Palliative care training in medical undergraduate education: a survey among the faculty

Abstract

Background
A minority of European countries have compulsory training in palliative care within all medical schools. The aim of the study was to examine palliative care education in Estonia.

Methods
We used the adapted version of the Palliative Education Assessment Tool (PEAT) to evaluate palliative care education at the University of Tartu, the only medical school in Estonia. The PEAT comprises of different palliative care domains and allows for assessing the curricula for palliative care education.

Results
26 hours (h) of palliative care is taught within the basic medical curriculum, which is divided between 14 courses. Ethical issues (4 h, lecture and seminar) and basics of palliative care (2.5 h, lecture) are well covered however, pain and symptom management (12.5 h, lecture, seminar, workshop), psychosocial, spiritual aspects (5.5 h, seminar), and communication (1.5 h, lecture) teaching do not reach the recommended number of hours. Teamwork and self-reflection are not taught at all.

Conclusions
Increased time, more diverse teaching strategies and clear learning outcomes are required to enable the development of palliative care education in Estonia. The teaching and learning of palliative care is a process that requires constant development and collaboration.

Full text

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Suija et al. BMC Palliative Care (2024) 23:19
https://doi.org/10.1186/s12904-024-01351-4
Background
e changing demographic prole of the European popu-
lation highlights an increasingly aged population, illus-
trating the growing need for palliative care [1]. Moreover,
providing high-quality palliative care training for under-
graduate medical students is one of the main keys to safe-
guarding access to palliative care [2, 3].
In 2019, the Atlas of Palliative Care in Europe reported
that only nine countries in Europe have compulsory
training in palliative care in all medical schools [4]. One
of these countries is Estonia. With just over 1.3million
inhabitants, Estonia is one of the least populous mem-
bers of the European Union. In Estonia there is only one
BMC Palliative Care
*Correspondence:
Stephen R. Mason
stephen.mason@liverpool.ac.uk
1Institute of Family Medicine and Public Health, Faculty of Medicine,
University of Tartu, Tartu, Estonia
2Institute of Public Health and Clinical Nutrition, Faculty of Health
Sciences, University of Eastern Finland, Kuopio, Finland
3Palliative Care Unit, Health and Life Sciences, Life Course and Medical
Sciences, University of Liverpool, Room G036, 200 London Road,
Liverpool L3 9TA, UK
4Department of Palliative Medicine, Medical Faculty, RWTH Aachen
University, Aachen, Germany
5Institute of Palliative Care, Paracelsus Medical University, Salzburg, Austria
Abstract
Background A minority of European countries have compulsory training in palliative care within all medical schools.
The aim of the study was to examine palliative care education in Estonia.
Methods We used the adapted version of the Palliative Education Assessment Tool (PEAT) to evaluate palliative care
education at the University of Tartu, the only medical school in Estonia. The PEAT comprises of dierent palliative care
domains and allows for assessing the curricula for palliative care education.
Results 26hours (h) of palliative care is taught within the basic medical curriculum, which is divided between 14
courses. Ethical issues (4h, lecture and seminar) and basics of palliative care (2.5h, lecture) are well covered however,
pain and symptom management (12.5h, lecture, seminar, workshop), psychosocial, spiritual aspects (5.5h, seminar),
and communication (1.5h, lecture) teaching do not reach the recommended number of hours. Teamwork and self-
reection are not taught at all.
Conclusions Increased time, more diverse teaching strategies and clear learning outcomes are required to enable
the development of palliative care education in Estonia. The teaching and learning of palliative care is a process that
requires constant development and collaboration.
Keywords Palliative care, Medical student education, Educational design
Palliative care training in medical
undergraduate education: a survey among
the faculty
KadriSuija1,2, Stephen R.Mason3*, FrankElsner4 and PiretPaal5
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Suija et al. BMC Palliative Care (2024) 23:19
medical school; the Faculty of Medicine at the University
of Tartu, founded in 1636.
In 2019, the European Association for Palliative Care
(EAPC) published updated recommendations for pallia-
tive care curriculum development, which includes seven
main topics: (1) basics of palliative care, (2) psychosocial
and spiritual issues, (3) pain management, (4) symptom
control, (5) ethical and legal issues, (6) communica-
tion, and (7) teamwork and self-reection [5]. Based on
the experience of Romania, one of the rst countries to
implement these recommendations, Medical Schools had
to allocate time to teach palliative care, and faculty com-
petencies and skills needed updating [6].
In Finland, recommendations for palliative care educa-
tion were formulated by a nationally funded programme.
