced diseases and reduces the burden on their families.^1–4 To provide high-quality palliative care, a sufficient number of well-trained palliative care specialists are urgently needed worldwide. Thousands of physicians have been certified as palliative care specialists in several countries, such as the United Kingdom, the United States (U.S.), Canada, and Australia. In these countries, extensive efforts have been made to establish quality training systems where trainees acquire competency not only in clinical care but also to varying degrees in education, research, administration, and quality improvement.^5–11

In Japan, the Cancer Control Act obliges all designated cancer hospitals (nearly 400 hospitals in 2015) to establish hospital palliative care teams.¹² Although the hospital palliative care team should meet various criteria, including having at least one full-time physician, only half of the teams have full-time physicians.¹² In contrast, training for palliative care specialists is only just beginning.¹² Physicians with any specialty backgrounds are eligible for specialty training in palliative care as long as they complete 2 years of residency. In general, most Japanese physicians choose to receive different specialty training beforehand (e.g., oncology, anesthesiology, surgery).

Palliative care specialty training in Japan is mainly offered at designated cancer hospitals (n = 397), palliative care units (n = 257), and institutions certified for palliative care training by the Japanese Society for Palliative Medicine (n = 452) (total number of institutions: 735, with overlaps). Unlike palliative care fellowship programs in some other countries, most Japanese institutions certified for specialty training in palliative care neither have standardized training programs nor do they set a predefined duration for the training. There is no mechanism of external review of the quality of palliative care training programs. As a result, the quality, contents, and duration of training vary widely among institutions.

The Japanese Society for Palliative Medicine launched board examinations for palliative care specialists in 2010.¹² Eligibility criteria for the board examinations include clinical experience in palliative care of more than 5 years, education in palliative care, and the first authorship of an original article on palliative care. Physicians can take board examinations irrespective of whether or not they have received training at a certified institution. The number of certified physicians still remains low (total number of 108 in 2015), and physicians can practice palliative care without board certification.

In 2012, we conducted a focus group discussion with 40 physicians receiving specialty training in palliative care to explore unmet learning needs and potential solutions to fulfill the needs. This domestic study suggested markedly unmet learning needs in multiple areas among physicians undergoing specialty training in palliative care.¹³ To develop an effective national training system based on need assessment in Japan, quantification of the relative importance of unmet learning needs and potential solutions would be of value.

The aims of this study were thus (1) to reveal unmet learning needs among physicians receiving specialty training in palliative care in Japan and (2) to clarify the potential solutions they favor to meet those needs. Our ultimate aim was to facilitate collaborative efforts to standardize national specialty training programs in palliative care by providing a comprehensive list of unmet learning needs and potential solutions.

Methods

We conducted a nationwide survey and asked participants to complete a self-administered questionnaire. The study was approved by the Institutional Review Board of Kawasaki Municipal Ida Hospital.

Participants and procedure

The target population was defined as physicians receiving specialty training in palliative care. Due to the lack of a complete registry of target physicians being available, we defined the target sample in the following criteria: (1) physicians who were working in palliative care teams in designated cancer hospitals, palliative care units, or other institutions certified for palliative care training by the Japanese Society for Palliative Medicine (total number of institutions: 735) and (2) physicians within 15 years after medical school graduation. We excluded resident physicians with less than 2 years of clinical experience because they would have had little opportunity to receive specialty training in palliative care during their residency training in Japan, as well as board-certified palliative care physicians.

We used a double-envelope method. We sent a participation request to each representative of the participating institutions, with five questionnaires for distribution to eligible physicians working at the institution. We did not specify the names of institution representatives on envelopes, but instead left the identification of representatives to each institution. Institution representatives were asked to note the number of physicians meeting the inclusion criteria and the number of physicians to whom the questionnaire was distributed. We sent a reminder postcard to all the institutions 2 weeks later. Responses were considered as consent to participate.

