Abstract
Abstract
Background:
In Europe in recent decades, university teaching of palliative medicine (PM) has evolved. In some countries it has been introduced as a compulsory subject in all medical schools, but in a majority of countries it remains an isolated subject at few universities.
Objective:
To explore how PM has been introduced into the curricula and how it is currently being taught at different European universities.
Method:
Case study method using face-to-face semistructured interviews with experienced PM professors, comparing how they have developed PM undergraduate programs at their universities.
Results:
An intentional sample of eight university professors from Spain, France, UK, Italy, Hungary, Sweden, Germany, and Poland was chosen. The introduction of PM in the universities depends on the existence of a favorable social and political context in relation to palliative care and the initiative of pioneers, trusted by students, to push this education forward. A PM curriculum frequently starts as an optional subject and becomes mandatory in a short period. In the reported universities, PM uses a wide variety of teaching methods, such as lectures, workshops, role-plays, and discussions. PM assessment included tests, discussions, reflections, portfolios, and research works. According to respondents' opinions, lack of recognition, funding, and accredited teachers, along with competition from other curricula, are the main barriers for palliative medicine teaching development at universities.
Conclusion:
Diverse paths and tools have been identified for PM teaching in Europe. The described cases may shed light on other medical schools to develop PM curricula.
Introduction
I
In addition, there is a great variation in the number of hours and the quality of content where PM is taught. Accurate information from the United Kingdom shows that despite being taught in all medical faculties, the number of hours varies from less than 10 hours in 10% of the faculties to around 100 hours in 13% of the faculties. 10 In Germany PM is taught in all faculties and in 20 of them, the curricula have over 20 hours. 11 Similar situations are to be found in Switzerland12,13 and Spain. 14 As a result, there are still major inconsistencies and heterogeneity, and the teaching hours still fall short of the 40 hours recommended by the EAPC. 15
Outside Europe, in the United States 90% of medical students are exposed to different PM programs, but on average, there is still a limited number of hours, amounting to around 14 hours. 16 In Asia, there are data on the Japanese situation, where over 50% of students have the possibility of undertaking a clinical internship in PC. 17
Besides this variation, students perceive PM courses at the university in a positive manner and consider them essential for their development as physicians. 18 To promote medical education in PC, it is essential to know and understand different ways of introducing and organizing PM in the university. This is particularly important in the European region where, despite having a common cultural history and framework for higher education, there are also many peculiarities in the educational systems of different countries, as well as different levels of PC development.
Our aim is to describe how PM is taught in eight European Universities through experienced teachers' reports from Central, Western, and Mediterranean countries of the European region, which might inspire and serve as an example to PM professors from countries of similar geographical and cultural environments. Finally, these descriptions of practical cases might be the first step to finding the main variables to design a future survey aimed at mapping PM undergraduate teaching in Europe.
Methods
Design of the study
“Multiple” and “cross-case” analysis case study.19,20 Each of the university educational programs constitutes a “case” and was “cross-case” compared to having the opportunity to find common trends or peculiarities across the different settings. The use of multiple and cross-case studies as research strategy is very coherent for PC contexts and has been extensively used.21,22
Setting and participants
Purposive sampling was used to identify experienced PM university teachers from different European countries: (1) pioneers or current leaders in PM education in their countries, (2) those in charge of PM teaching in their respective universities, (3) recognized participation in Task Force on Education at national or international level, and (4) research publications (Table 1). The first and the last author on the list invited informants to participate in the study. Verbal consent was recorded at the beginning of the interview.
Data collection
Three researchers designed a face-to-face semistructured interview guide, based on the EAPC Atlas for Palliative Care in Europe, 23 the EAPC Curriculum for PM, 15 and on a recent study about undergraduate PM education in Europe. 1
This interview examined 45 items regarding: (1) PM education in the university (history, main characteristics, attendance, contents, teaching methods, and evaluation); (2) professorship (experience, academic position, and other educational tasks); and (3) an overview of PM education in the country with two open questions about barriers and opportunities to PM undergraduate education. A pilot study was performed; it consisted of carrying out a semistructured interview with one of the respondents (Dr. Centeno) to ensure that the interview capability was accurately responded.
Three researchers conducted the interviews in June 2016, and these typically lasted 40–60 minutes. All interviews were audio-recorded and transcribed. The questions of the semistructured interview were also flexible, to enable participants to respond briefly or at length, with comments or experiences allowing better result interpretation. These answers have been used verbatim.
The dataset of answers with the written transcription was sent to the respondents for sense checking and data accuracy in the context of information from other universities. The data correspond to the 2015/16 academic years, and respondents updated it with 2016/17 changes.
Data analysis
Data were organized by section in tables to highlight the focus of the study. Two researchers analyzed this final dataset. Case studies were compared to isolate any themes or patterns among the eight participants.
Two researchers wrote a report as a narrative that integrates and summarizes key information around the focus of the case study. 24 The report was sent for revision and validation by the teachers to ensure proper interpretation of the data. Corrections received were then incorporated.
Results
Genesis of PM in European Universities
PM curriculum starting points differ among the studied universities. In Poland, Professor Jacek Luczak launched the first mandatory PM course in 1990 at the Poznan University of Medical Sciences. 25 In United Kingdom and France, PM started in the mid-nineties, in Germany and Spain at the beginning of the 21st century (Table 2). PM has usually started as an optional course that, over a short period of time of around five years, becomes a mandatory subject.
No course is mandatory in France.
