Postgraduate training in palliative care

27th November 2018

According to the World Health Organization, approximately 20.4 million people needed palliative care at the end of life in 2011.  CSI research shows that this need is set to escalate dramatically in the next 20 years with an increasing number of people dying of non-cancer disease associated with frailty and multi-morbidity.

Most end of life care (defined as care for patients likely to die within the next 12 months) is provided by generalists, such as general practitioners and specialists in clinical areas not exclusively concerned with specialist palliative care.  Basic symptom management knowledge and skills have been highlighted as areas of particular importance in the training of generalist palliative care providers.  Education is a potential key to achieve an integrated and collaborative model of care for EoLC.

Research published last month in the Journal of Pain and Symptom Management set out to investigate whether training in symptom management improves trainee doctors’ comfort, readiness and knowledge in assessing patients’ symptoms at the end of life.  Symptom management is a priority area within palliative care core competencies for generalist providers.

CSI researchers wanted to determine the effectiveness of training in symptom management in palliative care providers in non-palliative care specialties. The researchers conducted a systematic review of palliative care training within postgraduate medical curricula.

There has been an increase in palliative medicine rotations available at postgraduate level and trainees making use of these report better quality teaching in end of life care and preparedness to treat patients at the end of life.  However even after rotation some physicians felt uncomfortable providing palliative care independently, and reported feeling unprepared to address dying people’s needs.

Researchers found that pocket cards were a feasible and effective strategy to improve trainees’ comfort and knowledge around symptom control in different specialties.  Palliative care hospital wards or hospice rotations could also improve trainees’ knowledge on symptom management.  However the ideal length of rotations to improve learning is unclear.

Researchers identified a need for more rigorous evaluation, and for tools that capture a genuine change in the education outcome measured.  Most training effectiveness was self-assessed.  Other studies have shown a difference between self-assessment and external observation in clinical skills.  Moreover the research identified that physicians who felt the most confident were in fact the least skilled.  This finding was independent of the level of training, the specialty, or the means of assessment.  Measuring doctors’ attitudes alone is insufficient in evaluating the true level of competence. This highlights the need for more patient or family-related outcome measurement in medical education.

The researchers found few controlled studies examining the effectiveness of symptom management training for generalist providers of palliative care and highlight the need for more evidence of its direct impact on patient care.

Turrillas P, Teixeira MJ, Maddocks M. A Systematic Review of Training in Symptom Management in Palliative Care Within Postgraduate Medical Curriculums. J Pain Symptom Management. 2018 Oct 2. pii: S0885-3924(18)30504-9. doi: 10.1016/j.jpainsymman.2018.09.020. [Epub ahead of print]