Background
Methods
Participants
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Broad study objective: to survey the state of undergraduate palliative care teaching
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A cross-case outcome analysis: coverage of teaching at all universities in Austria
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High specificity of the sample through purposive sampling: recruitment of the best-informed key persons from all medical universities in Austria
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Theory-based study: extensive literature review, for example, in the context of the scoping review [35], established interview guide (see below), and high competence in qualitative analysis in the team of authors
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Variable quality of dialogues, which according to field notes and transcripts was predominantly positive
Primary data: qualitative data obtained through semi-structured expert interviews
Secondary data: quantitative data obtained through a closed questionnaire
Analysis
Integration of qualitative and quantitative results
Results
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Medical University of Vienna [52]
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Medical University of Innsbruck [53]
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Medical University of Graz [54]
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Paracelsus Medical University (Salzburg) [55]
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Karl Landsteiner University of Health Sciences (Krems) [56]
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Johannes Kepler University Linz [57]
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Sigmund Freud University of Vienna [58]
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Danube Private University (Krems) [59]
Participants
Category | Number | Percentage |
---|---|---|
Gender | ||
Female | 12 | 57.1% |
Male | 9 | 42.9% |
Relation to undergraduate palliative care education in Austria | ||
Current occupation in undergraduate palliative care education | 14 | 66.7% |
Current occupation in undergraduate non-palliative care education | 1 | 4.8% |
Former occupation in undergraduate palliative care education | 1 | 4.8% |
Future occupation in undergraduate palliative care education | 1 | 4.8% |
External experts | 4 | 19.0% |
University degree | ||
Professor | 8 | 38.1% |
Private lecturer (Privatdozent) | 2 | 9.5% |
No post-doc (Keine Habilitation) | 11 | 52.4% |
Profession | ||
Physician | 21 | 100.0% |
Clinical work environment | ||
Palliative care unit (Austria) | 10 | 47.6% |
Hospice (Austria) | 3 | 14.3% |
Palliative care unit (other country) | 3 | 14.3% |
Retirement (after palliative care work in Austria) | 2 | 9.5% |
Non-palliative care unit (Austria) | 1 | 4.8% |
Non-palliative care unit (other country) | 1 | 4.8% |
Medical directorate (Austria) | 1 | 4.8% |
Total | 21 |
Outline of the results
Structures
Chair
“Well, of course it would be desirable if we had a chair for palliative care […] because then the value of palliative care would increase […] and if you could then be even more involved in the curriculum, you would also have time for it. So that would be something that, I think, could improve teaching and research in the future.” (Transcript (T) 7, Item (I) 79–81).
“I miss the chairs [for palliative care] in Austria. I would like to have more.” (T 11, I 81)
Access to a palliative care unit
"There's no such structure that conducts clinic and research, and that is associated with the university. And you can just notice this deficit.” (T 8, I 55)
“Yes, unfortunately it [practice-oriented teaching] is difficult, of course, because […] there is no palliative care unit” (T 8, I 79)
Structures affiliated to the university | Statements of each of the eight Austrian universitiesa | Total | |||||||
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Palliative care unit in the affiliated university hospital | X | X | X | X | 4 | ||||
Palliative care unit in a teaching hospital of the university | X | X | X | 3 | |||||
Hospice | X | X | 2 | ||||||
Mobile palliative team | X | X | X | X | 4 | ||||
Other: “Palliative Consultation Service” | X | 1 | |||||||
Other: “anesthesia, intensive care, emergency medicine and pain therapy” | X | 1 |
“In the past, no one at the university was interested [in palliative care], and the hospices more or less took it over. And they also do most of the training of physicians and nursing staff. […] I think that's also one of the reasons why this distinction between hospice medicine and palliative medicine doesn't work, because 90% of the training that is done is through hospice institutions. And that […] [a palliative care unit] should actually be a throughput unit like an intermediate care unit, precisely for palliative patients, and dying can also take place somewhere else—that is unfortunately not in people's minds. And if you bring that back into people's minds, then maybe a […] university hospital will be more interested again.” (T 13, I 17).