Two hundred seventy Polish students and 120–150 international students per year.
The reference document that most inspired the design of the PM curricula is the EAPC report on medical education, 15 especially for universities in countries with less PC tradition. In other contexts, such as United Kingdom, the General Council document included in Tomorrow Doctors was used. 26
The incorporation of PM at European Universities has occurred in three different contexts: starting with a favorable political and social context, promoted by medical societies or led by local pioneers. Even if a favorable context is a good starting point, the development of undergraduate PM teaching commonly needs the drive of a pioneer, who will make the most of local circumstances. Other agents are medical students, whose positive evaluation after receiving PM strongly supports its implementation, as has happened in Spain 27 and Hungary (Table 3).
Verbatim extracted from respondents' interviews
JE, John Ellershaw; MF, Marilene Filbet; AK, Aleksandra Kotlinska; AC, Agnes Csikos; FE, Frank Elsner.
PM as a subject
As a general characteristic there is great diversity in the PM curricula structure: it is normally a separate course, but sometimes the main topics are integrated into other mandatory subjects, or in a transversal way, taught in different years (Table 3).
PM is usually taught during the last two years of medical studies, and the number of attendants is related to the nature of the course, varying from 200 students, if it is mandatory, to between 30 and 50 students (30–50%), if optional. The most common teaching activity is the lecture, but there is a great wealth of different activities, especially in Liverpool and Lund. It is important to highlight how respondents describe the way lectures are organized; clinical cases are the focal point, bringing the patient to the student. All the universities offer the possibility of PC clinical internships, not all of them mandatory. Despite the demonstrated utility of these internships, 15 there is a wide range in the length in days, from 10 offered in Liverpool or Lund to one offered in Navarra (Table 2).
All topics specified in the EAPC recommendations are taught in all the universities discussed. The most in-depth topics explained were pain and symptom control, communication, emotional and spiritual support, and ethics. There are also some specific topics, such as pediatric PC. 28 (Table 4)
Other contents included in the curriculum: Univ. of Lyon: Pediatrics Palliative Care. Univ. of Poznan: Pediatrics Palliative Care, Lymphedema, and chronic wound treatment.
Regarding assessment, all the universities observe the standard knowledge examination format, but with different and deeper methods to assess student progress. Some examples are ongoing Internet evaluation with clinical cases and reflective writing in Navarre, the PC portfolio in Liverpool, and Lund's PC phenomenon essay.
About the PM teachers
All the respondents started as clinicians, but are now working professors with academic positions while maintaining their clinical work. They are also concerned about the usefulness of developing interdisciplinary teaching teams and with the necessity of transversal teaching collaboration with other medical subjects, or even faculties (Table 5).
Opportunities for PM education improvement
The respondents mentioned opportunities for improving PM education, for example, the increasing awareness of society and among medical students, of the importance of dealing properly with death, dying, and suffering; the existence of PC professors as advocators; the integration of PM in core curriculum for medical education; student support; the acceptance and good evaluation of PM curricula; the innovative way of teaching led by PM education, focused on bedside teaching; and the growing prestige of PM thanks to good PC physicians.
Challenges to PM education improvement
Some barriers, as perceived by these leaders, include the lack of understanding of PM from some groups of physicians; the lack of public awareness; the lack of funding and competition with other curricula; and the lack of accredited PC teachers.
Discussion
Universities in leading PM countries, such as United Kingdom, have developed well-defined study programs. Other countries, such as Italy or Spain, have not yet incorporated PM courses into all university degree programs in their country. All in all, there exists a variety of situations, very much tied to the lead professor, his or her ability to enter the academic world, their cultural and professional credibility, and initiatives. Therefore, the academic preparation and motivation of teachers is a crucial point. This is an important issue that also highlights the need for leading professors to create a school that is capable of consolidating the takeoff phase and to sustain the gains made by distinguished professors over time.29,30
The disparity of training plans is recorded in this piece of research. Ideally there would be homogeneity of program contents, duration, assessment, and teachers across European Universities to construct a European “palliative culture” arising from the academic world. Europe is an aggregation of countries with different cultures and traditions whose diversity manifests itself in the organization of PM training plans at any level. Comparing diversity to common traits is a way of strengthening the whole subject. Comparison of different cultures is useful in increasing the “each-other understanding” capacity that might otherwise be a barrier to the “global” development of the matter. 31 This diversity might enrich the way that PM is taught.
Finally, the search for teaching models—that must respect the content— might be developed in relation to the characteristics and willingness of each university. This work indicates that there are generally dedicated courses, but there are not always teachers in charge of the specific sector. While waiting for PM teachers or specific courses, a possible solution might be to design longitudinal courses that involve professors of other disciplines entering core training in PC, teaching the “palliative slice” of their own discipline, so that the student receives progressive PM teaching. This way, PM could avoid confining itself to a specialist setting, with the risk of building a barrier itself. The main limitation of this study is that data cannot be generalized, a limited number of universities cannot represent a wider national situation, and therefore, we lose both representativeness and other good examples of PM teaching.
However, these successful cases may help professors in developing new curriculums, based on the practices in these universities. It may also serve to find the variables for a future study for mapping undergraduate PM teaching in Europe.
Footnotes
Acknowledgments
This work was partially funded with the support of Accademia delle Scienze di Medicina Palliativa. The Institute for Culture and Society of the University of Navarra contributed in kind through research time of the first, third, and last authors.
Author Disclosure Statement
No competing financial interests exist.