e nal report identied ways to harmonise teaching,
for example by formulating highly relevant topics. e
report also noted that basic knowledge and skills must be
covered in a separate/distinct course, while the additional
expertise can be taught through ‘horizontal integration’
within dierent courses [7].
Several studies indicated that it is important to under-
stand the current state of teaching of palliative care, and
to examine it systematically and regularly [8, 9]. Although
Estonia is highly ranked in the EAPC Atlas for having
mandatory palliative care training, the state of palliative
care teaching and learning has not been specically stud-
ied. e aim of the study was to examine palliative care
education in Estonia.
Methods
To understand the current state of palliative care edu-
cation and training in Estonia, we conducted a survey
among the faculty at the University of Tartu. e Pal-
liative Education Assessment Tool (PEAT) was obtained
as a survey inventory [10]. e PEAT consists of seven
areas, each with specic curricular objectives, such as:
(1) palliative care; (2) pain; (3) neuropsychological symp-
toms; (4) other symptoms, (5) ethics and law, (6) patient/
family and non-clinical caregiver perspectives on end-
of-life care, and (7) clinical communication skills. It has
been designed to help inform the development of curri-
cula for palliative care education [10].
First, we translated and adapted the PEAT. We used
forward-backward-translation method, using the prin-
ciples outlined in the translation guideline [11] - which
means that the instrument was translated into Estonian
by one translator and then back to English by another
translator. No signicant dierences in the translations
were found. Later we performed the instrument pilot
testing. We decided to exclude the ‘neuropsychological
symptoms’ and added the domain of ‘specic issues about
end-of-life care‘. e original domain focusses on neuro-
psychological symptoms associated with dying, including
those that are related to medications. As there may be
various symptoms associated with dying, and side-eects
of medications are covered in symptom care, we decided
that ‘specic issues about end-of-life care‘ would be a
more meaningful domain.
Secondly, we prepared the questions in table format
and tested the acuity of the questions by entering data
from two courses that cover aspects of palliative care.
We used the data available in the learning database of the
University. We pilot-tested the PEAT with faculty mem-
bers (n = 5) involved in teaching palliative care (the PEAT
is available as a supplementary le).
In January 2023, we emailed the survey to all heads of
departments of the faculty of medicine (n = 23). We asked
if they teach palliative care in their discipline to medical
students and if yes, to detail content and teaching time.
We gave three weeks to complete the survey, and after
a reminder granted an additional week. In February, we
contacted all clinical teachers who responded to acquire
further information about teaching methods and perfor-
mance assessment, which was not found in the learning
database.
All methods were carried out in accordance with rel-
evant local regulations. e Ethics Committee of the
University of Tartu was contacted but waived ethical
approval and a need for informed consent as the informa-
tion collected and analysed was available in the learning
database of the University of Tartu, which is freely avail-
able. In addition, the analysis was considered as a service
evaluation. No personal data was collected.
Results
Of 23 persons contacted, 13 responded and seven
reported about teaching palliative medicine in their disci-
pline. Data received provided information on 14 courses
covering various aspects of palliative care. Of these, ten
courses were for undergraduate medical students, two
for dentistry students, one within the physiotherapy
curriculum, and one for post-graduate studies (medical
residents). Within the medical curriculum, seven courses
were compulsory for all students, and three were elective.
e participants who reported that they were teaching
palliative medicine within basic medical curriculum were
from the following disciplines: medical theory and ethics,
geriatrics, clinical pharmacology, pulmonology and tho-
racic surgery, family medicine, neurology and neurosur-
gery, rehabilitation medicine (Table1).
e dentistry curriculum covers aspects including end-
of-life care ethics (4h (h)) and dental care of the elderly
and chronically ill people (6h). e physiotherapy curric-
ulum covers aspects of end-of-life care ethics (2h). ere
is one theoretical course (26h) for post-graduate medical
students, which covers topics such as the general princi-
ples of palliative care (4h), pain and other symptom care
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Suija et al. BMC Palliative Care (2024) 23:19
(12h), end-of-life care (1h), ethical and legal issues (4h),
communication (3h), and supporting relatives (2h).
ere are also elective courses and medical students
may meet palliative patients during their practical train-
ing in hospitals and primary care centres, but the elective
courses do not take place every year and not all students
take them. e opportunities for practical clinical train-
