[Clinical acute and emergency medicine curriculum-focus on internal medicine : Recommendations for advanced training in internal medicine in the emergency department]

In Germany, physicians qualify for emergency medicine by combining a specialty medical training-e.g. internal medicine-with advanced training in emergency medicine according to the statutes of the State Chambers of Physicians largely based upon the Guideline Regulations on Specialty Training of the German Medical Association. Internal medicine and their associated subspecialities represent an important column of emergency medicine. For the internal medicine aspects of emergency medicine, this curriculum presents an overview of knowledge, skills (competence levels I-III) as well as behaviours and attitudes allowing for the best treatment of patients. These include general aspects (structure and process quality, primary diagnostics and therapy as well as indication for subsequent treatment; resuscitation room management; diagnostics and monitoring; general therapeutic measures; hygiene measures; and pharmacotherapy) and also specific aspects concerning angiology, endocrinology, diabetology and metabolism, gastroenterology, geriatric medicine, hematology and oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology and toxicology. Publications focussing on contents of advanced training are quoted in order to support this concept. The curriculum has primarily been written for internists for their advanced emergency training, but it may generally show practising emergency physicians the broad spectrum of internal medicine diseases or comorbidities presented by patients attending the emergency department.

The outcomes of postgraduate palliative care education and training: assessment and comparison of nurses and physicians

BACKGROUND

Within Germany, there is a heterogeneous range of training and continuing education in palliative care for different professional groups. The German Society for Palliative Medicine (DGP), together with the German Hospice and Palliative Care Association (DHPV), have defined quality requirements for postgraduate training in palliative care. These requirements include the evaluation of course structures and the assessment of outcomes.

AIM

To assess the 'learning gains' in palliative care nurses and physicians undertaking continuing education programmes, and evaluate the structures and processes. To identify if/how the continuing education programmes could be improved.

MATERIAL AND METHODS

The development of Nurses' and Physicians' learning was determined using a retrospective self-assessment procedure. The evaluation was based on learning objectives developed in the DGP Education Working Group, using a six-point Likert scale for each item, and space for 'free-text' comments. Assessments were conducted after training.

RESULTS

Five hundred twenty nine self-assessments were recorded (456 nurses / 73 physicians). An increase in learning is demonstrated in all areas (knowledge, skills, social and self-competence) for each profession. The greatest gain was in symptom control. However, there were significant differences in the extent of learning gains between nurses and physicians.

CONCLUSION

Analysis suggests current training results in improvements, but personal competences progress less than knowledge and skills. One way to improve this would be to introduce more interprofessional continuing education elements. Evaluation, as a basis for improving training concepts, is essential for continual development.

Mindfulness and compassion training on daily work with patients and within the multiprofessional palliative care team: a retrospective self-assessment study

BACKGROUND

Palliative care teams work under challenging conditions in a sensitive setting with difficult tasks. The multi-professional team can play an important role. Mindfulness and compassion-based practices are used to build resilience. Our aim was to examine (1) feasibility and acceptability, (2) satisfaction and impact, and (3) opportunities and limitations of a mindfulness course.

METHODS

An eight-week mindfulness and compassion course was delivered in a university-based specialized palliative care unit. A meditation teacher provided preparatory evening sessions and meditation exercises that could be integrated into daily activities. The scientific analysis of the course was based on a questionnaire developed for quality assessmentThe first two parts consisted of demographic, Likert-type, and free-text items. Part 3 consisted of learning objectives that were self-assessed after finishing the course (post-then). In the analysis, we used descriptive statistics, qualitative content analysis, and comparative self-assessment.

RESULTS

Twenty four employees participated. 58% of participants attended 4 or more of the 7 voluntary mindfulness days. 91% expressed moderate to high satisfaction and would recommend the palliative care program to others. Three main categories emerged in the qualitative content analysis: providing feedback on the course, personal impact, and impact on professional life. The opportunity for self-care in a professional context was highlighted. Learning gains (CSA Gain) were high (38.5-49.4%) in terms of knowledge and techniques, moderate (26.2-34.5%) in terms of implementation of learned skills, and rather low (12.7-24.6%) in terms of changes to attitude.

CONCLUSION

Our evaluation shows that the participants of a mindfulness and compassion course considered it as a feasible and welcome tool to familiarize a multi-professional palliative care team with self-care techniques.

TRIAL REGISTRATION

Internal Clinical Trial Register of the Medical Faculty, Heinrich Heine University Düsseldorf, No. 2018074763 (registered retrospectively on 30^th July 2018).

