This article describes the results of a Robert Wood Johnson Foundation—funded project through which medical schools in New York State developed and implemented strategic plans for curricular change to enhance palliative care education. The curricular changes were accomplished by the development and implementation of the Palliative Education Assessment Tool (PEAT) and the facilitation of a strategic planning process within each school. The development of PEAT is described elsewhere.1 PEAT is a self-administered assessment tool that is used to examine all required courses in the entire four-year curriculum to uncover those areas in the curriculum where specific aspects of palliative care are taught.
In recent years, professional groups and the public in the United States have voiced increasing concern about physicians' lack of knowledge and skill in palliative and end-of-life care.2–4 Educational initiatives for nurses,5 residents in training,6 and practicing physicians7,8 have attempted to address these concerns. However, studies reveal little palliative care content in medical school curricula.3,6,9–13 To address the problem in the 14 medical schools in New York State, the New York Academy of Medicine in collaboration with the Associated Medical Schools, the organization representing the deans of the medical schools in New York, developed a plan to enhance palliative care curricula.
To define what ought to be taught in palliative care in medical schools and supply information about the actual palliative care content in the curricula of individual schools, the schools collected data on the palliative care content of each course in their four-year curricula using PEAT. We aggregated the data and returned them to the schools for analysis through a process of interactive meetings. A school's strategic plan for change was catalyzed by site visits to each school, and the strategic plan's specific objectives were documented by a representative of the school in a structured manner. One year after the implementation of the plans, we asked each school to report on the degree to which its specific objectives had been accomplished.
Curricular reform presents a challenge on a number of levels. Strong support from the dean and other medical school leaders is important but rarely sufficient to create meaningful and enduring change. Curricular reform also requires widespread faculty involvement to redesign existing formats or integrate new content.14,15 Curricular reform is often greeted by resistance from faculty because of the vast amount of information that needs to be taught in a limited time period. Faculty committees may be unaware of the actual content of the four-year curriculum unless a careful evaluation process has been implemented. This is particularly true for “orphan” subjects such as palliative care that are not the specific purview of one department.16,17 Such orphan subjects often benefit by being integrated in a developmental manner throughout the entire four-year curriculum. Thus, a process incorporating self-assessment, data collection, site visits, and strategic planning was thought to be an effective catalyst for curricular change.
COLLECTION OF CURRICULUM-CONTENT DATA
PEAT is the first assessment tool to map a thematic issue across an entire four-year curriculum. The goal of using PEAT is to provide the data based upon which a school might consider implementing change. PEAT was developed through an interative process of consultation with nationally recognized, multidisciplinary palliative care experts and individual school-based experts in curricular design and palliative care. As a self-assessment tool, it can determine the existence of palliative care education in a wide range of curriculum formats and facilitate the identification of “hidden” pallative care education within the basic science and clinical curriculum. Because palliative care is often thought of as an orphan subject that does not have a specific home within any one department, it is common for elements of palliative care to be dispersed throughout the curriculum. Thus, PEAT is designed to assess all required courses in the entire four-year curriculum as well as relevant electives to uncover those areas in the curriculum where varying aspects of palliative care are taught.
PEAT consists of seven major palliative care domains with specific objectives, skills, and competencies related to each domain (see Meekin et al. for a complete description of the PEAT domains1 and core competencies):
- Palliative medicine—a basic overview of palliative care and a population health perspective of the issue
- Pain—the basic science and applied clinical skills necessary to assess and manage pain
- Neuropsychologic symptoms
- Other symptoms
- Ethics and the law—the legal and ethical dimensions of palliative care
- Patient/family/caregiver perspectives on end-of-life care
- Clinical communication skills
Using PEAT, members of the office of education of each school, often with the assistance of a medical student, interviewed the course director or other responsible faculty member for each required course to determine the extent of palliative care content in that course. They noted whether any part of the course included material relevant to the multiple objectives of each domain in PEAT. The type of educational format and hours taught were recorded. Data were aggregated to allow the individual schools to view which domains were addressed in which courses and to identify obvious gaps in which whole domains or specific objectives were not covered. An example of aggregated data for a representative school is shown in Figure 1. Each school was also able to compare individual school data with aggregated data generated from other institutions confidentially.
