The students participating in this study are only one step away from their internships and their immediate contact with possible palliative patients. At this stage, a large proportion of students indicate that there is not enough time spent on palliative care and advance care planning. At the University of Antwerp, very limited time is spend on this topic at the moment. Despite this fact, students have a good background medical knowledge around palliative care.
Our study shows that students score themselves overall as being confident in general communicative skills (e.g.. empathically engage in a conversation, have respect for different cultures and believes, ask for informed consent). However, when it comes to communicative skills specific to palliative care and advance care planning (e.g. able to cope with a palliative/dying patient, discuss advance care planning, negotiate treatment goals), they score themselves as being non-confident before the lesson and insufficient-confident after the lesson. These specific skills need to be intensively trained during the internships. Students may underestimate the power of good communication skills in clinical practice. Even in situations where own clinical expertise is lacking, good communication can help overcome insecurities and improve patient-doctor relationship.
We see from the results that after the specific lessons, the students feel more competent to start a conversation about advance care planning. A few topics remain difficult. First of all, when we look at the topic 'discussing DNR code’, we see that this skill clearly improves after the lesson, but that there is still room for further improvement. Discussing a DNR-code is a very important issue in every hospital (and residential care facilities). Especially during the covid pandemic, it turned out that this is not obvious. It therefore seems to us to be a correct judgement of the students to label this skill as difficult. The difficulty of a DNR discussion is twofold. On the one hand, there is the medical aspect where underlying co-morbidities play an important role in the possible decision to restrict therapy. On the other hand, the timing and how to initiate this conversation, is an important communication skill that is regularly violated in practice. It goes without saying that this is a skill that students will only develop over time and with practice. Communicating this message in the lesson itself can already be helpful for students. This does not alter the fact that this remains a topic on which further work is needed. To explore this further, we have created a new survey to explore how this impacts physicians and physician assistants in clinical practice. Secondly, students also indicate that they find it difficult to inform relatives that a patient has died or will die soon. In our opinion, this seems to be a situation that can be practised on.(15) Telling the family that a patient is dying or has died is an important task as a doctor. Every doctor should be able to do this. Because of this result, we decided to implement a new scenario during the lesson "breaking bad news" in which the student has to tell a simulation patient that a family member is shortly going to die. Lastly, resolving or negotiating conflicts is scored as a difficult topic. Here, too, we share the view that this remains a difficult topic in practice. During the lesson on diversity, we try to provide tools for doctors to deal with other cultures, religions, norms and values. There is also a specific lesson in which we work with a potentially angry or aggressive patient. Further experience in practice is needed to develop this skill.
Another important result is that we notice the same trend in confidence scoring when teaching in real life or teaching online. Therefore, in the context of student’s self-confidence, online teaching forms a good alternative for the intense and focused group discussions. This could be of great importance as there are less teachers needed for teaching online compared to teaching these skills face-to-face in focused and limited groups. Nevertheless, for the effective learning of these communication skills, it seems appropriate to be able to teach these lessons in real-life.
The extra survey question regarding the covid-19 pandemic showed that students first of all think about the possible practical obstacles for end-of-life conversations (time constraints, little face-to-face contact, absence of family members, annoying aspect of mouth masks in both verbal and non-verbal communication, ...). After a reflective article as well as bringing it up in class, more students saw the possible benefits of the pandemic (self-reflection of patients, norms and values of individuals and families, the impossibility of receiving visitors during hospitalisation, …). With this lesson, we initiated a more considerate attention in students to recognise challenging situations as a starting point for entering into end-of-life conversations.
As possible limitations for our study we note that in the first year of our research, response for the second survey was much lower than for the first survey. This could possibly imply a selection of students with specific interest in the topic palliative care. Also, this study only provides a picture of the situation at our own university.