PEDIATRICS Vol. 117 No. 6 June 2006, pp. 1949-1954 (doi:10.1542/peds.2005-1111)
Pediatric Resident Education in Palliative Care: A Needs Assessment
a Department of Medicine, Division of General Internal Medicine
b Department of Pediatrics
c Section of Palliative Care and Medical Ethics, Center for Bioethics and Health Law
d Institute for Performance Improvement, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
e Departments of Medicine
f Pediatrics, Medical University of South Carolina, Charleston, South Carolina
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVE. The goal was to characterize pediatric residents' perceived educational needs for pediatric palliative care. The data generated from this study will facilitate the planning of specific educational interventions.
METHODS. All residents in the Children's Hospital of Pittsburgh pediatrics residency program were asked to complete a survey in September 2003. Participation in the study was voluntary. Residents rated their previous training, personal experience, knowledge, competence, and emotional comfort with 10 specific aspects of pediatric palliative care. This rating was followed by 13 questions related to attitudes about palliative care practices and training. The last section asked the respondents to rank 11 palliative care educational topics in order of importance.
RESULTS. Forty-nine of 75 eligible residents participated. Although residents thought that pediatricians should have an important role in providing palliative care, residents reported minimal training, experience, knowledge, competence, and comfort in virtually all areas of palliative care for children. We found no significant improvement in any of these areas from the pediatric level-1 year to the pediatric level-3 year. Residents wanted more training regarding pain management. After pain control, the next 4 educational needs were communication skills, namely, discussing prognosis, bad news, and code status and talking with children about end-of-life care.
CONCLUSIONS. There is a clear need for increased efforts in pediatric palliative care education during residency training. Pediatric residents do not think that they are trained adequately in palliative care, and this perception does not improve with time. Pediatric residents view palliative care as important for primary care physicians and desire more education.
Key Words: palliative care • resident education • end of life
Abbreviations: IPPC—Initiative for Pediatric Palliative Care • PL—pediatric level
Caring for dying children in a hospital setting requires expertise in pain and symptom management, as well as deft communication skills involving extremely sensitive issues. During the course of their training, pediatric residents care for 
35 children who die.1,2 Unfortunately, empirical evidence demonstrates clearly that parents are dissatisfied with how medical staff members respond to their child's terminal illness.3–5 Many questions remain regarding training in palliative medicine for pediatric residents. What kind of training would be necessary for pediatric residents to feel comfortable and competent in end-of-life care for children? Given the limits of what can be taught and learned effectively during a 3-year pediatric residency, how much emphasis on palliative care is sufficient?
The evidence is clear that pediatricians in general lack training regarding pain management and palliative care.5–7 A number of small studies documented that pediatric residents receive meager training in palliative care.7–9 One study suggested that, even without a specific palliative care curriculum, residents become more comfortable dealing with palliative care issues as they progress through their training.8 However, most of those studies assessed comfort rather than perceived competence, which, from a clinical point of view, is more important.
Recently, there has been increased emphasis on palliative care in pediatrics. In 2000, the American Academy of Pediatrics Committees on Bioethics and Hospital Care published guidelines on the provision of palliative care services for children.10 National Consensus Conference Guidelines identified 6 principles of end-of-life care in the pediatric setting.6 In addition, the Initiative for Pediatric Palliative Care (IPPC), in collaboration with the National Association of Children's Hospitals and Related Institutions, published curricular guidelines for the provision of palliative care services.11
Our goal in this study was to determine the extent of pediatric residents' training, knowledge, experience, comfort, and perceived competence in various areas of pediatric palliative care. We were particularly interested in the relationship between competence and comfort, as well as whether year of training had any relationship with perceived competence in the absence of formal palliative care training.8 Finally, we wanted to learn from residents about their views regarding palliative care, their desire for training, and the specific content areas in which they were interested. It is our hope that the data generated from this study will help our own pediatrics program and others across the country to plan specific educational interventions regarding palliative care for children.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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All residents in the Children's Hospital of Pittsburgh pediatrics residency program (n = 77) were asked to complete a survey in September 2003. The pediatrics residency program at the time of the study had, on average, 20 categorical, 4 medicine/pediatrics, and 1 pediatrics/psychiatry/child psychiatry residents per year. At the time of this study, there was no formal palliative care service available at Children's Hospital of Pittsburgh. The standard pediatrics curriculum includes 2 months of oncology training, 4 months in the NICU, and 3 months in the PICU over the 3 years. In May of the pediatric level (PL)-2 year, all residents are required to participate in a day-long workshop on death and dying. This workshop includes small-group discussions with parents of terminally ill children and role-playing exercises. Role-playing cases include delivering bad news and discussing a poor prognosis. There was no formal curriculum focusing on symptom management.