[Perceptions on the use of opioids in COVID-19 : A survey of members of the German Association for Palliative Medicine]

BACKGROUND

Opioids efficiently alleviate pain and dyspnea. However, guidelines on symptom management with opioids differ, which may lead to an uncertainty concerning opioid indication and ethical implication among medical staff, especially when caring for COVID-19 patients.

AIMS

We aimed to examine the perception of members of the German Association for Palliative Medicine (DGP) concerning the administration of morphine as the gold standard opioid (subsequently termed M/O) for symptom control within and outside of a palliative care (PC) setting, including care for COVID-19 patients.

METHODS

DGP members received an anonymized online questionnaire (Survey Monkey®) containing questions regarding their perception of symptom management with M/O in general and in particular concerning COVID-19 patients. Participants were asked to rate their perception within and outside of a PC setting.

RESULTS

Of the 6129 DGP members, N = 506 participated. DGP physicians and nurses perceived handling of M/O as "certain and confident" (98%) and "clearly regulated" within PC (95%) but rated it significantly lower for outside PC (48%/38%). When caring for COVID-19 patients, handling of M/O was even less often rated "certain and confident" (26%) or "clearly regulated" (23%) for outside PC. Dyspnea (99%/52%), relief from the dying process (62%/37%), restlessness (30%/15%) and fear or panic (27%/13%) were more frequently rated as general indications for morphine within versus outside PC. Most participants (89%) wished to involve palliative care consultation teams.

CONCLUSIONS

DGP members perceived substantial uncertainty in the handling of M/O for medical fields outside PC. Uniform interdisciplinary guidelines for symptom control, more education, and involvement of a PC consultation team should be increasingly considered in the future.

Communication in the face of death and dying - how does the encounter with death influence the patient management competence of medical students? An outcome-evaluation

BACKGROUND INFORMATION

As part of an elective course, the Interdisciplinary Centre for Palliative Medicine at Duesseldorf University Hospital offers medical students the opportunity to personally meet and talk to a seriously ill patient on one or more occasions. The future physicians are provided with an opportunity to broaden their professional competence, i.e. their knowledge and skills in patient-centred communication at the end of life, and enhance their personal competence, for example in how to professionally handle their own emotions. A topical e-learning module helps the students to prepare for the meetings, and writing a reflection paper forms the basis for the concluding reflection seminar.

OBJECTIVES

The study's objective is a global and outcome-based evaluation of the elective blended-learning course that provides real-world patient interaction. The outcome-based evaluation or outcome assessment aims to objectively evaluate changes identified in knowledge, skills and attitude among the participants of the elective-course. Furthermore, the evaluation aims to answer the question of whether changes especially in attitude (social skills and self-competence) should be expected after the students have met with severely ill or dying patients.

METHOD

On two questionnaires specifically developed for this survey the students were able to provide a global rating of the elective course and describe their learning gains in palliative care. The students' learning gains were measured by means of 14 items reflecting the specific educational objectives of the offered elective course. Using the German school grading system as a rating scale, the students assessed their learning progress by retrospectively evaluating their skills before and after completion of the elective course (Comparative Self-Assessment, CSA).

RESULTS

In the time from April 2018 till March 2020, 62 students participated in the evaluation. Overall, learning progress among students could be observed across all areas of competence, and in 50% of all retrospective self-assessment items the learning gains were ≥ 50%. The highest learning gain (63.6%) was observed in the students' ability to meet a severely ill patient without fear. The lowest learning gain was observed when students had to confront and accept their own mortality.

CONCLUSIONS

The offered elective course supports students in achieving social and self-competence development goals. According to the obtained results, contact with real-world patients helps mould the students' attitude.

[Undergraduate palliative care teaching in times of COVID-19]

BACKGROUND

Due to the coronavirus disease 2019 (COVID-19) pandemic classroom teaching was largely discontinued at all German medical faculties in the summer semester (SS) 2020. This also affected undergraduate education in palliative care, which is established with an average of 22 teaching units. Teachers were asked to rapidly develop digital teaching and assessment tools.

OBJECTIVE

The aim of this survey was to map the teaching situation in QB13 palliative medicine in SS 2020 under the influence of COVID-19 and from this to derive the need for networking and support for the coming semesters.

