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Original Article

Internal Medicine Residents’ Beliefs, Attitudes, and Experiences Relating to Palliative Care: A Qualitative Study

S. Kawaguchi, MD 1 , R. Mirza, PhD

2 , R. Nissim, PhD

3 ,

and J. Ridley, MD 4

Abstract Background: Internal medicine residents are frequently called upon to provide palliative care to hospitalized patients, but report feeling unprepared to do so effectively. Curricular development to enhance residents’ palliative care skills and competencies requires an understanding of current beliefs, attitudes and learning priorities. Methods: We conducted a qualitative study consisting of semi-structured interviews with ten internal medicine residents to explore their understanding of and experiences with palliative care. Results: All of the residents interviewed had a sound theoretical understanding of palliative care, but faced many challenges in being able to provide care in practice. The challenges described by residents were system- related, patient-related and provider-related. They identified several priority areas for further learning, and discussed ways in which their current education in palliative care could be enhanced. Conclusions: Our findings provide important insights to guide curricular development for internal medicine trainees. The top five learning priorities in palliative care that residents identified in our study were: 1) knowing how and when to initiate a palliative approach, 2) improving communication skills, 3) improving symptom management skills, 4) identifying available resources, and 5) understanding the importance of palliative care. Residents felt that their education in palliative care could be improved by having a mandatory rotation in palliative care, more frequent didactic teaching sessions, more case-based teaching from palliative care providers, opportunities to be directly observed, and increased support from palliative care providers after-hours.

Keywords palliative care, palliative care curriculum, palliative care education, internal medicine, resident education, medical education

Background

Education in palliative medicine is increasingly recognized as an

essential component of all physician training programs. Within

Canada, efforts are underway to make palliative medicine an accre-

dited subspecialty and to incorporate palliative care into existing

core curricula. 1

At the present time, however, education within

postgraduate programs has been described as less than adequate. 2

Internal medicine residents are a particularly critical group

when it comes to palliative care training. Although the majority

of Canadians would prefer a home death, approximately two-

thirds currently die in hospital. 3

Internal medicine residents are

frequently tasked with providing end-of-life care to hospita-

lized patients and are often required to do so very early in

residency. Despite this recognition, medicine residents have

reported feeling unsure of their skills when caring for a dying

patient 4,5

and infrequently receive feedback when engaging in

advance directive or end-of-life discussions. 6

A recent Cana-

dian cross-institutional, survey-based study found that almost

half of respondents felt guilty or a failure at least sometimes

after a patient’s death. 7

Educational interventions aimed at improving both symp-

tom management and communication skills have been previ-

ously implemented and published. For medicine residents,

these have included introduction of courses in palliative care

and communication, 8-11

order sets, 5

pocket reference tools, 12

and mandatory rotations in palliative care. 13,14

Their impact is

assessed through post-intervention knowledge testing and

1 Division of Palliative Care, Department of Family and Community Medicine,

Mount Sinai Hospital, Toronto, Ontario, Canada 2 Faculty of Medicine, Institute for Life Course and Aging, University of Tor-

onto, Toronto, Ontario, Canada 3 Department of Psychosocial Oncology and Palliative Care, Princess Margaret

Cancer Centre, University Health Network, Toronto, Ontario, Canada 4 Division of Palliative Care, Department of Family and Community Medicine,

Princess Margaret Cancer Centre, University Health Network, Toronto,

Ontario, Canada

Corresponding Author:

S. Kawaguchi, MD, Temmy Latner Centre for Palliative Care, 60 Murray Street,

4th floor, Toronto, Ontario, Canada M5T 3L9.

Email: [email protected]

American Journal of Hospice & Palliative Medicine®

2017, Vol. 34(4) 366-372 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909116628799 journals.sagepub.com/home/ajh

survey questions about perceived competence. What is missing

is an understanding of residents’ experiences and how those

experiences shape their learning needs. Given the increasing

complexity of palliative medicine and varied experiences of

residents, we undertook a qualitative study with the aim of

developing a deeper understanding of medicine residents’

experiences with palliative care.

Methods

In March 2015, we recruited internal medicine residents in

postgraduate year (PGY) 1 and 3 from 2 teaching hospital

sites in Toronto, Ontario. Approximately 60 residents in total

were approached for participation of whom 12 responded.