Mandatory palliative care teaching
Organisation of the mandatory teaching
“Palliative care received a part of all this, but that happens only once [during the medical studies], so not for the whole semester” (T 5, I 57)
“We are part of a module, which is actually organised by [another subject]” (T 20, I 49)
“But the time frame is simply far too short. […] You can really only teach them the basics.” (T 13, I 27)
“It certainly fails because of the time resources […]. But yes, of course you can't (laughs briefly) make the studies twice as long.” (T 2, I 80)
“A few years ago, the rector offered me the following: Let the hospital give you 20 h off per week and in return 20 h for the university—20 h for the clinic […]. That was simply not possible, because that is then missing in the daily clinical routine, and there we have to work on getting more staff again. And then, I think, a lot would be possible. Also in research.” (T 7, I 91)
“The unfortunate aspect of teaching is that it is always done as a side job. I think that is something that should be encouraged in general, that fixed times for teaching should also be established for physicians. [Currently,] it's always secondary. It's always second row, which is not good, actually.” (T 19, I 95)
Contents of the mandatory teaching
Percentages for each of the eight Austrian universitiesa | Mean valueb | ||||||||
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Basics of Palliative Care (5%) | 20% | 20% | 20% | 20% | 40% | 5% | 10% | No mandatory teaching | 19.3% |
Pain and symptom management (50%) | 20% | 40% | 30% | 40% | 20% | 5% | 65% | 31.4% | |
Psychosocial and spiritual aspects (20%) | 10% | 10% | 10% | 5% | 10% | 5% | 10% | 8.6% | |
Ethical and legal issues (5%) | 20% | 10% | 10% | 15% | 10% | 40% | 15% | 17.1% | |
Communication (15%) | 20% | 10% | 10% | 10% | 10% | 40% | 0% | 14.3% | |
Teamwork and self-reflection (5%) | 10% | 10% | 20% | 10% | 10% | 5% | 0% | 9.3% |
“I think that undergraduate teaching in palliative care is incredibly important, that you have to plant a seed early on, that students know what it actually means and that there are no longer these retro people, somehow still believing that palliative care means turning up the morphine syringe driver and putting them in bed and letting people die.” (T 5, I 97).
“We try to explain that there are obviously also cardiomyopathies and […] COPD. At some point, [these patients] will need palliative care, unless they get a lung transplant if they are still young, but a patient with massive dyspnea who does not get a lung transplant is clearly a palliative patient. And the exact same thing with cardiomyopathy. And it's the same with neurological diseases, [for example] with stroke symptoms” (T 13, I 59).
“It is also good if the students get to know palliative care as early as possible, giving them much more: because these are basic medical skills, and also medically competent skills of symptom treatment, which can always be used, not only now at the end of life, but in general. So you can make palliative care a little more attractive by saying: Wow, they really know how to treat the worst itch or how to deal with pain” (T 5, I 79).
“[Nowadays in medicine] we often forget this holistic view and this attitude or this patient-centered work, like: […] What does this patient need, what does he want from me, how can I best help him and when should I stop with therapy?” (T 19, I 77).
“It's an attitude that you just want to give them, like, 'how do I approach my counterpart', also like, 'what do I perceive'” (T 15, I 58)
“Palliative care is part of an overall treatment, a holistic concept” (T 10, I 73).
“So I think it is especially about […] in which way students—when they have [been] in their internship and have experienced a lot there—are also picked up by the university and asked: How was it? […] Serious illness, incurability and end of life, caring for relatives, I think these are important questions that are always impressive and that there then is a structured offer to talk about it and not only to share what has been experienced, but also to learn […] I think that would make perfect sense.” (T 16, I 27).
Teaching and assessment formats and areas
Statements of each of the eight Austrian universitiesa | Total | Proportionb | ||||||||
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Teaching formats | ||||||||||
Lecture | X | X | X | X | X | X | X | No mandatory teaching | 7 | 87.5% |
Bedside teaching | X | X | X | X | 4 | 50.0% | ||||
Patient presentation | X | X | X | X | 4 | 50.0% | ||||
Practical training | X | X | X | 3 | 37.5% | |||||
E-Learning | Xc | X | 2 | 25.0% | ||||||
Seminar | X | X | 2 | 25.0% | ||||||
Problem-based learning | X | X | 2 | 25.0% | ||||||
Case-based learning | X | X | 2 | 25.0% | ||||||
Training with simulation patients | X | 1 | 12.5% | |||||||
Taught areas | ||||||||||
Knowledge | X | X | X | X | X | X | X | No mandatory teaching | 7 | 87.5% |
Attitude | X | X | X | X | X | 5 | 62.5% | |||
Skills | X | X | X | 3 | 37.5% | |||||
Examination formats | ||||||||||
Written exam with multiple choice | X | X | X | X | X | X | No mandatory teaching | 6 | 75.0% | |
Oral exam | X | 1 | 12.5% | |||||||
Immanent examination | X | 1 | 12.5% | |||||||
Examined areas | ||||||||||
Knowledge | X | X | X | X | X | X | No mandatory teaching | 6 | 75.0% | |
Attitude | X | X | X | X | X | 5 | 62.5% | |||
Skills | X | X | 2 | 25.0% |
Areas of mandatory teaching
“[Teaching palliative care at the university] means to me above all to convey an attitude that the students do not only understand the medical profession as a scientific art or a technical art, but also […] that the care is really conveyed holistically. Yes, this is about this philosophy and otherwise, above all, making it clear that palliative care is a highly qualified complex treatment. That you don't have this fear that someone is being shunted off to die.” (T 10, I 87).