The survey asked the residents to rate their own levels of formal training, personal experience, knowledge, competence, and emotional comfort with 10 specific aspects of pediatric palliative care. These 10 areas match closely the elements of the IPPC curriculum11 (see Table 1 for definitions of terms). We do not suggest that perceived competence is equivalent to true competence. We are interested in distinguishing between the perceived ability to perform a task and the psychological/emotional comfort levels with the subject matter. Respondents were asked to rank-order a list of 11 items related to palliative care, according to importance to them as areas for future training. These items also matched closely the elements of the IPPC curriculum.
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The respondents were also asked to answer questions related to their attitudes about palliative care practices and training. The data for this study were collected between September 1 and December 20, 2003. Participation in the study was voluntary. Survey responses were identified only by study numbers. Demographic sheets and consent forms were entered and kept separately from the survey responses. The study was approved by the Human Rights Committee of the Children's Hospital of Pittsburgh.
For data analysis, Likert responses were translated into ordinal numbers (1 = none, 2 = minimal, 3 = moderate, 4 = good, 5 = exceptional). Means and SD were reported. Differences in mean responses between levels of training were compared by using Student's t test for parametric data and the Wilcoxon/Kruskal-Wallis rank sum test for nonparametric data. We considered P < .05 as evidence of a statistically significant difference. JMP version 3.2.1 software (SAS Institute, Cary, NC) was used to analyze the data.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Forty-nine (64%) of 77 eligible residents completed the survey. Response rates according to PL year were 76% for PL-1 and PL-3 and 44% for PL-2. Sixty-nine percent of respondents were female, and 94% of respondents were graduates of US medical schools. The average age of the respondents was 28.5 years. Respondents and nonrespondents were not significantly different with respect to age, gender, and type of training.
The mean number of reported patients who died whereas the resident was caring for them was 3 (SD: 4 patients). Residents reported caring for an average of 19 patients with terminal illnesses during residency. As expected, these numbers increased as individuals progressed through residency. The proportion of residents who reported receiving palliative care training before residency was 29 (59%) of 49 residents. Differences in medical school training among the PL levels did not achieve statistical significance (Table 2).
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The residents were asked to rate their training, experience, knowledge, competence, and comfort in 10 different palliative care domains with Likert responses (1 = none, 2 = minimal, 3 = moderate, 4 = good, 5 = exceptional). The domains were divided into 2 broad categories of communication skills and symptom relief (Tables 3 and 4). No mean response in any PL level for any domain achieved even a moderate level of training, education, knowledge, comfort, or competence. All mean responses were within the range of "none" to "minimal" (responses: 1.2–2.7). There were no statistically significant improvements according to PL year.
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The residents were also asked to rank-order a list of 11 items in order of preference for additional education. After pain control, the next 4 preferred topics were in the area of communication (Table 5).
