Background
The need for knowledge in palliative care is increasing due to the world’s ageing population and the growing incidence of cancer and other non-communicable diseases [
1]. Patients with chronic diseases are becoming increasingly frail and suffer from a wide spectrum of symptoms over months or years before they die. Physicians working in almost all specialties and in many care settings ranging from home and long-term care to outpatient clinics and acute hospitals are often tasked with taking care of these patients.
Despite the increased need for skills in palliative care, medical students and doctors report having insufficient knowledge and training in palliative medicine (PM) [
2‐
4]. Junior doctors often feel unprepared to provide end-of-life care to patients and their families [
5‐
8]. The teaching of PM at medical schools varies widely and is often provided by many disciplines hidden in the syllabus without a clear co-ordination [
9‐
11]. In Europe, no standardized core curriculum in PM exist, and this lack of education is stated as one of the barriers to the development of palliative care [
12].
The European Association for Palliative Care (EAPC) regards education in PM for health care professionals to be highly important. Therefore, the EAPC steering group has made recommendations for undergraduate curricula in PM to be utilized at medical schools in Europe [
13]. This 40-hour curriculum includes seven main domains of PM integrated in to six sections with a suggested split of the syllabus as well as recommendations for educational strategies and assessment methods [
13]. Although many Universities in Europe have a curriculum in PM, their congruence with the recommendations of the EAPC is widely unspecified [
9].
In Finland, five universities have a Faculty of Medicine. The University of Tampere has had a chair in PM since 1999 and the University of Helsinki has had one since 2014, while all the other universities lack this professorship. The School of Medicine at the University of Tampere implements a problem-based learning method in a vertically integrated spiral curriculum [
14]. The planning of the curriculum was initiated in 1994 when the School of Medicine started to completely innovate its undergraduate medical education. As a new medical subject, PM was gradually integrated into the curriculum following the establishment of PM as a new discipline in 1999. In Finland, Tampere University has thus far been the only university to establish a curriculum in PM.
The aims of this study were 1) to evaluate the undergraduate curriculum in PM at the University of Tampere by using the EAPC recommendations as a reference tool and 2) to evaluate the efficacy of this education by assessing the medical students’ knowledge in PM.
Discussion
We described the curriculum of PM at the University of Tampere, which integrated the education offered in many specialties in addition to the discipline of PM and compared favorably to the recommendations of the EAPC. Medical students demonstrated increasing knowledge in PM during their studies and they found the teaching very valuable.
In Finland, only the University of Tampere has a formal curriculum in PM thus far, while the other four universities with medical faculty are in the planning phase of a PM curriculum. The teaching in palliative care has increased at medical schools in many countries, but its availability still differs between universities [
18,
19]. A recent study from 43 European countries demonstrated that 28 (65%) of the countries include PM in the curriculum of at least one of its medical schools, but teaching in PM in all universities was compulsory in only six (14%) of the countries [
19].
Many medical schools report teaching PM, but the exact content of this education is either unknown or differs markedly [
9,
18,
20]. In the medical schools of the USA, education in PM ranges from 2 hours of lecturing to weeks of patient contacts and clinical training [
11]. A recent systematic review by DeCoste-Lopez et al. revealed a similar variation in the length and contents of PM education around the world, including reports from Europe. Notably, many of the curricula were not described in enough detail to achieve even basic information about the palliative care topics covered [
20]. Our study shows that the curriculum in PM at the University of Tampere is compliant with the recommendations made by the EAPC. In addition to lecturing, the teaching also included interactive and experiential methods such as patient encounters in hospital wards and hospice, which are also supported by the EAPC [
13]. In fact, after the addition of the two-days teaching session (Symptom management in palliative care) in 2012, the total hours of teaching issues of PM exceeded the recommended curriculum. This was especially true for pain and symptom management, while education concerning psychosocial and spiritual aspects together with teamwork and self-reflection did not meet the criteria of the EAPC. Psychosocial aspects are of great importance when facing patients with incurable diseases. Additionally, working in multidisciplinary teams is mandatory in the field of PM. Therefore, these aspects should scrutinized when both developing our formal nationwide core PM curriculum and ensuring the provision of a true holistic undergraduate curriculum without overloading it with symptom control issues.
