The workplace and psychosocial experiences of Australian junior doctors during the COVID-19 pandemic

Mandatory research projects during medical specialist training in Australia and New Zealand: a survey of trainees' experiences and reports

OBJECTIVE

To determine how many specialist trainees are required to conduct research projects, how they conduct these studies, and their views on the value of these activities; to assess the design and reporting quality of their research reports.

STUDY DESIGN

Online, anonymous survey.

SETTING, PARTICIPANTS

Current and recent trainees (past five years) at Australian and New Zealand specialist colleges, recruited through eleven colleges and snowballing; survey was available 31 March - 31 December 2021.

MAIN OUTCOME MEASURES

Whether trainees were required to conduct research as part of specialty training; how they conducted their projects; the skills mix of the project team and access to relevant expertise and supervision; trainee views on mandatory research during specialty training; research engagement after training. Respondents were invited to submit project reports for reporting and methodological quality evaluation.

RESULTS

A total of 371 people commenced the survey; 361 respondents provided answers about mandatory research projects during specialist training, including 311 (86%) who had been required to complete projects. Seventy-six of 177 people who had completed projects (43%) provided information about 92 projects and submitted 34 project reports for evaluation. Thirty-eight projects (41%) investigated questions developed by the trainees alone; in 48 cases (52%) trainees had planned their projects with little outside input; of the 69 study protocols developed (75% of projects), 60 were developed by the trainees. The median proportion of time devoted to the research project exceeded 50% for trainees in ten of twelve colleges. Respondents typically worked in non-collaborative teams, restricted to members of their own specialty, and additional expertise was limited to statisticians, allied health professionals, and nurses. Eighty-seven of 174 participants who had completed projects (50%) felt that doing so was very or moderately important for their clinical careers; 36 of 67 respondents (54%) supported the requirement for scholarly projects during specialty training; 33 of 61 respondents (54%) had participated in research after completing training, and 44 (72%) had considered doing so. Twenty-five of 34 available reports had been published; in 27 assessable reports, methods and results reporting was generally poor, and the risk of bias moderate to high in all but three. Participants criticised using their own time for projects and their potentially low quality results.

CONCLUSION

For trainees who undertake specialty training, the time commitment and poor quality research associated with mandatory research projects were frequently concerns. Medical colleges should focus on research training tailored to individual career aspirations and training needs.

Benefits of a near-peer program from the tutors' perspective: a survey of Australian junior doctors in a regional teaching program

BACKGROUND

Near-peer teaching has been shown to provide diverse benefits for both tutees and tutors in senior medical student and junior trainee settings. However, junior trainees may face more obstacles in teaching including competing clinical priorities and time management. We sought to investigate the challenges and benefits of engaging in near-peer teaching for junior trainees within our local context. Our Near-Peer Medical Teaching (NPMT) teaching program is designed and facilitated by junior doctors for medical students at the Central Coast Clinical School (University of Newcastle) of the Joint Medical Program.

METHODS

Current and past NPMT tutors participated in an online survey from October 2022 to April 2023. Tutors were asked about feasibility of teaching within a work environment, perceived benefits from their experience and attitudes towards medical education.

RESULTS

Teaching experience appears to be influenced by competing clinical priorities and convenience of session times, but it does not appear to exert considerable stress on tutors likely due to self-selection of tutors with prior enjoyable teaching experience. Furthermore, this study indicates that junior doctors derived enjoyment and developed clinical skills and professional qualities, which are important factors in increasing job satisfaction and ameliorating burn-out in this cohort.

CONCLUSIONS

Junior doctors appear to benefit from engaging in near-peer programs in the Australian teaching hospital setting. Further research should include qualitative methodologies to explore the perspectives of Australian junior doctors' more deeply.