Questionnaire

The questionnaire included information on participants' characteristics, unmet learning needs, and the potential solutions they favor to meet those needs. The questionnaire was developed based on a qualitative study using focus group discussion,¹³ a systematic literature review,^{5,10,11,14–17} and discussion among authors. Face validity was performed in a pilot sample of six physicians undergoing specialty training in palliative care who belonged to the coauthors' institutions and met the eligibility criteria.

Unmet learning needs

Because of the lack of standardized measurement tools to quantify unmet learning needs in specialty training in palliative care, we developed original questionnaire items based on qualitative studies and a systematic literature review.^{7,9,11–15,18} We applied response options of the Short-form Supportive Care Needs Survey questionnaire (SCNS-SF34), a self-administered instrument for assessing the perceived needs of patients with cancer.¹⁸ The participants were asked to indicate the level of their need for improvement over the last month in relation to their learning using the following five response options: no need/not applicable (1), need met/satisfied (2), mildly unmet need (3), moderately unmet need (4), and markedly unmet need (5). A rating of three or higher was regarded a priori as an unmet need, and a higher score indicated a more strongly perceived unmet need.

The potential solutions

We asked about the importance of each potential solution using a 7-point Likert-type scale from 1 (not important) to 7 (essential). Items were from item pools of our previous qualitative study.¹³ Based on the actual distributions of the responses, a rating of five or higher (i.e., important, very important, or essential) was regarded as an important solution.

Statistical analyses

The primary endpoints were the percentages of unmet learning needs regarding each item and the percentages of participants who perceived each potential solution as important.

Based on the actual distributions of the responses, we performed exploratory factor analysis to identify the underlying subscales of the unmet learning needs and we calculated Cronbach's alpha coefficients for each factor. Because of the excellent internal consistency, we calculated subscale scores by averaging individual item scores for each subscale. Each subscale score therefore ranged from 1 to 5, with a higher score indicating more markedly unmet learning needs for each subscale factor.

For sample size calculation, we assumed that 80% of the participants would have unmet needs regarding major items and determined that at least 246 participants were needed to calculate accuracy within 10% width in 95% confidence interval for a value of 80%. In all statistical evaluations, p-values of 0.05 or lower were considered significant. SPSS ver. 22.0 Statistical software for Windows was used to perform all statistical analyses.

Results

Participants' characteristics

In total, 253 of 735 institutions responded (institutional response rate: 34%). Of the 253 institutions, 142 institutions delivered the questionnaire to a total of 284 eligible physicians, while the remaining institutions could not deliver the questionnaire predominantly because of the lack of eligible physicians; of these physicians, 253 responded (physicians' response rate: 89%). We excluded resident physicians (n = 10) and board-certified palliative care physicians (n = 14). Thus, we analyzed responses from a total of 229 physicians (81%). The characteristics of the participants are summarized in Table 1.

Table 1.

Characteristics of the Study Participants (n = 229)

	No. of respondents (%)
Mean age (standard deviation)	35 (4.8)
Sex^a
Male	136 (59)
Female	92 (40)
Mean years of clinical experience (standard deviation)	8.9 (3.7)
Institutions^a
Designated cancer hospitals	100 (44)
University hospitals	72 (31)
Other hospitals	56 (25)
Working at institutions certified for palliative medicine training by the Japanese Society for Palliative Medicine^a
Yes	176 (77)
No	39 (17)
Duration working at current institution^a
<1 year	69 (30)
≥1 year	159 (69)
Main workplace over past month^b
Palliative care team	91 (40)
Palliative care units	66 (29)
Home	13 (5.7)
Specialties
Internal medicine	107 (47)
Anesthesiology	45 (20)
Surgery	27 (12)
Others	50 (22)
Median number of palliative care physicians at same institution (range)	3 (0–15)
Median number of cancer patients who died under the care of a participant in past year (range)	40 (0–500)

The total numbers were not 229 because of missing value(s).

The total number was 170, as we excluded duplicate responses to this item.