We found that at the University of Tampere different palliative care issues are taught by many other specialties in addition to the discipline of PM. This is important since symptom-centered care should be integrated in the treatment of every patient suffering from incurable disease (so-called horizontal integration). The amount of teaching concerning issues of PM increased closer to graduation from our medical school. Preclinical studies concentrated in the basics of palliative care and pain management, while broader knowledge in PM was achieved during clinical studies (so called vertical integration). This horizontal and vertical integration is also found in some other universities and is recommended by the EAPC [
13,
21]. However, a formal curriculum in PM is needed to co-ordinate teaching between many specialties and to optimize the content of teaching to ensure the overall knowledge and experience of the students.
We included all teaching from the electronic learning platform with topics and content concerning PM. However, there was no detailed cross-linking of single issues between different teaching lessons, and there might still be training hidden in the syllabi, since some teaching, such as discussions of patient cases in problem based learning and in clinical rounds on wards, probably contained aspects of PM. Thus, our evaluation offers a good overview of the curriculum in PM but has limitations in giving a detailed description of all PM issues covered in the teaching.
Earlier studies have revealed increased skills in palliative care among medical students after receiving education in PM [
22,
23]. A recent study by Gerlach et al. showed that a course consisting of seven times 90-minute classes in palliative care increased medical students’ self-confidence concerning somatic, spiritual and psychological aspects of PM and resulted in high knowledge in a post-course test [
24]. Education in PM may also help to adapt patient-centered care in general [
25]. However, most of these studies have concentrated on the short term effects of a single course of PM education [
20,
23,
24]. We tested the knowledge among medical students at different times in their studies through the whole curriculum in PM. The increase in the knowledge measured by a multiple-choice progress test started after the first teaching sessions provided by the discipline of PM during the third year and continued through the largest teaching sessions in PM in fifth and sixth years of medical school. Although we suggest that this increase in knowledge was mainly due to the increased teaching in different aspects of PM, it may also have been bolstered by more student encounters with patients suffering from incurable diseases during their studies at medical school. In addition, the students who had taken part in the optional course in PM achieved better results when compared with the others. The difference was largest among the fourth and fifth year students, when the obligatory teaching of PM was still sparse but remained significant among the graduating students.
Although our results clearly demonstrate the benefits of teaching PM, we acknowledge some limitations in our evaluation. First, only about half of the sixth-year students took part in their last progress test in February 2014–2016. Although their knowledge in PM increased and the effect of the optional course remained until sixth year at medical school, the final benefit of the curriculum at time of graduation and later is slightly uncertain. Second, students during their last years at medical school might have achieved some general experience in predicting the right answers on multiple choice tests compared to younger students. However, as the questions were changed in every progress test and as the students lost 0.5 point for a wrong answer, we suggest that trying to guess the right answer was uncommon. Third, progress tests do not evaluate all aspects of palliative care, as they are more suitable for verifying medical knowledge than qualities such as psychosocial caring, ethics and communication skills. Further studies are needed to evaluate the long-term effects of the whole PM curriculum after graduation. Such an evaluation should try to include patient outcomes and behavioural aspects, including communication skills and empathy assessments in addition to symptom control issues, as suggested in other reports [
13,
22,
24]. The impact of the curriculum on students’ career choices and participation in undergraduate education in PM should be further studied as well.
Feedback concerning the teaching of PM was achieved from the largest session (Symptom management in palliative care). Although this covers only about one-fifth of all the teaching in PM, the results reflect the positive views of the students. The quality of the teaching and its benefits in terms of achieving its aims were graded especially high. In Finland, medical students are allowed to work as junior doctors after their fourth year at medical school. Thus, most of the students had been challenged by caring for a dying patient before this teaching session, which probably increased their motivation for PM education. The other explanation could be the interactive nature of teaching in small groups instead of simple lecturing. Basics in PM should be taught early, but we suggest that more advanced learning is best achieved when its clinical context is understood. A formal assessment of the learning needs of the students, especially after their first contacts with dying patients, might be helpful for further development of the curriculum. Our results are in line with previous studies showing that education in PM is appreciated by medical students as well as by physicians [
25‐
27].
Acknowledgements
We thank all the teachers and learning coordinators in the Faculty of Medicine and Life Sciences of the University of Tampere, Finland, for providing the detailed information about the total syllabus. Especially, we give our warmest thanks to Mrs. Tarja Lehto for her great assistance.