Do Doctors Gain More Confidence from a Longer Palliative Medicine Posting?

Abstract

Background:

Doctors report inadequate training and lack confidence in providing palliative care. Although palliative care training improves self-assessed competence, it is not known whether the duration of a palliative medicine (PM) posting affects the extent of improvement in confidence.

Objective:

The aim of this study was to determine whether the duration of a PM posting affects the extent of improvement in doctors' confidence in various aspects of palliative care.

Methods:

This was a retrospective study analyzing doctors' self-rated competence level in different aspects of palliative care at the start and end of a PM posting. The change in scores was analyzed to determine the extent of improvement corresponding to the length of the posting. Seventy-one residents and medical officers participated in the study, which was conducted in a hospital-based palliative care consultative service.

Results:

Participants reported low baseline self-rated competence in palliative care. A longer posting duration resulted in a greater improvement in the doctors' confidence across different domains of palliative care, particularly in end-of-life communication.

Conclusion:

A one-month posting may suffice in training a doctor in basic end-of-life medical issues, but a longer posting duration results in a greater improvement in the doctors' confidence across different domains of palliative care, particularly in end-of-life communication. Trainee doctors in specialties that frequently deal with terminally ill patients should undertake a longer posting in PM to be further equipped with greater confidence to better care for these patients.

Introduction

An increasing awareness and recognition of the importance of palliative care have placed greater emphasis on undergraduate and postgraduate palliative care training. The European Association for Palliative Care recommends a total of 40 hours across the undergraduate medical education to achieve the goals of the palliative care curriculum.¹ The Accreditation Council for Graduate Medical Education (ACGME) recommends opportunities for experience in palliative medicine (PM) within internal medicine (IM) residency as a staple part of the postgraduate curriculum.² Despite these initiatives, physicians report that they have received inadequate formal training in palliative and end-of-life care,^3–9 and often do not feel equipped to provide this care, lacking confidence, comfort, and skills to do so.^10–17 Data suggest that clinical experience and training in palliative care bring about an improvement in confidence or perceived competence.^10,18–28 However, there is little published literature on whether a longer duration of posting further increases self-rated competence among doctors and what impact a prolonged posting has on the various competencies.

In this study, we aim to establish how the duration of a PM posting affects the extent of improvement in doctors' self-rated competence in various aspects of palliative care. The secondary aims are to determine the level of baseline self-rated competence and what the areas of lowest confidence are.

Methods

Study setting

Junior doctors such as residents and medical officers (MOs) are in a stage of their medical training where they have acquired basic medical knowledge and clinical skills, and yet have much to gain in terms of clinical and educational experience. The training they receive in these formative years of their careers is essential as it cultivates lifelong attitudes and practice behavior. In Singapore, a PM posting is an elective posting for IM residents within their three-year training programme. IM residency is seen as a stepping stone for specialist training such as advanced internal medicine and other medical subspecialties. MOs are junior doctors who are not in a structured training programme, who usually undertake a six-month posting through different disciplines, including PM. Junior doctors enter a PM posting with varying levels of medical experience and competencies.

As part of their postgraduate medical training, some junior doctors undertake a posting in the Division of Palliative Medicine (DPM) at the National Cancer Centre Singapore (NCCS). The DPM renders a consult service for inpatients at the Singapore General Hospital, the largest tertiary hospital in Singapore. During the posting, junior doctors work in a team alongside palliative care nurses and PM specialists to comprehensively assess the patient's physical and psychosocial issues, and make recommendations regarding the management of identified issues. Thereafter, the DPM team would comanage the patient with the primary team for the duration of the hospital stay. Throughout the posting, the junior doctors attend compulsory weekly interactive tutorials facilitated by a PM specialist in the department, as well as journal clubs, multidisciplinary meetings, and mortality rounds. Our NCCS PM rotation involves a multifaceted approach in the training of junior doctors through highly relevant clinical training and educational activities to help improve knowledge and experience in palliative care.