We undertook a qualitative approach and employed purpo-

sive sampling techniques. 15

As part of this approach, we

excluded residents intending to pursue subspecialty training

in palliative medicine as well as residents known personally

to one of the researchers. One resident was thereby excluded

while a second resident indicated interest late in the study, by

which point the authors felt that saturation had already been

reached within the data. Ten residents participated: 7 PGY3

residents and 3 PGY1 residents. Two of the 10 participants

had completed an elective in palliative care during residency

but none with the intent of becoming palliative care special-

ists. This sample size allowed us to uncover a range of

beliefs, attitudes, and experiences and to achieve data

saturation.

As the aim of the study was to gain insights into medicine

residents’ experiences with palliative care, semistructured

interviews were conducted. The study protocol and materials

were approved by the research ethics boards at the University

of Toronto and the relevant teaching hospital sites. Interviews

were conducted by SK using a semistructured guide, and RM

was also present to record field notes. The guide was developed

with input from all 4 authors to generally explore residents’

understanding of a palliative approach to care, to inquire about

challenges and perceived learning gaps, and to understand

experiences that had facilitated their learning. Interviews took

between 30 and 45 minutes. All interviews were recorded and

transcribed verbatim, personal identifiers were removed, and

the transcripts reviewed for completeness and accuracy.

Recruitment was stopped once no new themes were emergent,

and new data became redundant with respect to the framework

for analysis.

Data analysis began with the identification of major

topic areas based on priority questions in our interview

guide and current gaps in the literature. All 4 authors

agreed upon the selection of these major topics. A

content-based coding scheme was then developed and tri-

angulated among 3 authors (SK, RM, and J.R.). Transcripts

were coded by 2 authors (SK and RM), and axial coding

was then undertaken to identify connections between cate-

gories. Codes were then collapsed into major categories and

subcategories, and themes were extracted based on multiple

re-readings of the data.

Results

From the data, we identified themes within 3 major topic areas:

(1) residents’ evolving understanding of palliative care, (2)

challenges residents faced in providing effective palliative care

including system-related, patient-related, and provider-related

challenges; and (3) residents’ training needs and preferences.

Themes and supporting quotes are summarized in Table 1.

Evolving Understanding of Palliative Care

Palliative care as more than end-of-life care. When discussing a palliative approach to care, all participants understood that pal-

liative care is not limited to end-of-life care. They recognized the

value of early involvement of palliative care in terms of its

positive impact on patients’ quality of life. They also recognized

that palliative care can and often does occur concurrently with

active medical management.

Palliative care as more than cancer care. When discussing a typ- ical palliative patient, all participants also knew that palliative

care extends beyond just the treatment of patients with cancer.

They spoke about patients with a range of diagnoses including

cancer, organ failure, dementia, and acute catastrophic events.

However, many residents commented on how they had not

always understood palliative care in this way. They cited var-

ious experiences that had changed their understanding. The 2

participants who had completed an elective in palliative care

felt that it was primarily through their elective that their under-

standing had evolved. For the 3 PGY1 residents, either their

medical school curriculum or their personal experiences with

palliative care had shaped their understanding. The others

alluded to learning through lectures and through experiences

caring for patients during residency.

Challenges in Providing Effective Palliative Care

Despite participants’ clear understanding of the definition and

importance of palliative care, they experienced many chal-

lenges in providing effective palliative care for their patients.

These challenges were (a) system related, (b) patient related,

and (c) provider related.

System-related challenges Time constraints. Time constraints were a commonly cited

barrier to providing palliative care in an inpatient setting. Res-

idents felt that they needed more time to really focus on the

needs of patients in order to provide good palliative care, and

this was frequently not possible, given the nature of inpatient

medicine. They acknowledged that when they were unable to

dedicate time to their patients, the perception was that out-

comes suffered.

Care priorities. Although all participants recognized the value and importance of palliative care, many admitted that when

time was limited, they tended to prioritize ‘‘that person [who

is] crashing versus you know a pain crisis’’ (PC07_PGY3). In

Kawaguchi et al 367

Table 1. Internal Medicine Residents’ Experiences With Palliative Care: Themes and Supporting Quotes.

