Development of a Consensus Syllabus of Palliative Medicine for Physicians in Japan Using a Modified Delphi Method.

CONTEXT: Although palliative care is rapidly being disseminated throughout Japan as a result of government policy, a systematic syllabus of palliative medicine for physicians has not been developed. AIMS: This study aimed to develop a Japanese national consensus syllabus of palliative medicine for physicians.
DESIGN: We used a modified Delphi method to develop the consensus syllabus. METHODS AND
SETTING: We created a Delphi panel by selecting 20 expert eligible panelists consisting of Diplomate or Faculty of the Specialty Board of Palliative Medicine and certified by the Japanese Society for Palliative Medicine. We inducted external reviewers from 11 palliative care-related organizations.
RESULTS: Among 20 experts surveyed, 20 (100%) responded over all rounds. Ten (50%) participated in a panel meeting. In the first round, 179 of 179 (100%) learning objectives were judged to be appropriate and 5 of 179 (3%) learning objectives were judged to be too difficult. In the panel meeting, 25 learning objectives were excluded, three new learning objectives were added, and 15 learning objectives were reworded. In the second round, 18 of 18 (100%) learning objectives were judged to be appropriate. The final version of the syllabus developed consists of 157 specific behavioural objectives and 22 general instructional objectives across 22 courses.
CONCLUSIONS: We have developed the first national consensus syllabus of palliative medicine for physicians in Japan. Based on this syllabus, a training program on palliative medicine will be established by training facilities in Japan, and physicians will be able to practice specific palliative care.

INTRODUCTION

Improvement in palliative care is an important public healthcare issue worldwide.[1] According to the World Health Organization, palliative care aims to improve the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual, and psychosocial support from the diagnosis to end-of-life care, and support during bereavement. Further, the WHO recommends that palliative care should become an integral part of healthcare and that all patients affected by a life-threatening disease should have access to palliative care services. This statement is further supported by the European Association of Palliative Care[2] and is also in agreement with the European Council's guidelines for the European Union member states.[3] This consensus in favor of integrating palliative care within regular treatment offered to patients with life-threatening disease is supported by a growing amount of evidence indicating the effectiveness of palliative care in improving quality of life of these patients.[456]

The Cancer Control Act was implemented in 2007 in Japan and emphasized the importance of the early introduction of appropriate palliative care to maintain and improve patient quality of life over the course of illness; however, palliative care is yet to become sufficiently widespread throughout Japan. One of the reasons suggested for this is the lack of appropriate education and support systems enabling the implementation of basic palliative care.[7] In Japan, it has been reported that only approximately 20% of physicians responded that they “received sufficient education regarding palliative care” and only approximately 30% responded that they had “sufficient knowledge and skills regarding alleviation of symptoms.” Both of these figures are much lower than those reported in Western countries.[891011]

The training curriculum of palliative medicine in Japan comprises the “Training Curriculum for Physicians Aiming to Become Palliative Care Specialists” developed by the Japanese Society for Palliative Medicine in 2009, which is based on the curriculum for multiple disciplines developed by the Japan Hospice Palliative Care Association.[12] However, it has been reported that specialized palliative care training programs are required and that learning methods for acquiring specialized knowledge remain insufficient.[13] Therefore, in accordance with clinical needs and to respond to the demands of physicians studying palliative medicine, it appears necessary to revise the training curriculum for physicians.

In this study, we aimed to clarify the essential learning outcomes in palliative care that physicians aiming to become palliative medicine specialists should achieve by the time they graduate from the training program. We used a modified Delphi method,[14] which is widely used to in developing educational syllabuses.[151617181920]

SUBJECTS AND METHODS

We adopted a modified Delphi method[14] to develop a consensus syllabus of palliative medicine for physicians.

Development of a provisional syllabus

To develop a provisional syllabus, we adopted the following procedures. First, the authors established the structure and sections of the syllabus based on discussions and literature review.[121920212223242526272829] Second, one author (A. S.) generated an item pool of learning outcomes under each category of the syllabus based on a literature review. Third, the authors discussed the appropriateness and coverage of the item pool of learning outcomes to reach a consensus regarding their validity, and the provisional syllabus was then formulated.