FACILITATION OF STRATEGIC PLANNING
One or both of the principal investigators (ARF and JJF), along with the project director (SAM), visited each school in late winter or early spring. The main goal of these site visits was to provide feedback and catalyze a dialogue for strategic planning to enhance the palliative care curriculum in each school. The agenda for each visit included a meeting with the dean and senior associate dean for education, basic science and clinical course directors, the curriculum committee, and other essential faculty, as well as local palliative care experts. The site visitors explained the project, presented the data collected using PEAT, and identified strategic opportunities for improvement to the curriculum committee. This process initiated a discussion of strategic plans based on the PEAT data and the local needs expressed by participants.
Subsequent to the site visits, each school was given six to eight weeks to develop a written strategic plan, based on a standard one-page strategic planning guide, to enhance the palliative care content in its four-year curriculum. The guide asked each school to describe specific objectives for curricular change to reflect enhanced palliative care content. Schools were also asked to define the perceived barriers to change (previous and future), and to share with the other schools any exemplary practices presently in place.
During this strategic planning process, the schools also received a review of the literature on palliative care education and a collection of palliative care education initiatives from schools across the country identified as having required courses in palliative care. The schools were aware that at the end of one year there would be an evaluation process to assess the success of the strategic initiative and the degree to which their objectives had been implemented. Prior to the one-year follow up, specific objectives from the strategic plans were categorized into changes in courses in the pre-clerkship or clerkship years, faculty development, and electives and other special programs. Present and future barriers to implementing change were also enumerated.
One-year Follow Up
One year after the creation of a strategic plan, faculty members responsible for developing it received a form listing the proposed specific objectives for change that had been extracted from the plan. The responsible faculty were asked to indicate whether each objective had been implemented, was actively in the planning stage, or had not been accomplished. They were also asked to provide additional information, if necessary, and to elaborate if an objective was still in the planning process or had not been implemented. Faculty were also asked to indicate whether the present or potential barriers defined at the time of the development of the strategic plan were still in place or had been overcome. Last, if change had occurred, they were asked to enumerate those factors that had facilitated change. Every school that had not originally provided a strategic plan was asked to list any changes that had taken place in the curriculum relevant to palliative care and pain medicine and to list any barriers to change as well as any helpful factors that allowed for change to occur.
DEGREE OF IMPLEMENTATION
Of the 14 New York State medical schools, 13 participated in the PEAT process (one declined involvement). Ten schools provided strategic plans for change. Table 1 shows the overall degrees of implementation for the schools that participated. Of the ten strategic plans, there were 71 specific objectives, with a median of five per school. Sixty-seven (94.4%) of the stated objectives had been implemented or were in the active planning process one year after the plans were created. The percentages of changes in course content by category were pre-clerkship years (36.6%), clerkship years (36.6%), electives and special programs (9.8%), initiatives in faculty development (12.7%), and other (4.2%). (See Table 1.)
Content Changes in Pre-clerkship Courses
For the pre-clerkship years, schools' objectives included changes in palliative care content in the basic science courses (13 objectives) as well as integration of palliative care content into humanities and ethics courses (13 objectives). Of the seven schools that proposed explicit objectives to incorporate palliative care content into the basic science curriculum, all seven accomplished some or all of those objectives. Changes varied from a full curricular reform, where palliative care topics were integrated into the basic science years, to smaller-scale and focused changes in individual classes. Examples of these changes included incorporating core competencies in palliative care into a number of problem-based learning sessions, a death-awareness exercise in anatomy class, and a pharmacology session in which students learned about pain management with a specific focus on the use of opioids at the end of life.