Category Themes and subthemes Supporting quotation

Evolving understanding of palliative care

Palliative care as more than end- of-life care

‘‘I think when I first started, I thought it was a very sharp like, treatment stops and then palliation starts and I think I also perceived it as only people with very advanced like prognosis within days to weeks, maybe months, would be appropriate palliative care patients. I never thought that patients with a prognosis from months to years would be followed by palliative care providers.’’ (PC03_PGY3)

Palliative care as more than cancer care

‘‘That is what palliative care was to me beforehand. It wasn’t just imminent death, it was imminent cancer death.’’ (PC09_PGY3)

System-related challenges Time constraints ‘‘Providing good palliative care, good support and discussions with patients and their families requires time, no question about it. And sometimes with the pressures of managing a team and admitting patients and discharging patients, as much as I want to, that just doesn’t exist so I think sometimes we do a suboptimal job just because we can’t get around to it . . . ’’ (PC03_PGY3)

Care priorities ‘‘I find that most residents and myself included have made the subconscious decision to take care of more acute presentations when we’re not sure exactly what’s going on with that patient in the emergency room compared to something where we know where it’s coming from but we just don’t have good enough control of the symptoms.’’ (PC02_PGY3)

Patient-related challenges Public misconceptions about palliative care

‘‘I think sometimes there’s a stigma in using the term palliative medicine so I think when you initially broach it to patients and their loved ones they take a step back I think. People understand it to mean that they’re in their last few days.’’ (PC04_PGY1)

Conflicts between patients and their family members

‘‘When they [family members] hear about goals of care or even talking about code status they you know initially will want everything possible to be done, whereas I find patients themselves sometimes will want to be more comfortable . . . ’’ (PC06_PGY1)

Provider-related challenges Knowing how and when to initiate a palliative approach to care

‘‘Where do you draw that line when you’ve tried everything possibly medically to optimize their breathlessness to the point where you say, you know like, if they have a clot, that blood thinner is not going to work, if they have pneumonia, you optimize that by giving them antibiotics, how long would you wait before going to the narcotics and to some of the more advanced medications to say well right now, even though this may make them more drowsy and it might cause an earlier respiratory compromise, they’re going to be more comfortable.’’ (PC02_PGY3)

Communicating effectively with patients and families

‘‘I think um, maybe for pragmatic reasons, especially in an inpatient setting, people just, people need to know whether they are going to resuscitate somebody when they code, people need to know if we’re going to continue to draw bloodwork or not, people need to know if we’re going to continue or stop fluids and I think presenting things in that fashion allows us to answer those questions in a very yes/no manner which I think makes us feel good as clinicians and makes life for us easier but I’m not so sure that’s the greatest thing for a patient and their families.’’ (PC03_PGY3)

Managing patients’ symptoms ‘‘I think on internal medicine we don’t always think through a patient’s symptoms as much as a palliative care physician would. If they’re in pain we’ll give opioids. We won’t necessarily think you know is this pain neuropathic? I find with nausea on internal medicine we often again don’t really think, why is this patient nauseous? We just—we always use like Ondansetron or Maxeran.’’ (PC08_PGY3) ‘‘I really don’t think the medicine of palliative care is difficult. Look I don’t have that order set memorized but like it’s very easy to look up and I don’t think it’s—people know, secretions this, agitation that . . . ’’ (PC09_PGY3)

Understanding available resources ‘‘When families of patients or patients themselves are asking, okay you know, you said you wanted to involve the palliative care team, what can they offer me and other than the broad strokes of a sense of what palliative care actually is, I couldn’t tell them what kind of specifics are available. If I go home with palliative care, what type of resources can they provide me with at home? And I don’t have the answers to those things.’’ (PC01_PGY3)

(continued)

368 American Journal of Hospice & Palliative Medicine® 34(4)

other words, residents perceived that patients requiring resus-

citation needed to be seen more immediately than those requir-

ing symptom management, even in cases of palliative care

emergencies. In other cases, residents described a bias toward

diagnosing patients with unknown etiologies rather than opti-

mizing symptom management for patients for whom a diagno-

sis is already known.