Manifesting change: an organisation's approach to burnout, recruitment, and retention of junior doctors in Western Australia

Facing unprecedented levels of junior medical officer (JMO) vacancies, absenteeism, and burnout, the Sir Charles Gairdner Osborne Park Health Care Group (SCGOPHCG) collaborated with JMOs to create and implement the JMO Manifesto in January of 2023. With the aim of improving the organisation's attraction, recruitment, and retention of JMOs, this initiative consisted of five strategic imperatives that addressed key workplace issues affecting JMOs: (1) part-time work opportunities, (2) access to leave and (3) overtime pay, (4) limited support for workplace issues (particularly after-hours), and (5) poor workplace culture and bullying. Led by the Clinical Services team, the JMO Manifesto was an investment in building JMO wellbeing, trust, and engagement with simple but innovative strategies. The effectiveness of these strategies was evaluated by comparing pre- and post-JMO Manifesto results from routinely collected organisational data (e.g. vacancy rates) and JMO feedback through the annual Hospital Health Check survey by the Australian Medical Association. Within 6months, the SCGOPHCG was fully recruited, had created 35 new part-time positions and new processes for managing leave, overtime claims, and support for JMOs. Eighteenmonths in, we remain the top-ranking public health service provider for access to leave, claiming of un-rostered overtime, workplace culture and morale, and wellbeing support for JMOs in Western Australia. The JMO Manifesto highlights the importance of healthcare organisations investing in the engagement and wellbeing of their junior doctors to achieve a sustainable medical workforce.

Healthcare workers' well-being and perspectives on support during the COVID-19 pandemic: a systematic review and meta-synthesis of qualitative studies

BACKGROUND

Since the outbreak of the COVID-19 pandemic, healthcare workers (HCWs) have faced multiple difficulties in their work and personal lives. However, most of the quantitative reviews have focused on the extent of the pandemic's impact on the HCWs and have thus failed to fully capture the HCWs' experiences and the complexity of the problems they encountered. Therefore, this qualitative systematic review elucidates the HCWs' challenges brought about by the pandemic, their perceptions of the existing support and the support that require further attention.

METHODS

The literature search spanned five databases: Scopus, PubMed, Web of Science, CINAHL and PsycInfo, targeting qualitative studies of HCWs' pandemic experiences from December 2019 to December 2023. These studies underwent strict quality and relevance assessment, emphasising critical appraisal and selection. Findings were unified through meta-synthesis, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The study was registered in PROSPERO.

RESULTS

This study analysed 29 qualitative studies on HCWs' experiences during the pandemic and their perceptions of support, identifying four themes of HCWs' physical and mental well-being, the impact of the pandemic on their professional and personal lives, their work environments and the support they received. These themes encompassed 8 main categories and 25 codes. The research revealed that the pandemic and work conditions negatively influenced their health, affecting their professional and personal lives. Current support has lessened the pandemic's effects on HCWs but should also address future requirements like long-term psychological support.

CONCLUSION

The studies identified the challenges faced by HCWs during the pandemic, and the existing support. However, due to the complex interactions between the work and environmental factors, the effectiveness of the existing support remains challenging. To improve their effectiveness, the future support should target the interactions between the HCWs and the work system.

PROSPERO REGISTRATION NUMBER

CRD42023426238.

Revisiting the conceptualisation and implications of medicine's 'hidden curriculum'

In medical training and practice, our professional attributes, attitudes, perceptions, character traits and identities are fundamentally shaped by our lived experiences and observations in clinical and para-clinical settings instead of being inculcated through formal curriculum or classroom teaching. For instance, clinical acumen, communication skills and bedside manners are learnt through role modelling and experiential learning in the course of clinical rotations. Likewise, one's attitudes, professional behaviours and inclinations are often also influenced by direct/indirect observations of the actions of others in the medical fraternity in various clinical and non-clinical settings. This is also what is often termed as the 'hidden curriculum' of medicine. In this article, we sought to provide a practical conceptualisation of the hidden curriculum in medical training, which we describe as lived experiences and personal observations of medical trainees and residents in clinical and para-clinical spaces, which shape their perceptions of the medical profession (vocational identity and purpose), patients (patient-physician relationship) and colleagues (intra- and inter-professional relationships), with downstream implications on physician well-being and clinical decision-making. Although this idea of a 'hidden curriculum' has conventionally carried predominantly negative connotations in medical literature, we suggest that it is an inevitable part of medical education and practice, which, through deliberate regulation, can potentially be shaped to create more positive and meaningful effects in the professional development of medical trainees.

Coronavirus pandemic derived demands and inclusive leadership on junior doctors' well-being

BACKGROUND

International studies have revealed that numerous challenges (e.g. job demands) and opportunities (e.g. job resources as protective factors) affect the well-being of healthcare workers.