Expert panel selection

We selected expert and eligible panelists to create a Delphi panel that consisted of Diplomate or Faculty of the Specialty Board of Palliative Medicine and certified by the Japanese Society for Palliative Medicine. We contacted the Japanese Society for Palliative Medicine through mail and asked them to participate in this study and recommend panelists based on the following criteria: (1) physicians with adequate experience as part of a palliative care consultation team; (2) physicians with adequate experience at a palliative care unit; (3) physicians with adequate experience in community-based palliative care; and (4) coordinators of palliative care education at a university-level graduate school of medicine. Each group consisted of five expert panelists, making a total number of 20 expert panelists. All individuals who confirmed that they met the eligibility criteria and expressed a willingness to participate were included in the Delphi study. The study was conducted in accordance with the Declaration of Helsinki and ethical guidelines with regard to clinical research. This study was reviewed by the Institutional Review Board at Hyogo Prefectural Kakogawa Medical Center, which approved it with waiver of informed consent.

Survey process

Google Forms™ was used to conduct anonymous web-based surveys during the period from September 2016 to March 2017. Our Delphi study consisted of three rounds, each lasting 4 weeks with a 4-week gap between the rounds. Nonrespondents were sent weekly E-mail reminders. No financial incentives were provided.

First, each panelist was asked to review existing syllabi and literature to standardize their knowledge regarding learning outcomes in palliative medicine education for physicians.

Second, 4 weeks later, we implemented a first-round survey, mailing a questionnaire with the outline of the provisional learning outcomes to each panelist. Each member was asked to rate the appropriateness of each learning outcome using a nine-point Likert-type scale (inappropriate 1–3, intermediate 4–6, and appropriate 7–9). In cases where panelists were unfamiliar with items due to their specialty, an “incapable of rating” result was also generated. Panelists, who rated a statement with a score of <6, were asked to provide the reason. In addition, each member was asked to rate the difficulty in each learning outcome using a four-point Likert-type scale: 0 (easy), 1 (adequate), 2 (moderately difficult), 3 (too difficult), and the learning outcomes were reformulated to be more achievable as needed. Panelists who rated the outcome difficulty as 2 or 3 were asked to provide the reason. A consensus in this study was defined a priori as agreement (appropriate, 7–9) among a minimum of 75% of the experts. We also collected basic demographic information from the experts including age, gender, type of clinical practice, and years of experience. A summary of the first-round survey was sent to each panelist and author, and disagreements were discussed via E-mail over 2 weeks. We asked the panelists, especially those who would not be able to attend a panel meeting, to provide their opinions.

Third, we contacted 11 palliative care-related organizations [Table 1] through mail-in December 2016 and asked them to participate in the study and to recommend a representative in charge of education in palliative medicine as an external reviewer. We mailed them the provisional syllabus, summary of the first-round survey, and description of each panelist. We requested opinions regarding the provisional syllabus and each learning outcome from the external reviewers.

Table 1

List of palliative care-related organizations participating in this study

Hospice palliative care japan

Japan Primary Association

Japan Psycho-Oncology Society

Japan Society of Clinical Oncology

Japan Federation of Cancer Patient Groups

Japanese Society of Cancer Nursing

Japanese Society of Medical Oncology

Japanese Society for Palliative Medicine

Japanese Society of Pharmaceutical Palliative Care and Sciences

The Japanese Academy of Home Care Physicians

The Japanese Association for Clinical Research on Death and Dying

Fourth, following discussions through E-mail, an expert panel meeting was convened on December 24, 2016, in Tokyo to discuss statements causing disagreement in person. At the meeting, a summary of the first-round survey, discussion through E-mail, and opinions from the external reviewers were distributed. Following the panel meeting, a summary of the meeting and a revised version of the learning outcomes were sent to all panelists to confirm corrections or to determine whether there were additional opinions.

Fifth, we implemented a second-round survey using the same method as in the first-round survey, addressing only the learning outcomes that could not be agreed on in the first-round survey. For learning outcomes considered inappropriate, the relevant panelists were contacted via E-mail individually, and we attempted to reach an agreement.