Unmet learning needs

Overall, the frequencies of unmet learning needs were high across the subscales (Table 2). The most prevalent unmet learning need was “to learn areas other than medicine” (89%), followed by “to obtain research support from a data center” (87%), “to have access to an experienced researcher in palliative care” (87%), and “to learn ways to educate students and residents about palliative medicine” (87%).

Table 2.

The Prevalence of Unmet Learning Needs of the Study Participants (n = 229)

Unmet needs	No. of respondents (%)	95% confidence intervals	Factor loadings
Time (α = 0.86)
To have enough time for learning	159 (69)	63–75	0.90
To have enough time for self-reflection	149 (65)	59–72	0.85
To have work–life balance	146 (64)	58–70	0.82
To have enough time with patients	140 (61)	55–68	0.79
To have training opportunities outside the institution	113 (49)	43–56	0.59
Quality (α = 0.84)
No difference in quality of training among institutions	191 (83)	78–88	0.88
To have standardized training programs throughout Japan	195 (85)	80–89	0.81
To have Japanese textbooks on palliative medicine	165 (72)	66–78	0.69
To have faculty physicians who are good teachers	148 (65)	58–71	0.64
To learn areas other than medicine	204 (89)	85–93	0.60
To have palliative care departments in all medical universities	190 (83)	78–88	0.55
To have sufficient information about training institutions	163 (71)	65–77	0.52
Comprehensiveness (α = 0.77)
To have training on pediatric palliative care	190 (83)	78–87	0.89
To have training on noncancer palliative care	189 (83)	77–87	0.79
To have training in three settings: palliative care team, palliative care unit, and home setting	191 (83)	79–88	0.58
To encounter wide variety of patients (e.g., stages, diseases, or ages)	144 (63)	57–69	0.47
To choose training institution beyond university network	130 (57)	50–63	0.46
Specialist (α = 0.86)
To learn ways to educate students and residents about palliative medicine	199 (87)	82–91	0.97
To have career path as palliative care specialist	192 (84)	80–89	0.83
To have system of continuous training after board certification	195 (85)	81–90	0.77
To have sense of security regarding future as palliative care specialist	187 (82)	76–86	0.68
To find job without difficulties	162 (71)	65–77	0.65
To have realistic eligibility criteria for board certification	188 (82)	77–87	0.53
To be able to learn about stress management	182 (80)	74–84	0.33
Networks (α = 0.89)
To develop network with senior palliative care specialists	149 (65)	59–71	0.83
To develop regional informal network among palliative care specialists	171 (75)	69–80	0.82
To learn palliative care together with healthcare professionals in other disciplines	164 (72)	65–77	0.75
To develop network with professionals from other institutions	179 (78)	72–83	0.65
To develop network for palliative care physicians in same generation	186 (81)	76–86	0.54
Research (α = 0.95)
To learn about research methodology	197 (86)	82–91	0.95
To learn about article writing	195 (85)	80–89	0.93
To learn about biostatistics	197 (86)	81–90	0.93
To learn about writing abstracts and presenting scientific posters or slides	187 (82)	76–86	0.84
To obtain research support from data centers	200 (87)	83–91	0.83
To have access to experienced researchers in palliative care	199 (87)	82–91	0.81

Numbers and percentages of the participants who indicated unmet needs are demonstrated. Unmet needs were measured using the 5-point Likert-type scale from 1 (no need/not applicable) to 5 (markedly unmet need). A total of six subscales emerged on factor analyses: (1) time (“to have enough time for clinical and educational activities”), (2) quality (“to receive quality and standardized training”), (3) comprehensiveness (“to receive comprehensive training”), (4) specialist (“to have an established system to improve the capacity as a palliative care specialist”), (5) network (“to have a variety of professional networks available”), and (6) research (“to have ways to learn about research”).