ing also vary, and therefore, we have not included elective
courses in this analysis.
Comparisons with the EAPC recommended curriculum
26 h of palliative care are taught as part of the basic
medical curriculum (total number of points according
to the European Credit Transfer and Accumulation Sys-
tem is 360) (see Table1). Comparing the palliative care
topics covered in the undergraduate medical curriculum
with the EAPC recommendations identies that the gen-
eral principles of palliative care (2.5h, lecture based) are
well covered, however, pain and symptom management
(12.5 h, lecture, seminar, workshop), and psychosocial
and spiritual aspects (5.5h, seminar based) do not reach
the recommended number of hours. Communication
training (1.5h, lecture based) needs more allocated time
to match EAPC recommendations (15% of training time).
e ethical and legal aspects of palliative care at the Uni-
versity of Tartu are 4h (lecture and seminar) and exceed
EAPC recommendations (5%/up to 2h). Teamwork and
self-reection are not currently taught. Findings are sum-
marised in Fig.1.
Discussion
is rst report on the provision of palliative care educa-
tion in Estonia demonstrates that although highly ranked
in the EAPC Atlas, several issues in the palliative care
curriculum need revision and improvement. e 26h of
mostly lecture or seminar-based teaching across various
disciplines in rst, fourth and fth year is used for pallia-
tive care education within the basic medical curriculum
in Estonia. e learning goals as well as the performance
assessment varies across the courses. is means that a
signicant collaboration and planning is necessary to
ensure meaningful training.
ese results accord with information from systematic
reviews of palliative care education, which report that
teaching tends to be fragmented and uncoordinated or
concentrates more on knowledge acquisition, rather than
skills and attitudes. In addition, palliative care education
is rarely formally assessed, suggesting that the eective-
ness of training is not considered and the context for
revision and improvements is limited. Further, there are
diculties in recruiting suitable teachers [12, 13].
When comparing the training in Estonia with the rec-
ommendations of the Finnish report, it is noticeable that
horizontal integration (teaching within dierent special-
ity courses) is used more in Estonia than in Finland. is
may improve the integration of palliative care, but care
needs to be taken that there is parity in horizontal inte-
gration within speciality courses [7].
Table 1 Palliative care teaching in the Faculty of Medicine, University of Tartu
Year Speciality
Course
Palliative care topics and aims Teaching
method
Performance assessment Pallia-
tive care
teaching
hours
IMedical Theory
and Ethics
Ethics at the end of life Lecture,
seminar
Written examination, where there are
also questions about end-of-life care
ethics
4h (2h
lecture
and 2h
seminar)
IV Geriatrics Principles of palliative care, Communication and End-of-
life care with a focus on older people
Seminar Multiple-choice test, where there are
questions also about elderly palliative
care
3h
IV Clinical
Pharmacology
Pharmacological treatment of pain Seminar None, but participation in the seminar
is obligatory
4h
IV Pulmonology
and Thoracic
Surgery
Management of the chronic progressive lung disease,
brotic interstitial lung disease, pulmonary hypertension
Lecture None but participation is obligatory 0.5h
V Family Medicine
II
General principles of palliative care, symptom assess-
ment, pain care, nausea, constipation, dyspnoea man-
agement, general principles of end-of-life care, teamwork
and communication with a focus on primary care
Lecture,
workshop
One clinical case about primary pallia-
tive care in the written examination
5h (2h
lecture
and 3h
work-
shop)
V Neurology and
Neurosurgery
Management of the patients with neurodegenerative
diseases
Seminar Oral examination, where there are
also questions about palliative care of
neurological patients
7.5h
V Rehabilitation
Medicine
Nutrition and nutrition-related problems management,
oncological rehabilitation
Seminar None, but participation in the seminar
is obligatory
2h
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Suija et al. BMC Palliative Care (2024) 23:19
e main teaching methods in Estonia were lectures
and seminars, which when appropriately structure can
eectively disseminate knowledge and provide oppor-
tunities for critical discussion and reection with a
large number of students. Less were used workshops,
and there was no examples of bedside training, simula-
tion, or specic skills teaching. ere is strong evidence
that improved self-ecacy and outcome expectancies
result in behavioural changes in medical students that
lead to improved practice and better patient care [14].
Such changes are facilitated by sucient time for train-
ing, and more importantly, engaging appropriate content
and teaching strategies. ere is no ‘best way’ to teach
palliative care, although studies have shown that prac-
tice-based teaching, supported by experiential exercises
and using appropriate assessment techniques is optimal
[13]. e lack of practical, for example bedside learning,
as well as overarching learning goals and suitable perfor-