Participants

All the MOs and residents who rotated through DPM from May 2012 to June 2015 were included in the study, except those in their first postgraduate year (PGY1). MOs had either a three- or six-month PM posting, whereas residents spent either one or three months in this elective posting. All MOs have completed their internship and are in their second postgraduate year (PGY2) or more. On the contrary, all PGY1 doctors were only posted for one month as part of their residency program; hence, they were excluded to remove work experience as a possible confounding variable.

Study measures

A self-rated competence questionnaire is administered routinely to all junior doctors who undertake a posting in DPM. The questionnaire was adapted from a survey instrument developed by Weissman et al. to explore physician trainee-rated competencies and concerns surrounding end-of-life care,²⁹ and included various aspects of palliative care with 19 items categorized under the four domains of (1) end-of-life medical issues, (2) practical procedures, (3) end-of-life communication skills, and (4) terminal discharge. The original survey was able to discriminate between three groups of participants: third- and fourth-year medical students, IM interns (PGY1), and IM residents (PGY2 and PGY3), hence supporting construct validity of the survey. Face validity was established by the PM specialists in the department who determined that the items were appropriate for the junior doctors.

The MOs and residents rated their level of competence on a scale of 1 to 4 (1 = not competent, 2 = somewhat incompetent, 3 = somewhat competent, 4 = very competent). This is a retrospective study of these measures. A waiver of informed consent was granted by the institutional review board.

Study procedures

On the first day of posting, the self-rated competence questionnaire was administered to every MO and resident before any clinical exposure. At the end of the posting, all the doctors repeated the same self-rated competence questionnaire.

Data analysis

Data analysis was done using SPSS version 18. Descriptive statistics were used to explore the data. The chi-square test and independent t test were used to test between-group differences. Paired t test was performed to detect interpersonal differences.

Results

Demographics

A total of 71 junior doctors undertook a clinical posting in DPM from May 2012 to June 2015. The majority of doctors (56.3%) undertook a one-month posting. Seventy-one (100%) completed the baseline self-rated competence questionnaire, while 68 (96%) completed the end-of-posting questionnaire (Table 1).

Table 1.

Demographics

Characteristic	N = 71
Gender, n (%)
Female	47 (66.2)
Male	24 (33.8)
Age in years, mean (SD)	29.18 (2.57)
Posting length, n (%)
One month	40 (56.3)
Three months	19 (26.8)
Six months	12 (16.9)
Postgraduate year, mean (SD)	4.66 (2.26)

Baseline self-rated competence scores

The mean baseline self-rated competence score was 2.15 ± 0.69. Overall, the junior doctors felt the least competent in the following areas: administering a high fleet enema (mean score 1.49 ± 0.63), performing oral care for a terminally ill patient (1.52 ± 0.56), and assessment and management of symptoms in the last few days of life (1.79 ± 0.65). The areas they felt the most competent in were discussing DNR (do-not-resuscitate order) orders or “maximum ward management” decision (2.83 ± 0.65), giving bad news to a patient or family member (2.73 ± 0.65), and assessment and management of constipation (2.49 ± 0.69) (Table 2).

Table 2.

Baseline Self-Rated Competence Scores (in Descending Order)

Competency	Mean baseline self-rated competence score (SD) (N = 71)
Discussing DNR orders or “maximum ward management” decisions	2.83 (0.65)
Giving bad news to a patient or family member	2.73 (0.65)
Assessment and management of constipation	2.49 (0.69)
Pain assessment	2.49 (0.65)
Discussing referral to home hospice or inpatient hospice for a cancer patient	2.48 (0.77)
Discussing referral to home hospice or inpatient hospice for a noncancer patient	2.35 (0.72)
Assessment and management of nausea/vomiting	2.32 (0.69)
Responding to a family who does not want the patient informed about his or her condition	2.28 (0.70)
Assessment and management of dyspnea	2.24 (0.75)
Use of oral opioids	2.13 (0.74)
Explaining to a family about goal setting	2.11 (0.73)
Eliciting a patient's goals for the end of life	2.10 (0.72)
Use of adjuvant analgesics (e.g., for neuropathic pain)	1.99 (0.69)
Arranging a “terminal discharge” in the last days of life	1.93 (0.74)
Use of parenteral opioids	1.83 (0.76)
Helping a family to understand about caring for a terminally ill patient at home	1.82 (0.68)
Assessment and management of symptoms in the last few days of life	1.79 (0.65)
Performing oral care for a terminally ill patient	1.52 (0.56)
Administering a “high” fleet enema	1.49 (0.63)

DNR, do-not-resuscitate.