MATERIAL AND METHODS

The key persons involved in palliative care education in all 41 medical faculties in Germany were identified and invited by the coordination office of the German Society for Palliative Medicine (DGP) to participate in an online survey using SurveyMonkey®. The questionnaire consisted of 15 items dealing with the evaluation of the past semester and the need for support for the coming semester.

RESULTS

Out of 41 contacted teachers 16 participated in the survey. Most of them described the challenge of teaching in SS 2020 as successful. Support from the faculties was provided primarily in the form of digital teaching structures. A digital teaching design is also planned for the coming semester. Power point slides with sound and the conference tool Zoom® are often used.

CONCLUSION

The design of examinations in SS 2020 is rated worse in the self-evaluation than the teaching design. Multiple choice questions were often used in classroom examinations. Lecturers would like the DGP to create and collect teaching and assessment materials centrally.

[Virtual palliative care : Pilot study of an electronic tool to test cognitive, psychomotor and affective palliative medical and pain therapeutic learning contents during medical training]

BACKGROUND

This article describes a first use of an electronic case-based assessment tool in undergraduate palliative care education. It describes the development of the tool presenting strengths and shortcomings in order to contribute to an innovative design of assessment tools in medical education.

DESIGN AND METHOD

An electronic (virtual) case-based assessment tool (the virtual palliative patient, vPp) was developed. Palliative care levels of knowledge, skills and attitude of students were tested at a computer workplace as a voluntary and non-performance-relevant pilot project at four faculties.

RESULTS

On average the students achieved 80% of the points using the vPp tool, which is below the average score of 91% achieved in the regular examination. In particular, the free text task on reflection of dealing with the patient's death wish caused uncertainty, while multiple choice questions and an interactive conversation sequence were perceived as relatively easy. Technical problems were also identified in the evaluation but overall the concept was evaluated positively and establishment as a regular examination or e‑learning tool was desired.

CONCLUSION

The implementation of an innovative assessment tool in medical education is technically challenging. A coordination with contents of the individual faculties is necessary in order that students do not have a feeling of a lack of preparation. The development of the vPp describes an innovative assessment format. In the long term, all interested faculties could receive a form of toolbox containing the technical framework of the assessment tool, which can then be fed with new contents.

[Status of palliative care education in Germany : A survey of medical faculties in 2018]

BACKGROUND

To investigate the development in palliative care education in Germany, numerous surveys have been conducted since 2006. They showed differences of palliative care education between the faculties before and after the implementation of palliative care as a mandatory subject. The present study aims to document the status of palliative care education at German medical faculties in 2018.

MATERIALS AND METHODS

Using an online questionnaire with 19 questions, the structure, organization, content, and assessment of palliative care education of German medical faculties were assessed.

RESULTS

Of the 37 participating faculties, 30 reported improvements in terms of structural aspects, e.g., there were more palliative care units and full professorships. Due to increasing opportunities for final year rotations and innovative, practical teaching, students can now deepen their knowledge, skills, and attitude in palliative care.

CONCLUSION

This study showed clear progression in palliative care education. Nevertheless, there is still room for improvement in terms of examination formats and professorships. Complementary surveys with students would be helpful to evaluate the education outcome.

Comprehensive Cancer Center (CCC) in Deutschland: Ergebnisse einer Befragung zu Empfehlungen für die Palliativmedizinische Lehre im Medizinstudium

Hintergrund Die curriculare studentische palliativmedizinische Lehre ist in den geförderten Comprehensive Cancer Center (CCCs) unterschiedlich integriert. Da ein Strukturkonzept für die Förderung der Lehre zur spezialisierten Palliativmedizin in einem CCC gegeben sein soll, werden Empfehlungen diskutiert, konsentiert und berichtet.

Methodik Neun Aussagen zur Lehre in den CCCs wurden anhand von Richtlinien und Katalogen von Palliativmedizinern aus dem CCC-Netzwerk formuliert. Über ein quantitatives Untersuchungsdesign erfolgte zur Abstimmung eine Online-Befragung von 14 Ärzten aus den palliativmedizinischen Einrichtungen der CCCs, mit Leitungs- und Lehrverantwortung. Eine Aussage galt als konsentiert, insofern die Zustimmung in der Gruppe bei ≥ 80 % lag. Anmerkungen wurden über Freitextfelder erfasst.

