The organization and implementation of PC and PC training varies widely across countries.(11–13, 20–22) In Belgium, PC, palliative sedation and euthanasia develop synergistically, with euthanasia being an integrated as an option at the end of a PC pathway.(23) Of course, especially this latter option is strictly regulated, requiring doctors to gain insight into both medical and legal connotations at an early stage in their careers. The MD students participating in this study are only one step away from their internships and immediate contact with (palliative) patients. In 2011, Gibbins and colleagues already stated that junior doctors are not adequately prepared for the care of dying patients.(24) Other studies show that the interest of medical students in acquiring PC competencies is high.(25) Despite this fact and even though our respondents showed to have good basic knowledge of PC, many still expressed a need for more dedicated attention to PC and ACP, which is comparable to findings obtained in the United States and Germany.(10, 14)
The greater majority of our students rated their confidence in general communicative skills as good (most notably their empathetic abilities, sense of respect for and knowledge of different cultures and beliefs, and informed consent issues). However, when it came to communication skills specific to PC and ACP (e.g., their ability to cope with a palliative/dying patient, discussing ACP, and negotiating treatment goals), their scores before and after the PC training course reflected far less assuredness, indicating that these specific skills warrant more attention and training during the internships, especially since at this stage of their careers students may underestimate the power of good communication skills in clinical practice. Even when clinical expertise is still developing, verbal and interactive competency can help overcome insecurities and foster a mutually beneficial patient-doctor relationship. In their 2019 study among medical undergraduates in the Netherlands, Pieters et al. report similar findings, most notably that the current curriculum at the time paid too little attention to PC, where the students showed a particular lack of confidence in integrating the spiritual aspect of PC.(26)
Effective communication training has been shown to improve students’ knowledge, attitudes, confidence, empathy, patient-centeredness, interview structure and patient satisfaction.(27) We indeed found that after having completed the PC/ACP classes, our respondents felt more competent in initiating a conversation about ACP than before the training course. However, some topics remained difficult.
First of all, although the self-perceived confidence in discussing the option of a DNR code had improved following the training course, the numbers show there is still ample room for improvement. Clearly, the DNR code has always been a sensitive, emotionally charged subject in every hospital or residential care facility, but during the ongoing COVID-19 pandemic, it has become an even more urgent matter. The students’ trepidations around the issue were more than justified, since the timing and content of a DNR discussion poses distinct challenges. First and foremost, there is the medical aspect, where underlying co-morbidities and chance of recovery play an important role in the decision to expand, continue or restrict therapy for certain patients, which requires communicative competence to convey clearly. But when to broach the subject is another matter and the discussion is regularly postponed or not initiated at all. Although training how to communicate this message can already be helpful for students, it goes without saying that this is a competency that students will develop with time and much practice. We will be launching a new survey to explore the experience of attending physicians and physician assistants with end-of-life and DNR discussions in clinical practice to try and improve the curriculum and prepare students and interns better.
Secondly, the respondents also indicated to find it difficult to inform relatives of the impending or actual death of a loved one. Being another core task that can and should be practiced in a training context using simulation, we added this topic as a new scenario to the simulation class on "breaking bad news".(28) Interestingly, a study by Graf and colleagues described that communication skill training had improved the students’ self-confidence over seven semesters, but that external ratings (standardized patients) of their communicative skills showed a decline.(29)
Lastly and not unexpectedly, confidence scores in resolving or negotiating conflicts were relatively low. Although, during the classes on diversity, we try and provide starting doctors with tools to help them deal with issues arising from differences in cultures, religions and norms and values, where in the simulation we confront them with an angry or aggressive patient, it requires encounters in clinical practice to further develop this skill.
Importantly, in our study offline and online teaching showed similar trends in confidence scores, suggesting that internet-based communication skills training forms a good alternative for traditional practice classes. Requiring fewer teachers than face-to-face practice groups, we, nevertheless, feel that the latter are better suited for training this essential competency.
The question on the implications of the COVID-19 pandemic for ACP showed that the students in our 2020 cohort initially mostly saw practical obstacles for end-of-life conversations such as time constraints, restrictions regarding face-to-face contact and family members visiting, and mouth masks affecting both verbal and non-verbal communication. After having studied a reflective article and discussing views in breakout rooms, more students reflected on the potential of the COVID-19 pandemic in fostering ACP, mentioning among other aspects, the patients’ and caregivers’ heightened self-reflection and the restriction on receiving visitors in the hospital. With this highly topical class, we sought to raise the students’ awareness of events and situations they could utilize as a starting point for entering into end-of-life conversations.
It needs to be noted that our study may be limited in that in our first (2019) cohort, the number of students completing the pot-course survey (T2) was much lower than the number for the baseline assessment survey (T1). This could imply a bias, with only students with a special interest in PC responding at T2. Also, the results presented reflect the state of affairs at our university and relate to our specific PC program, where data of our respondents are not necessarily generalizable to second master’s year MD students elsewhere, given that views and values concerning PC and ACP vary per country and for students from different cultures and origins. Furthermore, ours is a descriptive study without values indicating the statistical significance of the outcomes.
As alluded to above, since besides practice, the acquisition of good communication skills takes time and clinical experience, investigations to gauge PC/ACP related competencies rather than self-perceived adequacy after internships have been launched, where we will be focusing on the aspects and themes that were rated as most challenging (most specifically the DNR code) to thus be able to anticipate on these aspects in our training programs. As Frey and co-authors concluded, to be able to effectively do so, dedicated, standardized tools need to be developed and validated.(18)