Patient-Related Challenges Public misconceptions about palliative care. Many residents dis-

cussed misconceptions that their patients and patients’ families

held about palliative care. The 2 common misconceptions cited

were (1) the perception that palliative care is synonymous with

end-of-life care and (2) the perception that making a patient

palliative means abandoning their care. Residents found that

these misconceptions often led to resistance to involving pal-

liative care teams or discussing palliative interventions.

Conflicts between patients and their family members. Many residents had encountered situations in which patients and fam-

ily members disagreed about how their care should proceed.

Conflict between patients and their families frequently led to

conflict between family members and the medical team. Res-

idents struggled with this because they acknowledged that pal-

liative care is ‘‘about not only addressing the suffering of the

patient but also the suffering of the loved ones that they leave

behind’’ (PC10_PGY1). Residents often felt the need to

involve palliative care teams to help address these challenging

situations.

Provider-Related Challenges Knowing how and when to initiate a palliative approach to care.

Nearly all residents expressed uncertainty about how to inte-

grate elements of active medical management with comfort-

focused modalities. In one resident’s words, ‘‘when patients are

kind of deemed palliative . . . what are our roles in providing treatment for the patient?’’ (PC06_PGY1). The ‘‘gray’’ scenar-

ios in which a patient identifies that he or she wishes to focus

on comfort but still wishes to have reversible causes treated

were found to be more challenging than those in which patients

are comfort measures only. For a minority of the residents,

despite recognizing an overlap between palliative and ‘‘active’’

care, they still perceived the need to delineate a sharp transition

point between the two. They perceived a trade-off between

quality and quantity of life and therefore felt that that they

needed to carefully select the moment to initiate a palliative

approach.

Communicating effectively with patients and families. Residents identified challenges with some of the more difficult discus-

sions in palliative care, particularly around breaking bad news

and approaching goals of care. Despite understanding that

goals of care are intended to be ‘‘more holistic,’’ many admit-

ted that their approach to discussing a patient’s preferences for

Table 1. (continued)

Category Themes and subthemes Supporting quotation

What can internal medicine programs do differently

Increase didactic teaching opportunities

‘‘We don’t get a lot of didactic palliative care teaching first of all. Like I’m trying to remember we may have had one half-day on it in three years so like we don’t get a lot of it even though it is something that we see a lot of.’’ (PC07_PGY3)

Make palliative care a mandatory rotation

‘‘We are able to do a palliative care rotation but right now I would say, just like I did it as an elective, it’s not a mandatory rotation. And not a lot of people are as interested as I think that they might be if they had a little bit of exposure . . . ’’ (PC01_PGY3)

What can palliative care providers do differently

Provide informal teaching around cases

‘‘Part of it is reading through the consult notes, part of it is reading through the suggest orders but I mean part of it is also just pull us aside, say hey, we’ve seen your patient, this is what we suggest, do you know what a PPS score is, I can tell you what it is.’’ (PC04_PGY1)

Teach about the importance of palliative care

‘‘His [referring to a Toronto palliative care physician] talk is one of the best palliative care talks and he teaches you nothing about the process of palliative care. He just teaches you why palliative care is important um, and shows you data and whatever else . . . I don’t think it’s that hard to find a palliative care doctor at all the sites to sort of give that kind of a talk. I think that would be another way to sort of make it, reinforce the importance of it and make people think about it a little bit.’’ (PC09_PGY3)

Observe residents and provide feedback

‘‘I’ve done those [family meetings] kind of on my own and no one has really observed me doing it . . . I unfortunately haven’t had someone to tell me about things that I could change.’’ (PC06_PGY1)

Be available to residents after hours

‘‘Sometimes I have had good experiences at specific hospitals . . . where you can actually call a palliative care staff on call if there are certain things that you are not as familiar with, one of those being, for example, how do you manage respiratory distress because the specific medication titrations in that sense that we are not used to giving.’’ (PC02_PGY3)

Kawaguchi et al 369

care becomes ‘‘very much like a checklist . . . often used as sort of code for CPR status’’ (PC03_PGY3). This was felt to be

the result of not only time constraints but also lack of experi-

ence with having these discussions. Residents expressed a

desire for further training to improve their communication

skills, particularly with respect to goals of care discussions.

Managing patients’ symptoms. Almost all of the residents identified specific symptoms in palliative care that they found

particularly difficult to manage. Four of the 10 residents spoke

about challenges with pain management, specifically relating

to the use of adjuvant treatments and safe titration of opioids.