AIMS

Building on the job demands-resources theory, we explored how job-related demands and the role of inclusive leadership as a job resource influenced the well-being of junior doctors during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

A cross-sectional web survey was conducted in July 2022 for 82 junior doctors who had experienced the 3-year COVID-19 pandemic. The survey captured their perceived physical, psychological and COVID-19-related job demands and the inclusive leadership behaviours exhibited by their clinical unit supervisors as job resources. Data were also collected on junior doctors' experiences of burnout, compassion satisfaction and occupational commitment as variables of job outcomes. Hierarchical linear regression analysis was applied to explore the relationships between the variables.

RESULTS

Physical and COVID-19-related job demands were associated with increased burnout among junior doctors. Inclusive leadership as a job resource was associated with junior doctors' reduced burnout and increased compassion satisfaction and buffered the negative effects of psychological demands on their compassion satisfaction. Only COVID-19-related job demands were associated with junior doctors' occupational commitment.

CONCLUSIONS

Our study highlights the critical effects of COVID-19-related job demands on junior doctors' burnout and occupational commitment. Inclusive leadership behaviours exhibited by clinical unit supervisors are a valuable job resource, which can be incorporated as one of the competencies training for medical staff.

Work-related impacts on doctors' mental health: a qualitative study exploring organisational and systems-level risk factors

BACKGROUND

Protecting doctors' mental health has typically focused on individuals, rather than addressing organisational and structural-level factors in the work environment.

OBJECTIVES

This study uses the socioecological model (SEM) to illuminate and explore how these broader factors inform the mental health of individual doctors.

DESIGN

Semi-structured interviews (20-25 hours) and ethnographic observations (90 hours) involving work shadowing doctors (n=14).

PARTICIPANTS

Doctors representing various career stages, specialty areas, genders and cultural backgrounds.

SETTING

Three specialties in a public South Australian hospital. Thematic analysis revealed work-related risk factors for poor mental health.

RESULTS

The SEM framework was used to analyse the work environment's impact on doctors' mental health. The analysis identified how the layers interconnect to influence risk factors for individual doctors. Microsystem: lack of control over career advancement, disenfranchisement due to understaffing and concerns about handling complex cases relative to experience. Mesosystem: negative impacts of shift work and fragmented teams, leading doctors to absorb pressure despite exhaustion to maintain professional credibility. Exosystem: high patient loads with time constraints and geographical limitations hindering care delivery, compounded by administrative burdens. Macrosystem: the commercialisation of medicine emphasising corporatisation and bureaucratic processes, which devalues professional autonomy.

CONCLUSIONS

This study highlights how doctors experience layers of interconnected factors that compromise their mental health but over which they have very little control. Interventions must therefore address these issues at organisational and systemic levels, for which starting points evident within our data are identified.

In the shoes of junior doctors: a qualitative exploration of job performance using the job-demands resources model

Background

This qualitative study aimed to explore the factors affecting job performance amongst junior doctors working for public healthcare institutions in Singapore. Within these institutions, junior doctors experience challenges with maintaining a balance in job demands and resources, leading to strain. Exploring the lived experiences of these junior doctors is essential when reviewing workplace and organizational factors that contribute to stress on an individual level, providing valuable insights to address these challenges effectively.

Method

Semi-structured interviews were conducted with 20 junior doctors in Singapore, ranging from house officers to senior residents. Framework analysis was performed on transcribed de-identified interviews to identify themes deductively based on the Job Demands-Resources (JD-R) Model.

Results

Themes were identified and contextualized based on the exiting JD-R model. These themes shed light on how work demands, resources and personal factors influence the job performance of junior doctors and job satisfaction.

Conclusion

The study offers valuable insights into the specific issues disrupting the job demands and resource balance in Singapore Public Healthcare Institutions and their correlation with job performance. Our data suggests that job performance may be associated with job satisfaction. By understanding these factors, targeted efforts can be developed to improve working conditions for junior doctors, fostering their growth and engagement within the public healthcare system.

Can compassionate leadership of senior hospital leaders help retain trainee doctors?

BACKGROUND

High burnout and low retention rates among trainee doctors threaten the future viability of the UK medical workforce. This study empirically examined factors that can sustain trainee doctors.

METHOD

A total of 323 trainee doctors from 25 National Health Service (NHS) Trusts in England and Wales completed an online survey on their training and employment experiences. A mixed method approach was employed.