Using factor analyses, six subscales of the unmet learning needs emerged: (1) time, (2) quality, (3) comprehensiveness, (4) specialist, (5) network, and (6) research (Table 2). The mean score (standard deviation) of each subscale was 3.0 (0.8), 3.5 (0.8), 3.5 (0.9), 3.5 (0.9), 3.2 (0.9), and 3.8 (1.1), respectively.

The potential solutions participants favor to meet their needs

The potential solutions most participants favored to meet those needs included “to develop a comprehensive training program, including oncology, psycho-oncology, pain medicine, and home care” (74%), “to develop systems, which reflect trainees' opinions on the improvement of training programs” (71%), “to increase the number of training institutions” (69%), “to develop core palliative care institutions for education” (65%), and “to develop opportunities to learn about research methodologies” (59%) (Table 3).

Table 3.

Perceived Importance of Potential Solutions Reported by Palliative Care Physicians in Training (n = 229)

	Important: No. of respondents (%)	95% confidence interval
To develop a comprehensive training program, including oncology, psycho-oncology, pain medicine, and home care	169 (74)	68, 79
To develop systems to reflect trainees' opinions on the improvement of training programs	162 (71)	65, 77
To increase the number of training institutions	159 (69)	63, 75
To develop core palliative care institutions for education	148 (65)	59, 71
To develop opportunities to learn about research methodologies	135 (59)	53, 66
To develop easily accessible educational tools, such as e-learning	123 (54)	47, 60
To enable medical education specialists to be involved in the development of training programs	122 (53)	47, 60
To develop a system of evaluation/feedback from teaching faculty physicians to trainees	119 (52)	46, 59
To develop career models as palliative care specialists	117 (51)	45, 58
To develop an informal network for palliative care physicians in training	111 (48)	42, 55
To reflect experience about specialist training in other specialty areas, such as home practice	109 (48)	41, 54
To provide information about training in palliative medicine performed abroad	106 (46)	40, 53
To provide a standardized syllabus of undergraduate training for palliative medicine	92 (40)	34, 47
To develop Internet/social network services	61 (27)	21, 33
To have the Japanese Society for Palliative Medicine send palliative care physicians to institutions without palliative care specialists	51 (22)	17, 28
To develop stricter criteria for the certification of training institutions	43 (19)	14, 25

Measured using the 7-point Likert-type scale from 1 (not important) to 7 (essential). Numbers and percentages of the participants who rated factors as important, very important, or essential are demonstrated.

Discussion

This nationwide survey is, to our knowledge, the first study to clarify unmet learning needs among physicians in specialty training in palliative care and the potential solutions they favor to meet those needs in Japan. Our comprehensive findings represent a key step toward multilevel large-scale collaboration to establish standardized quality national training programs.

The first and most important finding was that we quantified the relative importance of unmet learning needs of physicians in specialty training in palliative care. The five most prevalent unmet learning needs were related to the establishment of standardized training of comprehensive contents, methodology for education, and research support. These findings are consistent with the prior studies on palliative care and end-of-life education in the United States, showing that training for education and research skills was insufficient during postgraduate education compared with training for clinical knowledge and skills.^{5,10,11,14–17}

Furthermore, this study revealed that the majority of physicians in specialty training had a broad range of unmet earning needs not only for education but also for the time, network, and training as a specialist. These are largely related to the areas of mentoring and faculty development. While considered essential to physicians' career enhancement, mentoring and faculty development are challenging within recently developed specialties, such as palliative medicine and family practice in Japan, which have few mid-level to senior physicians serving at training institutions.^19,20 The effective implementation of some core methodologies of mentoring and faculty development might help faculty physicians in palliative care navigate trainees through the early phase of their career development.²¹

The second most important finding was clarification of the rates of potential solutions the physicians in specialty training favored to meet those needs. Previous studies did not investigate the potential solutions proposed by trainees, and our study has the unique aspect of directly collecting opinions from physicians in specialty training. Our findings on unmet needs and the potential solutions they favor to meet those needs strongly recommend that, to fulfill unmet learning needs, all parties, including physicians in specialty training, faculty physicians, and academic societies/government, should launch a collaborative approach.