Teaching formats of mandatory teaching
“I have case reports and I do them interactively with voting devices. That means patient cases are talked through and […] there are questions about them and of course every question is discussed. […] Naturally I hold my monologues first, so that the basic knowledge is conveyed, but then it continues practically with the cases.” (T 12, I 25).
“I avoid showing any structure or instructive slides. I only show very briefly which facilities there are in Austria, how they are graduated and apart from that I tell patient stories […] These convey much more than anything else in the world” (T 9, I 37–39).
“I think you have to [approach it] with creative methods, like we're trying to do now with the medical comics, where we're putting a lot of effort into using those in the courses to teach very challenging content as well” (T 5, I 89).
“Yes, the seminar is […] a small group lesson, there is a lot of interaction, […] case reports are brought up and then discussed with the students, pros and cons are pointed out and this is just a process of working it out together with the students” (T 2, I 13).
“Sometimes you have teaching courses where no one says anything and you think or you can see that people are playing on their laptops […] and in the seminar I notice that at the beginning it's the same as in all seminars: someone always comes later […] and it's a hustle and bustle and then at a certain point there is absolute silence, so that there is concentration and we always interpret that as interest” (T 6, I 23).
“I am always surprised by how well they familiarise themselves with such a thematic area during the seminar. […] You get the feeling that there is a profound desire to absorb those topics.” (T 10, I 13).
“In theory, everything always sounds completely different than it is in the end for the individual patient.” (T 20, I 19)
“So, I don't think that the frontal lecture is a good tool for this topic. […] Instead I think it is very important that people come into contact with each other, directly.” (T 1, I 90)
“[It is] our goal that every student has seen a palliative care unit once, that means a practical training at a palliative care unit with interdisciplinary case discussions about the patients.” (T 19, I 4).
“I don't want to drag the patient down during rounds. […] You can show things to the student, […] but you shouldn't discuss cases […] at the patient's bedside, […] I don't think much of that.” (T 12, I 57).
“This means that we can only offer theoretical lectures, which is a pity, because I believe that palliative care would benefit greatly from bedside teaching. Which is of course also a huge problem: as I said, we don't have a palliative care unit.” (T 13, I 3).
“You can't just have lectures from morning until evening, it just doesn't work. I think the mix is quite good with lectures and a lot of practical training. Well, that wasn't the case in my studies. […] I went into work very theory-oriented, so I thought at the beginning: I didn't study at all. (laughs) Because then you were suddenly confronted with problems, which you could solve theoretically, but not practically.” (T 2, I 82).
“They often build a lot on active formats and here you have a seminar, and there problem-based learning, and there again physical examination, and there again the simulation patient and this and this and this. And sometimes I think, students don't have enough time for studying by themselves.” (T 21, I 71).
Assessment formats of mandatory teaching
“Well, you won’t fail if you can’t answer the palliative questions. (laughs)” (T 3, I 167)
“It’s not about the exam there, it’s about saying, okay, this topic just interests me, right?” (T 12, I 9)
Other aspects of palliative care teaching
Mandatory teaching versus elective teaching
“At the beginning, they [the students] always say, ‘Yeah palliative…. – I don’t want to become a palliative physician’, but that is always the first thing I say in the lecture: that no matter what specialty they then do later, in every department there are palliative patients that you then have to care for. And I think that often (laughs) the attention is then suddenly higher.” (T 2, I 15).
Elective palliative care teaching
Interprofessional teaching
“[For medical school] I would like to think about: How do you get this interprofessional approach to be tangible and that it's enjoyable as well, and that eventually a complete and successful image can be conveyed.” (T 16, I 45).
“We can only ever say it, more or less strikingly: We have to work in a multi-professional, interdisciplinary way and we need the team and there are meetings here. But that is not practised for the students. […] However, it would be a very important part, especially because it would change the students' view a bit from this (raises fists) 'I am a doctor and I can do everything'.” (T 13, I 71–77).
Clinical practical year
“There is no palliative care unit at the teaching hospital. […] [Instead], you can do an internship [in a hospice facility] voluntarily, you will of course get it recognised somehow, but they are not in the curriculum of the university. […] And this is not applicable for clinical practical year.” (T 13, I 83).
“I: In principle, does the university allow students to do the clinical practical year in palliative care units? – T 3: No, exactly. So that is prohibited so far” (T 3, I 184–185).