RESULTS

Structural equation modelling revealed that perceived compassionate leadership of hospital senior leaders (CLSL) (i.e., doctors in senior clinical and management positions, and senior managers) is directly and negatively associated with trainee doctors' burnout and intention to quit. We propose the associations may be indirectly strengthened through two mediating pathways: increased psychological contract fulfilment (PCF) of training/organisational support and reduced worry about the state of the NHS; however, only the former is supported. The model can explain a substantial 37% of the variance in reported burnout and 28% of intention to quit among trainee doctors. Being a Foundation Year (FY) trainee was significantly associated with poor PCF and burnout. Rich qualitative data further elaborated on their experiences in terms of senior leaders' awareness of their training/working experiences, listening to and acting on.

CONCLUSIONS

Active and demonstrable CLSL plays a vital role in trainee doctors' retention. It has both direct (through support) and indirect effects through improving trainee doctors' PCF to reduce burnout and intention to quit. This seems particularly valuable among FY doctors. Implications for the development and management of the medical workforce are discussed.

The benefits, barriers and facilitators of mentoring programs for first-year doctors: A systematic review

INTRODUCTION

The transition from medical student to first-year doctor is notoriously difficult, yielding a high rate of transition failure, burn-out and mental health deterioration. Doctors in this cohort experience unique challenges during this time, which manifest through performance gaps, issues of professional identity, new occupational pressures, and cultural expectations. Mentoring programs are commonly utilised in the medical profession to foster personal and professional development and improve psychosocial well-being and career satisfaction. However, there exist no systematic reviews examining the use of mentorship specifically for the first-year doctor cohort, given the unique transition challenges faced by this vulnerable group.

PURPOSE

Due to their transition difficulties, evaluate the research on mentorship specifically for first-year doctors, and identify the emerging themes that can inform the benefits to this group, the barriers that impede program implementation and the facilitators that contribute to successful mentorship programs for this cohort.

MATERIALS AND METHODS

The PEO (population, exposure outcome) framework was adopted to develop the research inquiry, after which, a systematic review was conducted, adhering to PRISMA guidelines. The search strategy was conducted with assistance from an experienced university librarian. Screening and selection were completed independently against inclusion/exclusion criteria, by two reviewers. The methodological quality of included studies was assessed using Joanna Briggs critical appraisal instruments. Data sources used included Web of Science Medline, Ebsco Cinahl Plus, Scopus, Web of Science Core Collection and Ovid Journals. Search parameters were restricted to English language and peer-reviewed; date range was unobstructed up to 26 August 2022.

RESULTS

A total of 4137 articles were retrieved, with 13 considered to have met full inclusion criteria. An integrative review synthesis identified three major themes; benefits of mentoring for first-year doctors, intrinsic and extrinsic barriers to mentoring programs and facilitating factors that improve successful program implementation.

CONCLUSION

First-year doctors report untenable and highly strenuous working conditions, that result in poor mental health and high attrition rates. Formalised, near-peer, tier mosaic mentoring programs provide significant psychosocial and career benefits to this cohort specifically, bridge the training gap from medical student to first-year doctor and ameliorate patterns of intergenerational bullying, hierarchy and emotional inhibition. However, mentorship is inextricably interrelated to societal-cultural considerations of identity. Mentorship alone cannot overcome endemic cultural challenges within medicine without broader systemic change; however, programs are a valuable option towards positive support for first-year doctors.

A scoping review of mental health status in Australian medical students and doctors-in-training (DiT)

Background and Aims

The study and practice of medicine are known to contribute to burnout in medical students and junior doctors. There is limited data on the degree of mental health burden for Australian medical students and doctors-in-training (DiT). This scoping review aims to explore the impact of medical training on the mental health of Australian medical students and DiT. Exploring the mental health landscape across different stages of training will help to establish putative factors underlying psychiatric comorbidities in this demographic.

Methods

The Joanna Brigs Institute (JBI) framework for scoping review was utilized, involving the Population/Concept/Context (PCC) criteria to identify the target population and develop the search strategy. Peer-reviewed articles, published in English from 2012 to 2022 focusing on Australian medical students' and doctors-in-training mental health were considered.