Physicians in specialty training can take the initiative to develop a regional and/or national network for themselves. Some of them have recently launched national networks through the Internet/social networking services where they share information on clinical, research, and educational opportunities, as well as tips for various career development topics such as self-learning, time management, and work–life balance. They can also take active roles in multicenter studies in palliative care, which would facilitate mentorship and help them learn research methodology, basic biostatistics, grant application, and abstract/manuscript writing. Recent research projects from Japan, including this study, are the products of such a network and have been published in domestic and international palliative care journals.

Faculty physicians and training programs have central roles in addressing all aspects of the unmet needs. Within each program, faculty physicians should develop interprofessional education and systems to directly reflect trainees' opinions in the improvement of training programs. Outside the program, they may develop regional collaboration to provide comprehensive quality education that would cover various areas (e.g., oncology, psycho-oncology, as well as interventional and pain management), patient populations (e.g., noncancer, chronically-ill patients, and children), and settings (e.g., palliative care units, palliative care teams, and home palliative care).

Finally, academic societies and the government should develop easily accessible educational tools and increase the number of training institutions. The establishment of feasible faculty development and mentoring programs such as those for early-career palliative care professionals in the United States will be urgently required in Japan.²²

Academic societies may also develop and update (1) a recommended curriculum for training programs, (2) a list of training programs and what they have to offer, and (3) introduction of several career paths as clinicians, educators, and researchers. In annual meetings, they may provide presentations on successful grant application, protocol development, manuscript writing, and career development. For example, the American College of Physicians-Japan Chapter has held workshops focused on career development skills, including time management, work–life balance, mentorship, and middle management during recent annual meetings. Future follow-up studies on palliative care training are needed to explore the most effective strategies at individual, institutional, and national levels and evaluate their feasibility and effectiveness.

This study had several limitations. First, our broad eligibility criteria and use of the double-envelope method might have introduced a bias and the subjects might not be representative of the target population of physicians in specialty training in palliative care. As the collection of background data on nonresponders was not possible, we could not explore differences in characteristics between responders and nonresponders. In addition, there are currently no estimates of the number of physicians in Japan that would qualify as physicians in specialty training in palliative care, which further restricts the generalizability of our findings. We believe that these are acceptable due to the lack of a complete registry of targeted physicians in Japan. As our respondents might have been motivated to undergo specialty training overall, their proposed solutions may need to be further modified before application at institutional and individual levels.

Second, the measurement instruments were not formally validated. We believe that this is an acceptable limitation, because there are no standardized measurement tools for our study aims and the results obtained in this study are highly interpretable.

Third, our findings may not be applicable to palliative care training internationally, as the state of palliative care training in Japan may be markedly different from that in other countries. We believe, however, that our findings may potentially provide insight into similar development in other countries.

In conclusion, this first nationwide Japanese survey revealed that a majority of physicians in specialty training in palliative care had unmet learning needs regarding training on comprehensive contents, especially the methodology for education, and research support. They stressed the importance of establishing comprehensive training programs for palliative care specialists, developing systems to reflect trainees' opinions, and increasing the number of training institutions. Although we focused solely on Japan, our comprehensive results may also help other countries systematically identify challenges in palliative care specialty training and streamline and standardize their specialty training in a structured manner.

Our findings will help physicians in palliative care training, faculty physicians, training programs, academic societies, and the government to develop collaborative efforts to standardize national training programs in palliative care.

Footnotes

Acknowledgments

The authors would like to express gratitude to Drs. Toru Okuyama and Asao Ogawa for their support in the development of the questionnaire, and Ms. Chieko Suzuki for her technical support.

Funding: This work was supported by the Sasakawa Memorial Health Foundation for its generous grant support (2013-a009). The foundation was not involved in the conducting of the study or the submission.

Author Disclosure Statement

No competing financial interests exist.

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