Sixth, we conducted a third-round survey using the same methods as in the first-and second-round surveys, addressing only the learning outcomes that could not be agreed upon in the first-and second-round surveys. We eliminated learning outcomes that could not be agreed on during the third round.

Statistical analysis

Data analysis was performed using the software Statistical Package for Social Science version 22.0 (SPSS Japan, Tokyo, Japan).

RESULTS

Participant characteristics

The participants’ characteristics are summarized in Table 2. Among 20 experts surveyed, 20 (100%) responded over all rounds. Ten (50%) participated in a panel meeting.

Table 2

Background of panelists in this study (n=20)

	n (%)
Sex
Male	11 (55)
Female	9 (45)
Age
30-39	4 (20)
40-49	10 (50)
50-59	6 (30)
Clinical experience (years)
10-19	10 (50)
20-29	9 (45)
≥30	1 (5)
Clinical experience in palliative care of more than 5 years	18 (90)
Experience in palliative care education of more than 5 years	14 (70)

First Delphi round

In the first-round survey, 179 of 179 (100%) learning objectives were judged to be appropriate by more than 75% of the respondents, and 5 of 179 (3%) learning objectives were judged to be too difficult by more than 10% of the respondents.

In the panel meeting, all learning objectives were examined carefully. Subsequently, 3 new learning objectives were added, and 25 learning objectives were excluded, owing to their high difficulty, during the panel meeting. In case of satisfactory statements that included correcting modes of expression, shuffling of learning objectives among courses, and binding similar objectives together, we made revisions based on a discussion among the participants and authors. In addition, we reworded 15 learning objectives judged to be difficult to make them more understandable and achievable. The number of learning objectives was 157 across 22 courses after the panel meeting. Following the panel meeting, a summary of the panel meeting and a revised version of the learning objectives were sent to all panelists to confirm corrections or determine whether there were additional opinions. We revised them based on a discussion among authors, resulting in 18 learning objectives being reworded, and then conducted the second Delphi round.

Second Delphi round

In the second-round survey, all panelists responded with 18 of 18 (100%) learning objectives judged to be appropriate by more than 75% of the respondents. No learning objectives were rated to be unnecessary or unimportant by more than 75% of the respondents. We decided to conclude the Delphi rounds after the second-round survey because most of the stated learning outcomes had achieved consensus. The final version of the syllabus [Appendix] consists of 157 specific behavioral objectives and 22 general instructional objectives across 22 courses [Table 3].

Table 3

List of courses and general instructional objectives in the consensus syllabus

Courses	General instructional objectives
Comprehensive assessment	To be able to holistically understand patients and comprehend both patients’ pain and what constitutes support for these individuals
Pain management	To be able to assess patients’ pain and use pharmacotherapy as well as other methods, including nonpharmacological therapy to alleviate pain
Management of physical symptoms other than pain	To be able to evaluate symptoms other than pain and use pharmacotherapy and various other methods including nonpharmacological therapy to alleviate these symptoms
Management of psychiatric symptoms	To be able to evaluate psychiatric symptoms and use pharmacotherapy and various other methods, including nonpharmacological therapy to alleviate these symptoms
Palliative care of noncancer illnesses	To be able to cooperate with specialists to investigate the indications for palliative care for patients with noncancer illnesses and provide appropriate palliative care
Psychological reaction	To be able to evaluate psychological reactions and respond appropriately
Social issues	To be able to evaluate social issues and respond appropriately
Spiritual care	To be able to accurately understand patients’ spiritual pain and offer appropriate support
Ethical issues	To be able to understand ethical issues associated with palliative care and respond appropriately
Decision-making support	To be able to support decision-making while considering the wishes of the patients and their families
Communication	To be able to engage in communication while considering patients’ personalities
Palliative sedation	To be able to implement appropriate sedation to relieve otherwise intolerable suffering for patients
Disease trajectory	To be able to understand the disease trajectory and predict the prognosis
Care of dying patients	To be able to respond appropriately to patients in the end stages of their lives as well as to their families
Family care	To be able to notice challenges faced by patients’ families and implement appropriate care for them
Bereaved family care	To be able to notice reactions of grief to bereavement and loss and respond appropriately
Psychological care for healthcare providers	To be able to provide psychological care for oneself and staff
Team work in medicine	To be able to practice medicine as a team
Consultation	To be able to provide appropriate consultations regarding palliative care
Regional coordination	To be able to coordinate with regional medical facilities and provide medical care appropriate for each region
Oncology	To acquire knowledge of oncology and be able to offer the best medical options for the patient
Education and research	To be able to contribute to the development of palliative care by being involved in education and research as well as constantly updating knowledge as a palliative care specialist