Results

Of the 177 articles identified, 24 studies were included in the review. The majority of the studies focused on DiT (n = 19) of which interns and residents were most well represented (n = 12) followed by surgical training (n = 5), with general practice (GP) (n = 2) and physician specialties (nil) being poorly represented. Most studies were quantitative (n = 18), with qualitative studies(n = 6) under represented. Common mental health themes identified were overall psychological distress, burnout, and depression/suicidal ideation with workplace harassment and discrimination being less well represented.

Conclusions

Australian DiT are not equally represented in the literature with how different specialty training pathways impact their mental health. Most studies were cross-sectional, preventing a detailed longitudinal assessment of burnout and work-associated psychological distress.

Integrating training in evidence-based medicine and shared decision-making: a qualitative study of junior doctors and consultants

BACKGROUND

In the past, evidence-based medicine (EBM) and shared decision-making (SDM) have been taught separately in health sciences and medical education. However, recognition is increasing of the importance of EBM training that includes SDM, whereby practitioners incorporate all steps of EBM, including person-centered decision-making using SDM. However, there are few empirical investigations into the benefits of training that integrates EBM and SDM (EBM-SDM) for junior doctors, and their influencing factors. This study aimed to explore how integrated EBM-SDM training can influence junior doctors' attitudes to and practice of EBM and SDM; to identify the barriers and facilitators associated with junior doctors' EBM-SDM learning and practice; and to examine how supervising consultants' attitudes and authority impact on junior doctors' opportunities for EBM-SDM learning and practice.

METHODS

We developed and ran a series of EBM-SDM courses for junior doctors within a private healthcare setting with protected time for educational activities. Using an emergent qualitative design, we first conducted pre- and post-course semi-structured interviews with 12 junior doctors and thematically analysed the influence of an EBM-SDM course on their attitudes and practice of both EBM and SDM, and the barriers and facilitators to the integrated learning and practice of EBM and SDM. Based on the responses of junior doctors, we then conducted interviews with ten of their supervising consultants and used a second thematic analysis to understand the influence of consultants on junior doctors' EBM-SDM learning and practice.

RESULTS

Junior doctors appreciated EBM-SDM training that involved patient participation. After the training course, they intended to improve their skills in person-centered decision-making including SDM. However, junior doctors identified medical hierarchy, time factors, and lack of prior training as barriers to the learning and practice of EBM-SDM, whilst the private healthcare setting with protected learning time and supportive consultants were considered facilitators. Consultants had mixed attitudes towards EBM and SDM and varied perceptions of the role of junior doctors in either practice, both of which influenced the practice of junior doctors.

CONCLUSIONS

These findings suggested that future medical education and research should include training that integrates EBM and SDM that acknowledges the complex environment in which this training must be put into practice, and considers strategies to overcome barriers to the implementation of EBM-SDM learning in practice.

The impact of pandemics on healthcare providers' workloads: A scoping review

AIMS

To review and synthesize available evidence exploring the impact of pandemics on direct healthcare providers' workloads in the acute care setting.

DESIGN

Scoping review.

DATA SOURCES

A review of English research articles published up to August 2022 that examined the impact of pandemics on healthcare providers' workloads was undertaken. Studies were identified by searching four electronic databases: Medline (EBSCO), CINAHL (EBSCO), Web of Science and PsychInfo (EBSCO). Fifty-five studies met the inclusion criteria.

REVIEW METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses Scoping Review checklist.

RESULTS

Healthcare workers experience an increase in workload pressures during a pandemic. This included patients requiring more care, undertaking non-normal work activities, increase in work content including changes to documentation, increase in demand and skills required, an increase in overtime and hours of work per week and higher patient-to-nurse ratios. The review also highlighted changes to the work environment and worsened work environments, including staffing shortages.

CONCLUSION

Focused efforts from health organizations to prioritize supportive conditions, policies focused on improved work environments, staffing adequacy and fair and reasonable workloads will enhance retention of the current workforce and future planning for pandemics.

IMPACT

Understanding workload challenges faced by frontline health professionals during the pandemic can improve planning, including policies and procedures, and resource allocation for future pandemic or emergency situations. In addition, extended periods of high workloads can impact staff retention. As many countries return to life after COVID-19, it is important that healthcare organizations examine staff pressures and identify ways to support staff moving forward. This will be vital for the future sustainability of the workforce.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Mental health, psychological distress and burnout in Australian dental practitioners

BACKGROUND

Dental practitioners are known to experience a high level of stress, but little is known about the mental health of Australian dental practitioners. The aim of this study was to investigate the prevalence of mental health conditions among Australian dental practitioners.