Of the six schools that listed objectives for implementing palliative care content into humanities and ethics courses, all six accomplished those objectives or reported they were in the process of accomplishing them, with only one objective not initiated. These courses had integrated palliative care content focusing on curricular objectives in domains I, palliative medicine, V, ethics and the law, VI, patient/family/caregiver perspectives on end-of-life care, and VII, clinical communication skills. For example, a course at one school that extends through years one and two added a session on the culture of pain, drawing upon students' knowledge of the physiology and anatomy of pain, to put the education about pain in a personal and cultural perspective. Other objectives that were accomplished included an increased focus on communication skills relevant to telling bad news and discussing advance directives, as well as increasing students' awareness and understanding of the social, psychological, cultural, and spiritual implications of chronic and terminal disease for the patient and family.
Content Changes in Clerkship Courses
Evidence of the implementation of curricular change in the clerkship years was most notable in the integration of palliative care content into blocks during clerkship rotations. All ten schools either accomplished their objectives for incorporating palliative care content into the clerkship years or reported that they were in the planning phase of incorporating those objectives. Specifically, palliative care content or sessions on palliation were added to various clinical rotations, including obstetrics and gynecology, neurology, pediatrics, family medicine, and geriatrics. The content was also incorporated through case-based exercises, small-group discussions, role plays, and problem-based learning sessions, and by incorporating several modules of the American Medical Association's (AMA's) Education for Physicians on End-of-Life Care (EPEC) curriculum into a third-year family medicine clerkship. Other examples included a new required clerkship in palliative care for all third- or fourth-year students that integrated basic science issues into the clinical dimensions of the course. At another school, a section on bereavement was being incorporated into a module on death and dying in the psychiatry clerkship, and best strategies were being identified to incorporate knowledge gained from the study of chronic and terminal diseases into all clerkships.
Elective or Specialty Programs
In addition to enhancing the required curriculum, the schools initiated several elective experiences related to palliative care. Of the ten schools, six planned new electives in palliative care. Of these, three schools had initiated these electives and two responded that they would begin these programs soon. The electives included a rotation on the palliative care consult service for fourth-year students, an elective at a residential hospice facility, and interactions with an elderly chronically ill patient during a mandatory patient-related experience that students must successfully complete.
Faculty development was also seen as an important strategic initiative to enhance palliative care education in both the pre-clerkship and the clerkship years. Three schools had presented a total of nine specific objectives for faculty development in the area of palliative medicine, and all nine objectives were accomplished. The objectives involved educating faculty about the importance of palliative care and raising the visibility of palliative care and pain medicine at the institution, hiring new faculty with expertise in palliative care, and offering the AMA's EPEC curriculum to relevant faculty members. At one school, faculty development also was encouraged by establishing a new division of medical ethics, where the coordination of teaching and research activities in palliative care would be a primary function. A final objective involved promoting palliative care faculty to more visible positions in the medical school.
Nine schools embarked on developing comprehensive longitudinal curricula to integrate palliative care seamlessly throughout the four-year educational experience. Two of the nine schools accomplished full integration of palliative care education throughout the four years. At one school, this integration was reflected in a new model of end-of-life training in which aspects of end-of-life and palliative care were fully integrated with basic science, clinical science, and psychosocial content over four years. Seven of the schools were still in the planning stages of this integrative process, but they had already accomplished many of the specific objectives to facilitate this goal.
Only four of the 71 strategic objectives were not accomplished or were rejected entirely by curriculum committees. Two were planned electives, one was a change in an ethics and humanities pre-clerkship curriculum, and one was a proposed clerkship change.
BARRIERS TO CHANGE
Despite the number of objectives that were successfully accomplished and the number on their way to being accomplished, barriers to incorporating palliative care content into the medical school curriculum remained. Of the 37 barriers to change described by the ten schools, 15 were overcome. Major barriers to change remained, including lack of faculty time and commitment, lack of curriculum time because of competing content areas and a decrease in the number of total student-contact hours, lack of funding, lack of faculty competence in palliative care, inappropriate patient populations, and lack of palliative care faculty role models.