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Finally, the residents were asked to respond to a series of statements regarding common attitudes to palliative care (Likert responses: 5 = totally agree, 4 = mostly agree, 3 = somewhat agree, 2 = agree a little, 1 = disagree). Residents thought that palliative care is an important competence for primary care providers (mean response: 4.6). They disagreed that palliative care should be left to oncologists, critical care specialists, or palliative care specialists (mean responses for PL-1, PL-2, and PL-3: 1.2, 1.2, and 1.5, respectively). They also disagreed that initiating conversations about palliative care in pediatrics means that "you are giving up on the patient" (mean response: 1.1). The residents showed a strong desire for more palliative care training during residency (mean response: 4.7). They also felt strongly that a palliative care service would contribute positively to both patient care and resident education (mean responses: 4.5). None of the responses differed according to PL year.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The results of our needs assessment demonstrate several important facts about the status of palliative care training for pediatric residents. First, we found that pediatric residents report minimal training, experience, knowledge, competence, and comfort in virtually all areas of palliative care for children. The responses in no area achieved even a moderate level. The responses were equally low in the areas of symptom management and communication skills. Perhaps the most striking and important finding was the lack of significant improvement in any of these areas from the PL-1 year to the PL-3 year. These results contrast with those reported by Varizani et al.8 Our results suggest that pediatric residents do not perceive that their ability to provide palliative care improves through the course of their residency training. One reason for the differing results is that our survey asked more-specific questions about the provision of palliative care. The survey by Varizani et al8 contained more-general statements such as, "My medical education is preparing me to deal with the issues of death and dying." Residents may feel generally better about their education but still lack the requisite skills in specific areas needed for palliative care.
On the basis of our data, it cannot be assumed that pediatric residents learn important skills in palliative medicine. Despite caring for a large number of dying patients, spending almost one sixth of their time in the ICU, NICU, or oncology unit, and participating in a yearly workshop on death and dying, graduating residents felt they lacked even moderate ability to treat common symptoms among patients with life-limiting illnesses. Given that parents have expressed dissatisfaction with physician communication at the end of life, it is worrisome that pediatric residents do not feel confident in these skills.3 There are a number of reasons why increased experience did not result in improved perceived competence. First, no formal palliative care service was available in our hospital at the time of this survey administration. It may be that residents did not receive specific mentorship and role modeling in the delivery of palliative care in the hospital setting. In other studies, the presence of a palliative care service and specific palliative care rotations were associated with perceived preparedness to provide end-of-life care.12,13 Second, attending physicians have training in neither palliative care nor how to teach palliative care skills to residents. We did not survey attending physicians at our institution about this issue. Contro et al4,5 found that 30% to 50% of attending physicians felt inexperienced discussing palliative care with patients and families. These data are likely generalizable to our hospital. Given residents' discomfort in palliative care, it seems unrealistic to think that substantial improvements in these results would be gained in the absence of focused clinical experiences, role modeling, and feedback.
Given the difficult and emotional nature of palliative care for children, it may simply be that a didactic curriculum does not result in improved perceived comfort or competence. Research in continuing medical education has shown the limited effect of didactic lectures on behavior.14 Educational theory suggests that, in addition to information, residents need to see how to perform a task (role modeling) and need the opportunity to practice the task and to receive feedback. It may be too much to expect residency programs to perform this well enough in the absence of formal palliative care services. For institutions and training programs without the ability to employ palliative care services, educational efforts for the housestaff would be best spent in developing interactive training and feedback regarding appropriate pain management and difficult end-of-life conversations.
There were strong sentiments that a palliative care service would improve patient care and resident education. There is supporting evidence for the benefits of palliative care consultations in the care of neonates and infants.15 The specific effects of palliative care consultation services on resident education in pediatrics have not been studied. Data from the adult literature suggest that there is an educational benefit to palliative care consultation services for trainees.13 The respondents in our study thought that they would benefit from additional training in palliative care. They also perceived the role of a primary care physician in providing palliative care as important. They felt strongly that palliative care should not be the province of palliative care specialists, intensivists, or oncologists alone. Therefore, residents are strongly motivated to learn palliative medicine topics.
Our rank-order list will help to prioritize the topics for our future palliative care curricula and teaching exercises. The Accreditation Council for Graduate Medical Education requires that pediatrics training programs "include formal instruction on pain control and the impact of chronic diseases, terminal conditions, and death on patients and their families."16 It is important to plan educational interventions in these areas on the basis of learner needs. Pain control was the item about which resident physicians of all groups most wanted more training. The desire for more training in pain control is not surprising, because 90% of children receive pain medication in the last 72 hours of life.17 Pain management is a common and important topic in palliative care for pediatrics, but our residents received little formal training in it. This would be an easy uncontroversial way to begin to teach palliative care in pediatric residency programs. This list suggests that the most important topics to trainees are pain management and end-of-life communication. Given the constraints of pediatric residency curricula, initial educational interventions in palliative care should perhaps focus on these 2 areas.