METHODS

A cross sectional survey of 1483 Australian dental practitioners was carried out from October to December 2021. Participants reported aspects of mental health including depression, anxiety disorder, burnout (Sydney Burnout Measure) and psychological distress (Kessler Psychological Distress Scale and General Health Questionnaire 12).

RESULTS

Self-reported psychological distress was high, with 32.0% rated as having moderate or severe psychological distress and 59.4% a high likelihood of minor (or more severe) psychological distress. One in four participants (24.8%) were classified as likely to be experiencing burnout, with 25.9% reporting ever having a diagnosis of depression, 11.4% a current diagnosis of depression, 23.1% ever having a diagnosis of anxiety disorder and 12.9% a current diagnosis of anxiety disorder.

CONCLUSION

Australian dental practitioners reported a high burden of psychological distress, burnout and mental health issues, suggesting a need for education and programmes to support their mental health and wellbeing. © 2023 Australian Dental Association.

Gender Differences in Professional Adversities and Mental Health Among Surgical and Nonsurgical Medical Trainees: An Internet-Based Survey

BACKGROUND

Physicians in training face a variety of stressors throughout their professional development and according to their gender. Among them, surgical trainees appear to be especially at risk for mental health problems.

OBJECTIVE

The aim of the present study was to compare demographic features, professional activities and adversities, depression, anxiety, and distress among men and women trainees of surgical and nonsurgical medical specialties.

DESIGN AND PARTICIPANTS

A cross-sectional, retrospective, comparative study was conducted on a total of 12,424 trainees (68.7% nonsurgical and 31.3% surgical) from Mexico through an online survey. Demographic features, variables related to professional activities and adversities, depression, anxiety, and distress were evaluated through self-administered measures. Comparative analyses using the Cochran-Mantel-Haenszel test for categorical variables and multivariate analysis of variance including medical residency program and gender as fixed factors to test their interaction effect for continuous variables were used.

RESULTS

An important interaction between medical specialty and gender was found. Women trainees from surgical specialties report more frequent psychological and physical aggressions. Women from both specialties had higher distress, significant anxiety, and depression than men. Men from surgical specialties worked more hours per day.

CONCLUSIONS

Gender differences are evident in trainees for medical specialties, with a larger impact in surgical fields. Mistreatment of students is a pervasive behavior that affects society as a whole, and actions to improve learning and working environments in all medical specialties, but mostly in surgical fields, are urgently needed.

'Now I can train myself to be with death': a phenomenological study with young doctors in care homes supported by a palliative care unit during the second wave of the pandemic in Italy

OBJECTIVE

During the second wave of the COVID-19 pandemic, one of the organisational strategies established by the Italian National Health System was the special units for continuity of care (SUCCs). In the province of Ravenna, those units enrolled novice doctors to care for elderly patients with COVID-19 in care homes (CHs). The local palliative care (PC) unit decided to offer consultations and support to them. This study aimed to comprehend the experience of young doctors who asked for consultations when facing, during their first early years of practice, complex situations.

DESIGN

We conducted a qualitative study employing a phenomenological approach and in-depth interviews.

PARTICIPANTS

We involved 10 young doctors who worked in Italian SUCC during the pandemic and used a PC consultation support service.

RESULTS

What describes our participants' experience is related to four main themes: (1) reducing distances, (2) perceiving medical futility and improvising, (3) being supported to learn how to be with death and (4) narrowed timing to humanise care. The pandemic was, for our participants, a moment of reflection and critique on the skills acquired during the university course. It was a strong experience of human and professional growth that helped them reshape and deepen their role and skills, incorporating the approach of PC into their professional identity.

CONCLUSIONS

Integration between specialists and young doctors with an early entry into the workforce during the pandemic in CHs set out a 'shift' to a proactive and creative approach through a new awareness of professional and personal roles in doctor-patient relations. The continuity of care models should be rethought by integrating CHs and PC. Adequate PC training for young doctors (at pregraduate and postgraduate levels) can change doctors' vision and daily practice in assisting patients at the end of life.