Change in self-rated competence questionnaire scores

All doctors reported a statistically significant improvement in self-rated competence for all items in the questionnaire. However, doctors who had a longer posting reported greater improvement in some competencies (Table 3). Compared to those who undertook a one-month posting, those who undertook a three-month posting reported greater improvement in (1) discussing referral to home hospice or inpatient hospice for a cancer patient (mean change in score 1.29 ± 0.77 vs. 0.79 ± 0.73, p = 0.025) and (2) arranging a “terminal discharge” in the last days of life (1.71 ± 0.77 vs. 0.81 ± 0.81, p = 0.000). A “terminal discharge” is the transfer of an imminently dying patient with a prognosis of hours to short days from hospital to home to allow death to occur at home. Those who undertook an even longer six-month posting reported greater improvement in 15 out of 19 competencies.

Table 3.

Change in Self-Rated Competence Scores, One Month Versus Three Months Versus Six Months

Domain	Questionnaire item	Mean change in score for one-month posting (SD) (n = 39)	Mean change in score for three-month posting (SD) (n = 17)	Mean change in score for six-month posting (SD) (n = 12)	p-Value for one month vs. three months	p-Value for three months vs. six months	p-Value for one month vs. six months
I. End-of-life medical issues	1. Pain assessment	0.72 (0.69)	0.76 (0.66)	1.25 (0.97)	0.814	0.120	0.039
	2. Use of oral opioids	1.05 (0.69)	1.06 (0.75)	1.92 (0.90)	0.971	0.009	0.001
	3. Use of parenteral opioids	1.36 (0.90)	1.12 (0.781)	1.92 (1.31)	0.343	0.050	0.100
	4. Use of adjuvant analgesics (e.g., for neuropathic pain)	1.08 (0.66)	0.82 (0.64)	1.25 (0.97)	0.189	0.162	0.483
	5. Assessment and management of dyspnea	1.00 (0.89)	0.88 (0.70)	1.42 (1.16)	0.630	0.134	0.194
	6. Assessment and management of nausea/vomiting	0.64 (0.71)	0.88 (0.78)	1.33 (0.98)	0.260	0.180	0.010
	7. Assessment and management of constipation	0.69 (0.69)	0.76 (0.66)	1.17 (1.03)	0.718	0.211	0.072
	8. Assessment and management of symptoms in the last few days of life	1.26 (0.72)	1.29 (0.69)	1.83 (1.19)	0.855	0.134	0.044
II. Practical procedures	9. Performing oral care for a terminally ill patient	1.31 (0.80)	1.53 (0.80)	1.83 (0.72)	0.344	0.303	0.047
	10. Administering a “high” fleet enema	1.31 (1.00)	1.76 (0.90)	2.25 (0.75)	0.113	0.140	0.004
III. End-of-life communication skills	11. Giving bad news to a patient or family member	0.59 (0.68)	0.82 (0.64)	1.25 (0.87)	0.232	0.137	0.008
	12. Discussing DNR orders or “maximum ward management” decisions	0.41 (0.64)	0.71 (0.69)	1.17 (0.72)	0.125	0.092	0.001
	13. Discussing referral to home hospice or inpatient hospice for a cancer patient	0.79 (0.73)	1.29 (0.77)	1.92 (0.79)	0.025	0.044	0.000
	14. Discussing referral to home hospice or inpatient hospice for a noncancer patient	0.82 (0.76)	1.24 (0.75)	2.00 (0.60)	0.064	0.007	0.000
	15. Responding to a family who does not want the patient informed about his or her condition	0.77 (0.78)	1.12 (0.93)	1.50 (0.80)	0.152	0.258	0.007
	16. Eliciting a patient's goals for the end of life	1.03 (0.74)	1.35 (0.61)	2.00 (1.04)	0.116	0.044	0.001
	17. Explaining to a family about goal setting	1.04 (0.85)	1.41 (1.00)	1.67 (0.78)	0.157	0.468	0.026
IV. Terminal discharge	18. Arranging a “terminal discharge” in the last days of life	0.81 (0.81)	1.71 (0.77)	2.17 (0.83)	0.000	0.137	0.000
	19. Helping a family to understand about caring for a terminally ill patient at home	1.23 (0.74)	1.65 (0.79)	1.92 (0.79)	0.063	0.373	0.008