Because most pediatric deaths occur in the PICU, NICU, or oncology ward settings, it is logical to plan educational efforts in these areas.17,18 The type of knowledge or experience desired will determine the type of intervention. At our institution, we are fortunate to have a supportive (palliative) care consultation service now in existence. This service was not widely available at the time of our survey. Our palliative care consultants have since taken an active role in teaching pain management at the bedside. In addition to this bedside teaching, we are planning interactive, case-based discussions regarding pain and symptom management for end-of-life care. Our curriculum will expand on standards for palliative care education outlined by the National Consensus Conference on Medical Education for Care Near the End-of-Life, as well as the IPPC.6,11
After pain control, the next 4 items listed were communication skills, namely, discussing prognoses, bad news, and code status and talking with children about end-of-life care. There are increasing data indicating that parents of children with malignancies regret not talking to children about death.19 Training in this area should encourage parents to discuss dying with their children. Emotional support for physicians was listed as the least important item. This contrasts somewhat with the results of Khaneja and Milrod,9 who found that 100% of residents expressed a need for additional support in dealing with death and dying. To address communication skills, we plan to have interactive small-group discussions, with role-playing, for residents during their oncology and PICU experiences. In addition, we intend to expand the curriculum of the 1-day workshop on death and dying to incorporate specific aspects of communicating with families and children about end-of-life care.
There were several limitations to our study. The response rate for our residents was somewhat less than we anticipated. The PL-2 class was underrepresented in our sample; the reasons for this were unclear. All residents received a printed copy of the survey in their mailboxes, as well as an e-mail version. There were no demographic differences between respondents and nonrespondents. The respondents were like the nonrespondents with respect to gender, year of training, and age. Another limitation was the closed-ended nature of our survey. We designed our needs-assessment survey on the basis of the areas identified in the existing literature and by the National Consensus Conference on Medical Education for Care Near the End-of-Life.6 Our rank-order list did allow the residents to write in another topic they would like to have covered, but none chose to do so. Our study was not designed to implement objective measures of competence in these areas. If such measures had been used and had shown that residents did perform competently, then the extreme levels of discomfort and lack of perception of competence would still need to be addressed formally. Given the data by Harper and Wisian3 and Contro et al4,5 indicating that families are not satisfied with care, it is important to address the reasons why physicians and residents do not feel competent or comfortable. This again suggests that role-modeling, role-playing, and communication skills may be more important than knowledge-based educational interventions. We did not assess resident preferences for types of educational interventions, for example, lectures, small-group discussions, role-playing, attendance at family conferences, or bedside teaching. Some authors found that residents preferred interactive case-based discussions to lectures or role-playing.7
Because this survey was administered before the creation of our supportive (palliative) care service, we are planning a follow-up survey. We hope to measure the effects of the palliative care service on resident education regarding end-of-life care for children.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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There is a clear need for increased efforts in pediatric palliative care education during residency training. Our study suggests that pediatric residents view palliative care as important for primary care physicians and desire more education. However, they do not think that they are trained adequately in palliative care, and this perception does not improve with time. Specific educational interventions should be based on residents' perceived needs.
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ACKNOWLEDGMENTS |
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R.M.A. is supported by the Project on Death in America Faculty Scholars Program, the Greenwall Foundation, the Ladies Hospital Aid Society of Western Pennsylvania, and the Ladies Aid Society Trust Foundation.
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FOOTNOTES |
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Accepted Dec 19, 2005.
Address correspondence to Russ C. Kolarik, MD, University of Pittsburgh Medical Center Shadyside, 5230 Centre Ave, 206 SON Building, Pittsburgh, PA 15232. E-mail: kolarikrc{at}upmc.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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