Implementing the cross-disciplinary subject of palliative medicine (Q13) against the backdrop of recent changes of the legal framework using University Medical School Göttingen as an example.

Palliative care for patients with advanced and progressive diseases has recently become an integrated and compulsory part of undergraduate training in Germany. Up until now, undergraduate teaching in this cross-disciplinary medical field varied and therefore problems during the implementation process with regard to formal aspects and teaching content are to be expected. This contribution summarizes the new legislative framework for palliative care as an independent specialty in undergraduate medical training and describes format, content and problems of the current implementation process at the University Medical School Göttingen, in order to provide advice and support for other faculties.

Background

Development of Palliative Care in Germany

Palliative medical treatment of incurable patients or patients with advanced illnesses has made increasing inroads into regular health care provision. For example, the introduction of the procedure “Palliative Medical Complex Treatment”, covered by the national health insurance, or the decision on “Specialised Palliative out-patient Care (SAPV)” (GKV Competition Reinforcement Law / SGB V §37b) implements palliative medical care services both for in- and out-patients with the number of palliative care wards having risen to currently 193 (Wegweiser Palliativmedizin 2008/2009). Research into palliative medicine has increased considerably in the last years; for example the number of scientific abstracts on the scientific forums of the European Association for Palliative Care (EAPC) has risen from 153 in 2000 (with some 350 participants) to 663 in 2010 (with some 1100 participants). Also, the increasingly broad debate within society, the medical profession and national ethics bodies (of late including the German Medical Association BÄK and the Central Ethics Commission ZEKO, 2010) on assisted suicide and the role of living wills makes the significance of comprehensive palliative medical care clear [1].

Development of Palliative Medical Care in Undergraduate Teaching

In contrast, palliative medical care in undergraduate teaching to date has only been integrated into the set curriculum by a small number of medical schools. A questionnaire by the German Medical Students’ Association (bvmd) in 2008 found that only five chairs for palliative medicine (Aachen, Göttingen, Cologne, LMU Munich; one advertised in Bonn) and that only six faculties offered palliative medicine as a subject within the set curriculum: Aachen, Munich (both since 2003), Cologne, Bonn, Gießen, and Witten/Herdecke – the first three of these six also offering certificates [2].

This is also reflected by the decision of the Federal Parliament on 10.07.2009 to tie the subject of palliative medicine into the Medical Licensure Act (AppOÄ as of 03.07.2002, last amended am 31.07.2009, § 27 and Supplement 15 to § 29 Sect 3 Sentence 2) as the 13th cross-disciplinary subject (Q13). Following this decision, all medical faculties must offer the subject of palliative medicine as a compulsory subject for teaching and examination starting with the summer term of 2013. The individual examination certificates then have to be presented either at the start of the Practical Year (prior to the 6th year of studies) in August 2013 or, at the latest, when registering for the Second Medical Examination in October 2014, with the deadlines for the latter being some three months earlier. Final examinations in medicine from then on will only be possible with appropriate certificates on this cross-disciplinary subject [2], [3].

The German Society for Palliative Medicine (DGP), against the backdrop of these developments, has re-worked a second edition of its curriculum for students (the “Basics of Palliative Medicine") dated 10.08.2009 [4] and presented study goals, the curricular framework and the cross-disciplinary aspects of the subject of palliative medicine. Table 1 (Tab. 1) offers and overview over the recommended weighting of the topics to be implemented in Q13, which should thread themselves through the students’ curriculum in the form of teaching events and whilst making concrete reference to other subject areas.

Table 1

Recommended Weighting of Palliative Medical Topics in Q13, Curriculum for Students, DGP 2009

In view of these new legal and curricular conditions, we shall describe the process of implementation and re-structuring at the University Medical Scholl Göttingen (UMG) as an example case, looking at implementation to date, first evaluation results and future perspectives but also the difficulties associated with implementation.

Results

Undergraduate Teaching in the Subject of Palliative Medicine at Göttingen University

The UMG has had a palliative section which is attached to the Centre for Anaesthesiology, Emergency and Intensive Medicine since 1991, including a palliative ward and an out-patient palliative care service. It was first integrated at the level of non-compulsory courses with a main emphasis on paint treatment but later on also as a module within modular teaching as “Basics of Tumour Diseases”. Since 01.10.2006, an independent palliative medicine department has existed which includes the Chair of Palliative Medicine (Prof F Nauck, an endowed chair funded by German Cancer Aid), a 10 bed ward, the out-patient palliative care service including an SAPV team, a medical consultations’ service, a day clinic (under construction) and the research and teaching section. Since then, the number of semester hours taught (SAT) in the palliative medicine department has increased from 14 to about 128 at the last count. In particular the establishment of palliative medicine as an elective course has contributed to this growth (26 THs, see Table 2 (Tab. 2)). As is the case at some other universities already, the opportunity to take an entire elective tertial in the subject of palliative medicine was created in addition to the existing 1-2 weekly rotations within the anaesthesiology elective tertial.