SUCCESSFUL CURRICULAR CHANGE
The process of self-assessment, curriculum mapping of a specific thematic area, and strategic planning for change appears to have successfully enhanced the palliative care content in medical schools' curricula. In the past decade, we have witnessed a radical change in medical education that has involved adapting curricula to move from a lecture-dominated and departmentally run format to a centrally governed, multi-model, goal-oriented, integrated approach.14 As a result, many of the basic science courses students are exposed to during their pre-clerkship years are evolving to diminish lecture time and emphasize students' achievement of a level of scientific fluency rather than rote memorization of scientific facts. This new approach integrates more problem-based learning sessions as well as offers a longitudinally designed, interdisciplinary curriculum where the line between the pre-clerkship and the clerkship years is not as decisive as it has been in the past. While the change in curriculum format and design creates a challenge to assessing where orphan topics such as palliative care are taught, it also offers an opportunity for medical schools to determine areas where content can be integrated seamlessly into the curriculum.
This project did not seek to create a model palliative care curriculum to impose on the schools in New York State. Rather, we chose to create an atmosphere conducive to curricular reform by developing a self-assessment and strategic planning process. We encouraged best practices to be shared among the schools, but these were never intended as recommendations for wholesale adoption. As previous studies have shown, involving the institution in the process through collaboration, collection of institutional data, and feedback, coupled with site visits for more in-depth analysis and discussion of the issues, is often the most effective means of implementing change.18
While there is no universally accepted or proven method for assuring successful curricular reform, there are certain elements that may ease the barriers encountered in the process: a commitment from the dean and other educational leaders of the medical school, an awareness of national recommendations for curricular reform established by accrediting authorities, school-specific data on perceived deficiencies, committee structures to discuss and implement change, and mechanisms for evaluation of the effectiveness of educational initiatives.14 Most of the schools involved in our project mentioned that some of these had enhanced changes in the palliative care content of their curricula. Some also noted the usefulness of bringing together clinicians and basic scientists to design integrated modules in palliative care, which helped to change entrenched attitudes about content and formats.
Site visits appeared to be an important intervention for facilitating curricular reform. Curriculum committees and associate deans for education often reviewed the PEAT results and reported their findings to the dean prior to the site visit. Because there was little disagreement that palliative care is an important part of medical education, this process catalyzed focused discussions about what was needed in palliative care education, what was possible within the curriculum schedule, and what additional resources might be required.
AREAS FOR FURTHER INQUIRY
This project did not specifically evaluate the associations between the use of PEAT, the process surrounding its implementation, the development of strategic plans, and curricular reform in palliative care. In our work, there were no objective validated measures of curricular content in any of the schools because this self-assessment process was not intended to measure actual curricular content that was comparable among institutions. Rather, we concentrated on catalyzing change at individual schools. We used no control group to measure whether similar changes were also taking place in medical school curricula in other institutions. The design and implementation of this project came during a time when the awareness of the importance of palliative care education was on the rise, which was probably helpful in creating the curriculum change we documented.
Further, it will be important to have an objective outcome measure of medical students' knowledge, skills, or attitudes to determine whether changes in curriculum have an impact. Some schools that participated in the project developed evaluation strategies to assess the degree to which new initiatives have an impact on students' knowledge of palliative care. We look forward to the findings of those studies.
With an aging population and an increasing prevalence of chronic illness, it is important for future physicians to be able to address palliative medical care, from managing pain and other symptoms of illness to communicating with patients and families about end-of-life care. Medical educators are responsible for assuring that curricula reflect these important subjects. The development of an assessment tool for palliative care content in the curriculum that it self-administered and provides the evidence for strategic planning seems to be an effective method of enhancing palliative care education in medical school curricula. This method of curricular mapping and focused strategic planning may be applicable to other reforms of the undergraduate medical education curriculum.
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