Ergebnisse Von 14 haben 12 Personen von Mai bis August 2016 an der Umfrage teilgenommen, durch die 7 der 9 Empfehlungen konsentiert wurden. Einstimmig (100 %) verlief die Abtimmung zum Pflichtanteil der Lehre (mindestens 1,5 Semesterwochenstunden = 20 Unterrichtseinheiten à 45 min). Die Befragten befürworten überdies eine Wahlmöglichkeit im Praktischen Jahr für die Palliativmedizin (92 %). Die Empfehlung, eine Vollzeitkraft für die Lehre einzusetzen, erzielte keinen Konsens (75 %). Der lehrverantwortlichen Person sollte jedoch eine ¼-Stelle für administrative Aufgaben zugeordnet sein (83 %).

Diskussion Die ärztlichen Leiter der spezialisierten Palliativmedizin in den deutschen CCCs sind sich überwiegend einig, welche Strukturmerkmale der studentischen palliativmedizinischen Lehre zugrunde zu legen sind. Diese Empfehlungen können in ein Strukturkonzept zur Förderung der spezialisierten palliativmedizinischen Lehre eines CCC einfließen.

Undergraduate education in palliative medicine in Germany: a longitudinal perspective on curricular and infrastructural development

BACKGROUND

In 2009, palliative medicine became an integrated and compulsory part of undergraduate training in Germany by legislation. After a transitional period, all medical faculties were required to provide adequate teaching with an according examination and certification procedure. In parallel, we conducted bi-annual surveys on all medical faculties in Germany to examine for potential discrepancies between the implementation process and their intended consequences on teaching time and content.

METHODS

Four consecutive bi-annual surveys (2006, 2008, 2010, 2012) of all 36 medical faculties in Germany were performed, using purposively for this study developed questionnaires. Likert scales and closed questions were analyzed descriptively.

RESULTS

Medical Faculty response rate increased from 50 % in 2006 to 88.9 % in 2012. Teaching coordinators in palliative medicine primarily had an anesthesiology or internal medicine background. There was a noted increase over time of the involvement of specialized palliative care units (PCUs) as providing the setting for education. The number of faculties that were able to offer a complete 16 weeks of training in palliative medicine during the "final year" rose steadily. In addition, increased patient-centered teaching formats have been implemented over time. The faculties which offered innovative teaching formats with actors as patients (standardized patient interaction) increased, as did the total number of mandatory examinations. The number of faculties that provided compulsory teaching in a condensed manner within a single academic year increased sharply from 3 of 31 responding faculties in 2010 to 19 of 32 responding faculties in 2012.

CONCLUSIONS

Until now, teaching conditions and structures in palliative medicine in Germany have proven to be extraordinarily heterogeneous. Although professorships ("Chairs") in palliative medicine proved to be particularly beneficial and supportive in curricular and structural development, only a minority of faculties provide leading academic positions in palliative medicine.

Implementation of palliative care as a mandatory cross-disciplinary subject (QB13) at the Medical Faculty of the Heinrich-Heine-University Düsseldorf, Germany

Background: By means of the revision of the Medical Licensure Act for Physicians (ÄAppO) in 2009, undergraduate palliative care education (UPCE) was incorporated as a mandatory cross sectional examination subject (QB13) in medical education in Germany. Its implementation still constitutes a major challenge for German medical faculties. There is a discrepancy between limited university resources and limited patient availabilities and high numbers of medical students. Apart from teaching theoretical knowledge and skills, palliative care education is faced with the particular challenge of imparting a professional and adequate attitude towards incurably ill and dying patients and their relatives.

Project description: Against this background, an evidence-based longitudinal UPCE curriculum was systematically developed following Kern’s Cycle [1] and partly implemented and evaluated by the students participating in the pilot project. Innovative teaching methods (virtual standardised/simulated patient contacts, e-learning courses, interdisciplinary and interprofessional collaborative teaching, and group sessions for reflective self-development) aim at teaching palliative care-related core competencies within the clinical context and on an interdisciplinary and interprofessional basis.

Results: After almost five years of development and evaluation, the UPCE curriculum comprises 60 teaching units and is being fully implemented and taught for the first time in the winter semester 2014/15. The previous pilot phases were successfully concluded. To date, the pilot phases (n=26), the subproject “E-learning in palliative care” (n=518) and the blended-learning elective course “Communication with dying patients” (n=12) have been successfully evaluated.

Conclusion: All conducted development steps and all developed programmes are available for other palliative care educators (Open Access). The integrated teaching formats and methods (video, e-learning module, interprofessional education, group sessions for reflexive self-development) and their evaluations are intended to make a contribution to an evidence-based development of palliative care curricula in Germany.