Third Delphi round

We concluded the study with the third-round survey, and no further Delphi round because all of the stated learning outcomes had achieved consensus after the second-round survey.

DISCUSSION

To the best of our knowledge, this study generated the first consensus syllabus of palliative medicine for physicians developed using a modified Delphi method.

The most important finding was that we used innovative processes to develop the syllabus. First, based on the modified Delphi method, we used E-mail discussion and panel meetings between the first and the second rounds of our Delphi study. The participants discussed backgrounds and reasons for their ratings of each learning objective and shared their opinions with each other, with the aim of making the learning objectives more adequate and achievable. Second, in the survey on the provisional syllabus and the first Delphi round, we evaluated the degree of difficulty for each learning outcome. In general, while developing the syllabus, learning objectives tended to increase in number during the process. We subsequently discussed and rewrote the objectives rated as too difficult by more than 10% of the panelists to make them more achievable and understandable. Third, external reviewers enabled us to be indirectly aware of perspectives from patients, families, and other disciplines, leading to a wider range of opinions regarding the syllabus. Subsequently, 25 learning objectives were excluded and three learning objectives were added. We surmise that these same three innovative processes undertaken to develop the educational syllabus on palliative care could also be adapted for other medical specialties, and indeed for any investigations using a Delphi method.

The second important result of the present study was that palliative care of noncancer illnesses was added as learning objectives. Although palliative care is rapidly being disseminated throughout Japan as a result of government policy,[7] palliative care is not provided for illnesses other than cancer. In the year 2007, the Cancer Control Act and the Basic Plan to Promote Cancer Control Programs were enacted in Japan, addressing palliative care as one of the major issues in improving cancer care. This program required all government-designated cancer-care hospitals to organize hospital-based palliative care teams within each institute. However, it was pointed out that palliative care continues to be primarily intended for cancer patients and is less accessible to those with other illnesses, compared to the situation in Western countries.[30] The syllabus developed here may also be useful as an audit tool. Several institutions have developed palliative medicine curricula and may not wish to extensively revamp them. The syllabus might be used as a benchmark to compare their own programs with a national syllabus produced by an expert body of opinion or to assess the effectiveness of palliative care teaching in institutions.

This study has several limitations. First, the E-mail discussion and the panel meeting between the two Delphi rounds did not protect the anonymity of an individual's views, which might have affected the ratings during the second Delphi round, although the Delphi round itself retained its anonymity. Second, we only surveyed physicians in this study. Experts in other disciplines and patients may have different perspectives that would need to be explored in future studies. The syllabus might not reflect user or consumer perspectives sufficiently because of the panel selection process used. We aimed to overcome this limitation by seeking opinions of external reviewers that enabled us to gather a wider range of opinions regarding the syllabus. It might be useful to also conduct separate focus groups or external reviews involving patients, bereaved families, trainees, or experts in other disciplines. Third, we only surveyed learning objectives in our study. The education curriculum comprises learning objectives, educational strategies, implementation, and evaluation. Further, we need to examine educational strategies, and implementation and evaluation of training programs on palliative medicine.

CONCLUSIONS

We developed a consensus syllabus of palliative medicine for physicians using a systematic methodology. Based on this syllabus, a training program on palliative medicine will be established by training facilities in Japan, and all physicians will be able to practice specific palliative care. Subsequent steps will involve implementation of this program and assessment of whether this syllabus achieves the desired endpoint, which is enabling qualified physicians with broad knowledge and understanding of the principles and practice of palliative medicine.

Financial support and sponsorship

This study was funded by the Japanese Society for Palliative Medicine.

Conflicts of interest

There are no conflicts of interest.