Table 2

Palliative Medicine as an elective course

For the establishment of a compulsory cross-sectional curriculum of palliative medicine the existing modular curriculum at Göttingen as a whole was systematically checked for potential overlaps with learning and teaching content relevant to palliative care from winter term 2009/2010 onwards, also in relation to the study goal catalogue at Göttingen (http://www.med.uni-goettingen.de/media/global/G1-2_lehre/lernzielkatalog.pdf). It was possible to identify a large number of potential linkages for a cross-sectional approach (see Table 3 (Tab. 3)).

Table 3

Overview: General Topics Relevant to Palliative Medicine in the Undergraduate Curriculum of UMG (as of 02/2010)

Currently, core palliative medical content is taught at all potential linkage points relevant to the teaching of palliative medicine listed in Table 3 (Tab. 3), especially within module 3.3 “Basics of Tumour Illnesses“ (3rd clinical semester) and in the follow-on module 6.3 (6th clinical semester). To date, teaching staff of the Palliative Medicine Department handle one main lecture (1 x 2 THs) and one seminar (approx. 20 students, 10 x 1 TH, with interdisciplinary staff recruited from the areas of oncology and palliative medicine) for all students of a year within module 3.3. Teaching by the patient’s bedside (TBPB) in groups of three on the palliative ward is possible for approx. 1/6 of all students of a year (10 x 3 THs). In module 6.3 the Palliative Medicine Department independently runs a pharmacologically oriented seminar (“Drug Therapy in Palliative Medicine", 10 x 2 THs) and in conjunction with Haematology/Oncology, General Practice, Psychosomatic Medicine/Psychotherapy runs the interactive course on “Giving Bad News” (2 x 2 THs, cf Table 4 (Tab. 4)). Both teaching modules listed in 3.3 and 6.3 (9 THs) to date form the primary content run by the Palliative Medicine Department and currently represent the only aspect relevant to obtaining the certificate/taking the exam in Q13.

Table 4

Interdisciplinary Course Aspect “Giving Bad News"

Many teaching events which are relevant from a palliative medical perspective are continued, in line with the cross-departmental approach, unchanged by the department originally responsible and supplemented by contributions from the members of staff of the Palliative Medicine Department (for example the course in Medical Psychology/Sociology, cf Table 3 (Tab. 3)). In collaboration with the Centre for Anaesthesiology or the Department for Pain Treatment, from the next winter term onwards four additional THs will be added to module 6.2. as part of the compulsory and examination relevant core curriculum of Q13. This will increase the number of compulsory hours within the compulsory components of Q13 to 13 THs.

Imparting a Medical Mindset as Training Goal

In this implementation process the special challenge is not only the teaching of knowledge and skills (for example in relation to the treatment of symptoms such as pain, dyspnoea or vomiting) but rather imparting a medical underlying mindset which integrates the treatment and support of patients with incurable illnesses and dying patients as an integral part of the role of a doctor. The aim is a platform for reflection which enables (possible the first) encounters with the topics of “death” and “dying” which will enable the student throughout their entire university time to develop their own views as a medical professional on issues relating to medicine, care, psycho-sociology and ethics.

The aim to impart this fundamental medical mindset in relation to fellow human beings with severe illnesses or dying patients runs throughout the titles of the Q13 teaching components and the selection of examination formats which seek to do justice to these multiple layers and which are summed up in Tables 5 (Tab. 5) and 6 (Tab. 6).

Table 5

Desired Palliative Medicine Cross-section (Teaching Project Q13) with compulsory courses relevant to examinations in the Department of Palliative Medicine and further associated courses in related departments

Table 6

Optional Course Offers in Addition to the Cross-disciplinary Subject Palliative Medicine (Teaching Goal Q13)

This thread for an underlying medical mindset and one’s own ethical reflections beings in the form of an impulse on the topic “Death and Dying” and how to deal with the deceased in the introductory lecture to the dissection course (currently being prepared in conjunction with the Anatomy Department) and continues, even in the pre-clinical phase, through encounters with palliative medicine (on the palliative ward) and the hospice idea (at the in-patient hospice of Göttingen-Weende) as part of the Medical Psychology/Sociology course (see Figure 1 (Fig. 1)).

Figure 1

Thread through the Cross-disciplinary Subject of Palliative Medicine at UMG

In the third clinical semester the content focuses more heavily on imparting subject knowledge which is taught regularly, in view of the complexity of the decision making process in treatment towards the end of life, using authentic case studies.

The emphasis of palliative medical training and “imprinting” will be the sixth clinical semester which will again pick up the thread of complex case studies (at this stage normally under aspects of psycho-social support and ethical issues in module 6.2, as well as complex pharmacological problem in module 6.3). The course component “Giving Bad News” which is also part of module 6.3 has, its interdisciplinary preparation aside, the following characteristics:

interactive-practical aspects, in particular in role play (+/- simulated patients)

transmitting communicative-theoretical knowledge as a structuring element

reflective teaching components (perceiving moods and communication levels based on an example from the literature; reflecting on one’s own experiences and emotions; transmitting elements of burnout prevention; anticipating critical communication situations).