Compared to doctors with a three-month posting, those with a six-month posting reported a greater improvement in the following areas:

(1) Use of oral opioids (mean change in score 1.92 ± 0.90 for six months vs. 1.06 ± 0.75 for three months, p = 0.009)

(2) Discussing referral to home hospice or inpatient hospice for a cancer patient (1.92 ± 0.79 vs. 1.29 ± 0.77, p = 0.044)

(3) Discussing referral to home hospice or inpatient hospice for a noncancer patient (2.00 ± 0.60 vs. 1.24 ± 0.75, p = 0.007)

(4) Eliciting a patient's goals for the end of life (2.00 ± 1.04 vs. 1.35 ± 0.61, p = 0.044)

Discussion

Similar to past literature,^9–11,30 our study demonstrates low self-perceived competence among junior doctors across all domains of palliative care at the beginning of the PM posting. This is particularly so in the areas of (1) practical procedures—administering a high fleet enema and performing oral care, (2) end-of-life medical care—assessing and managing symptoms in the last few days of life and arranging a terminal discharge in the last days of life, (3) opioid use—including both parenteral and oral opioids, and (4) communication skills—helping a family to understand about caring for a terminally ill patient at home, eliciting goals of care, and explaining to family about goal setting.

This low level of self-assessed competence in palliative care among junior doctors raises concern over their inadequacy when dealing with patients with life-limiting illnesses. Most residents will invariably be faced with such patients in their careers, whether as junior doctors or when they become specialists in the future. This is the case for doctors in many specialties, including IM, family medicine, and other medical subspecialties. Hence, it is imperative that they are equipped with the necessary skills, knowledge, and confidence to provide high-quality palliative care for these patients.

One of the ACGME core competencies and IM subspecialty milestones is interpersonal and communication skills, with residents expected to communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds.^31,32 IM residents need to be able to identify and incorporate patient preference in shared decision making in complex patient care conversations and the plan of care.³² The United Kingdom General Medical Council (GMC) states that postgraduate training programs must give doctors in training sufficient practical experience to achieve and maintain the clinical or medical competences (or both) required by their curriculum and the opportunity to develop their clinical, medical, and practical skills and generic professional capabilities.³³ Communication, partnership, and teamwork is one of the four domains in good medical practice, the GMC core guidance for doctors.³⁴ Hence, it is vital for junior doctors to have adequate communication skills training, which can be better provided by a longer PM posting.

Our study shows that the most significant differences in score improvements occurred between a six-month posting and a one-month one. Compared with a one-month posting, a six-month posting resulted in a greater extent of improvement across multiple domains of end-of-life communication skills, practical procedures, and terminal discharge, with improvement in some areas of end-of-life medical issues also. In particular, a six-month posting brought about a statistically significant improvement in all seven items within the domain of end-of-life communication skills. This indicates that although a one-month posting may be sufficient in training a junior doctor in basic end-of-life medical issues such as symptom assessment and management, it may be inadequate in communication skills training. A longer posting duration is likely to have afforded doctors more experience and opportunities in witnessing as well as carrying out end-of-life communication with patients and families, resulting in the doctors feeling more confident and comfortable in holding these conversations.