mance assessment are shortcomings in teaching. ere
are few practical training places for palliative care avail-
able, and not enough qualied tutor doctors/teachers in
Estonia. Preparing such training needs commitment and
skills, and requires investment at the university level to
improve educators’ knowledge about immersive train-
ing methods. e importance of collaborative planning
to develop overarching learning objectives for all courses
was reported by Afshar et al., in their study about the
development of the interdisciplinary and cross-sectional
palliative care course at the Hannover Medical School
[15].
It is clear that if there is no overall assessment which is
related to learning goals and teaching methods, we can-
not know how well newly qualied doctors are prepared
for palliative care. A recent systematic review identied
that palliative care education has a signicant positive
eect on junior doctors’ emotional well-being and pro-
fessional attitudes. Further, around half of the medical
students felt that their medical education is failing to pre-
pare them to deliver good end-of-life care, and most stu-
dents did not feel prepared to address ethical challenges
at the end-of-life [16]. To change this, palliative care pro-
fessors across Europe believe that a general increase in
awareness of society, including medical students, of the
importance of dealing properly with death, dying, and
suering is needed, and therefore, palliative care should
be appropriately integrated into all education [6]. Fur-
thermore, while general recommendations such as the
EAPC recommendation for basic medical education are
helpful, each country has its own problems and medical
education curricula need to be adapted to local condi-
tions [8, 13, 15, 17].
is study highlights the need for future research to
assess the dierential impact of small and large educa-
tional interventions in palliative care, whether interven-
tions lead to behaviour change, and how teaching aects
clinical practice. e impact of teaching on specic ele-
ments of patient care also needs to be explored and could
utilise markers of clinical assessment, management and
patient/family feedback.
Strength and limitations
is is the rst time that palliative care education has
been mapped in Estonia. Data were collected directly
from educators, so may be open to over or under-repre-
sentation/application using the PEAT [10]. No informa-
tion was collected from students in this study, and this
should be engaged in future studies.
As curricula in medicine are usually already full, it
can be dicult for new specialities such as palliative
medicine, to nd and maintain their place and teaching
Fig. 1 EAPC recommended hours and current hours of palliative care in the medical curriculum
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Page 5 of 5
Suija et al. BMC Palliative Care (2024) 23:19
points. Finding optimal ways to integrate palliative care
into existing curricula necessitates regular assessments
to enable meaningful review. We hope that results of
this study will support not only development of palliative
care education but also medical curricula in general. e
results from countries where the development of pallia-
tive care is still ongoing, such as Estonia, are valuable for
other countries and may help to identify the most impor-
tant decits and where to make improvements. More
harmonization in palliative care education is needed.
Conclusions
Increased time, more diverse teaching strategies and
clear learning outcomes are required to enable the
development of palliative care education in Estonia. e
teaching and learning of palliative care is a process that
requires constant development and collaboration.
Abbreviations
EAPC The European Association for Palliative Care
PEAT The Palliative Education Assessment Tool
hours h
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12904-024-01351-4.
Supplementary Material 1: The adapted version of the Palliative Educa-
tion Assessment Tool (PEAT), which was used as the survey inventory
Acknowledgements
The authors wish to thank all participants for sharing information.
Author contributions
K.S. and P.P. conceived of the analysis with input and recommendations from
F.E. and S.M. K.S. conducted data analysis. P.P. and K.S. prepared the rst draft,
F.E. and S.M. contributed to revising the article. All authors approved the nal
manuscript.
Funding
Not applicable.
Data availability
All data generated or analysed during this study are included in this published
article.
Declarations
Ethics approval and consent to participate
All methods were carried out in accordance with relevant local regulations.
The Ethics Committee of the University of Tartu was contacted but waived
ethical approval and informed consent because the information collected
and analysed was available in the learning database of the University of Tartu,
which is freely available. The analysis was considered as a service evaluation.
No personal data was collected.
Consent for publication
Not applicable. This study does not contain any individual identifying and/or
personal data.
Competing interests
The authors declare no competing interests.
Received: 18 August 2023 / Accepted: 10 January 2024
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