Through these teaching events grouped together in Table 5 (Tab. 5) and the selected teaching methods - via the formal rules of the new Medical Licensure Act and going beyond purely reproductive or application-related learning goals - aspects of ethical sensitisation and support in finding a fundamental medical mindset and personality development shall move to the fore.

Examination Formats

Alternative examination formats are needed to test said competences and mindsets that go beyond testing knowledge (for example using multiple choice questions). Participation in a cross-disciplinary OSCE (objective structured clinical examination) as an examination with certificate prior to the Practical Year is planned. Until this is implemented, the proof of achievement will be given without a grading.

Training and Cooperation Concept

All newly established teaching modules have been developed in open internal or interdisciplinary cooperation and use the infrastructure innovations at the UMG (for example STÄPS (Student Training Centre for Medical Practice and Simulation); implementation of learning content in palliative medicine is supported widely by the faculty. As a cross-disciplinary subject, more cooperation efforts are urgently required in the near future, for example in respect of the area of general medicine (for example in relation to comprehensive care of chronically ill patients) or with the areas of internal medicine or neurology (for example in relation to patients with non-cancer disease in palliative care).

Student Evaluation

Similarly to the selection of the examination format, there is a question if conventional student evaluation methods can be transferred to learning content which aim for reflection and mindset. First results of the department and module internal evaluation carried out in relation to the increased knowledge in passing on bad news using the parameter of “I feel confident in finding the right words when giving bad news to patients and their relatives” (+36.2% knowledge increase) could indicate a high appreciation amongst students. Nonetheless a systematic course and concept evaluation using multi-dimensional evaluation methods is yet to be carried out.

Concomitant Research

The bvmd collects the varying intensity of palliative medical training at all German faculties every two years (cf [2]). The 2010 survey this year will also question the individual faculties on their plans and concepts for implementing Q13. Also involved are the German Society of Palliative Medicine (DGP), the German Society for Haematology and Oncology (DGHO), the German Cancer Society (DKG) and the German Society for the Study of Pain (DGSS). It is to be expected that the Q13 teaching concepts and the teaching and examination formats aimed for will be clearly different at the various faculties. It is hoped that first results will be presented at the DGP congress (Dresden, 9.-11.09.2010). In addition, the current state of knowledge of palliative medicine at the start and finish of the Practical Year will be evaluated in a cooperative project between the Universities of Mainz and Göttingen to generate further data and requirements for the teaching of palliative medicine as a cross-disciplinary subject.

Problems

In addition to the general problems of implementing each new course component which is linked with the personnel and financial resources (with the aim for 20-40 THs according to the DGP) and the curricular boundaries (for example in relation to the given number of standard teaching hours) may lead to specific hurdles in the implementation of Q13. As a cross-disciplinary subject, palliative medicine shows an intrinsic proximity in terms of its content to many other clinical areas (such as tumour or pain treatment related areas) so that the need for an independent teaching subject could not be divided equally in all directions or that the current division of teaching content without specialised palliative medical content could be seen as sufficiently implemented. Especially in faculties without their own chair for palliative medicine, this could prevent a smooth implementation process. It also requires additional discussion in how much general and specialised pain treatment should be elevated to the level of an independent cross-disciplinary subject or, as promoted by the DGSS, be joined with Q13 as a shared cross-disciplinary subject of “Palliative Medicine and Pain Treatment”. The expert commissions are currently also debating the question if such an approach would not weaken both the subject areas of pain treatment and palliative medicine, rather than strengthen them. From our point of view both pain treatment and palliative medicine should be integrated into compulsory undergraduate teaching.

Summary and Outlook

As a result of the new legal framework, undergraduate studies in Q13 are in a crucial phase of the conceptual realisation which impacts the curricula of all medical faculties in Germany. Therefore an exchange of ideas and existing concepts would seem much needed and is to be promoted via the concomitant research project mentioned above. In addition to questions regarding the conceptual implementation, concrete aspects of content are also in need of further work, such as formulating a catalogue of learning targets for palliative medicine or a student textbook for palliative medicine based on such a catalogue. In addition to isolated concrete activities, for example at the University Department of Medicine Göttingen, chief responsibility will lie with the responsible scientific bodies, the German Society of Palliative Medicine or, for example, the Society for Medical Training (GMA).

Competing interests

The authors declare that they have no competing interests.

Erratum

In the section "Background/Development of Palliative Medical Care in Undergraduate Teaching", 1st paragraph, "four chairs for palliative medicine" has been replaced by "five chairs for palliative medicine".

In the section "Results/Undergraduate Teaching in the Subject of Palliative Medicine at Göttingen University", 1st paragraph, "the establishment of the compulsory subject of palliative medicine" has been replaced by "the establishment of palliative medicine as an elective course" and "Anaesthetics" has been replaced by "Anaesthesiology".

In the section "Results/Training and Cooperation Concept", "non-oncological underlying illnesses" has been replaced by "non-cancer disease".

In Tab. 3 some translation errors have been corrected.