On the contrary, the score changes between a one- and three-month, and a three- and six-month posting duration were less significant. A three-month posting offered additional improvement in only two questionnaire items over a one-month one, with the main difference being arranging a terminal discharge in the last days of life. A terminal discharge is usually done under urgent and potentially stressful circumstances as time is of essence and involves considerable logistics and coordination. A doctor who has undertaken a three-month posting is likely to have gained more exposure and experience in arranging a terminal discharge to feel more confident than one with a one-month posting.

As junior doctors acquire cumulative palliative care skills and knowledge during the course of their posting, their confidence is likely to increase correspondingly over time. It is likely that in the first few months from initial exposure, the junior doctors are only starting to appreciate the different aspects of palliative care. With greater exposure and experience from a longer posting duration, they begin to consolidate their learning to develop a firm grasp of these concepts and issues, resulting in a significant increase in their confidence in these areas. Within the domains of end-of-life communication skills and terminal discharge, in particular, multiple factors can contribute to an increased level of confidence. Many of the questionnaire items within these domains involve a deeper and more sophisticated knowledge and understanding of the issues faced by a patient and family, the support palliative care can offer, the palliative care services available in the community, and logistics involved in arranging future care, which can only be attained through a longer posting duration.

To the best of our knowledge, this is the first study of its kind to analyze the impact of a PM posting duration on the extent of improvement in self-rated competence. The results of our study demonstrate that with a longer posting duration, there is extra mileage to be gained for a doctor's self-rated competence in various aspects of palliative care. While a one-month posting may suffice in training a junior doctor in basic end-of-life medical issues, a longer posting duration results in a greater improvement in the doctors' confidence across different domains of palliative care, particularly in end-of-life communication.

Strengths and Limitations

Response rates were high for the baseline self-rated competence questionnaire (100%), as well as end-of-posting questionnaire (96%). However, there are several limitations. First, self-assessed competence may not be an accurate reflection of true competence and performance. It does not assess improvement in knowledge or clinical skills, or other important aspects of palliative care such as communication skills and professionalism. It is unclear whether an improvement in self-rated competence translates to an actual improvement in patient care. The appraisal of junior doctors should be a multidimensional process that includes analysis of the impact of training on practice. In addition, it is unknown if the improvement in self-rated competence is sustainable in the long run. Finally, the number of doctors undertaking a longer three- or six-month rotation was small, with only 12 doctors posted for six months.

Further studies looking into whether a PM posting leads to an improvement in knowledge and clinical skills, perceived improvement in patient care from the patients' and families' perspectives, and a sustainable impact on change in practice are warranted. A follow-up palliative care self-competence survey of the junior doctors in one to two years' time would be helpful to assess if the improvement in confidence is sustainable in the longer term.

Conclusion

Doctors without prior experience in palliative care lack confidence when managing terminally ill patients. More focus should be placed on postgraduate palliative care education and training so that junior doctors can be more confident when managing these patients. The results of our study reflect that to a large extent, self-rated competence in palliative care can be gained through a clinical posting in PM and that a longer posting duration results in further improvement in confidence in various aspects of palliative care, particularly in end-of-life communication.

This study reinforces that a posting in PM should be recommended for all junior doctors regardless of specialty. For trainee doctors in specialties that frequently deal with terminally ill patients, such as medical oncology, IM, nephrology, and pulmonary medicine, a longer posting duration would benefit them in terms of further equipping them with even greater confidence to better care for their palliative care patients.

Footnotes

Acknowledgments

In memory of the late Dr. Deborah Watkinson, who took the lead in developing the competency survey and instituted routine administration of these for all junior doctors posted to the DPM. We thank the palliative care specialists in the department—Associate Professor Cynthia Goh, Dr. Patricia Neo, Dr. Shirlynn Ho, Dr. Daniel Quah, Dr. Gwendoline Soh, Dr. Lo Tong Jen, and Dr. Shirlyn Neo—for their tireless dedication in training junior doctors. This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author Disclosure Statement

No competing financial interests exist.

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