Respiratory distress, nausea, and agitation were also discussed

as challenging symptoms. Many of the residents spoke about

symptom management in terms of an empiric approach in

which medications are selected to generally target the symptom

at hand. Only 1 resident explicitly recognized the value of

understanding the etiology behind a symptom and identified

this as an area for potential learning and growth. A minority of

the residents interviewed felt comfortable with all areas of

symptom management. Residents reflected that increased

exposure to palliative care could lead to greater recognition

of the nuances of symptom management and greater confi-

dence in managing symptoms.

Understanding available resources. Another common theme was the challenge of knowing what resources were available

to patients with a palliative diagnosis, especially when transi-

tioning home. One concern was that resources were context and

setting dependent, and therefore the resources available at one

hospital were not the same at another one. Residents felt that

without knowing what resources were available, they were

often unable to have complete conversations with patients and

their families.

Training Needs and Preferences

What can internal medicine programs do differently Increase didactic teaching opportunities. Participants uniformly

found lectures relating to palliative care helpful in terms of

increasing their knowledge but felt that they were not done

with great enough frequency. They expressed a need for more

sessions relating to both symptom management and

communication-related issues, but many felt that communica-

tion would be better taught through sessions in which they

could practice their skills and receive feedback.

Make palliative care a mandatory rotation. A resounding theme was the value of experiential learning and therefore the value of

having a dedicated rotation in palliative care. At the University

of Toronto, medicine residents are able to complete an elective

in palliative care, but it is not mandatory. Many of the PGY3

residents recognized that earlier in their training, they might

not have appreciated the value of a palliative care elective.

They felt that making palliative care a mandatory rotation

would ensure that that opportunity for further experiential

learning was not lost.

What can Palliative Care Providers do Differently Provide informal teaching around cases. All of the participants

valued their interactions with palliative care teams. They found

it particularly helpful to be able to observe family meetings and

discussions led by physicians or nurse practitioners. Although

they found learning value in just seeing what was suggested

and how different scenarios were navigated, many expressed a

desire for more informal teaching around cases.

Teach about the importance of palliative care. A few of the residents felt that a lecture about the importance of palliative

care, rather than a lecture about the process of palliative care,

symptom management or goals of care discussions, would

carry the greatest weight in terms of changing residents’

attitudes.

Observe residents and provide feedback. Although residents had often found it helpful to sit in on discussions led by pallia-

tive care practitioners, they reported being inconsistently

observed and rarely given feedback when leading discussions

on their own. Residents felt that they would benefit from reg-

ular feedback from a more senior resident, a staff physician, or

a palliative care provider.

Be available to residents after hours. Residents often found it challenging to manage patients’ symptoms overnight without

the help of a palliative care provider. They were therefore

appreciative when palliative care physicians made themselves

available to residents by phone in case of urgent symptom

management issues. The ability to engage with palliative care

teams around these acute scenarios was felt to not only improve

outcomes but also to enhance learning.

Discussion

Our results highlight many important challenges that internal

medicine residents face in being able to provide palliative care

for their patients. Consistent with past research, 16

time con-

straints were a frequently cited challenge for residents manag-

ing a busy clinical service. Also in keeping with previous

studies were residents’ comments about patient-related factors

that posed barriers to having goals of care discussions. 6,17

However, in contrast to these studies in which physician-

related factors were felt to be minimal, residents in the present

study did identify several knowledge limitations. Importantly,

these perceived limitations very often coexisted with a sound

theoretical knowledge base relating to palliative care. For

example, residents cited challenges in knowing when to initiate

a palliative approach, despite having acknowledged that active

and palliative care exist on a continuum. Understanding how to

bridge that gap between theory and practice will be critical to

enhancing the care that residents are able to deliver.

A discrepancy between residents’ attitudes toward palliative

care and the translation of these attitudes to practice was also

apparent. Although various learning opportunities had taught

them that palliative care is important and valuable, residents

often admitted to prioritizing ‘‘active’’ over ‘‘palliative’’

370 American Journal of Hospice & Palliative Medicine® 34(4)

patients. Perhaps teaching residents about the importance of

palliative care, as was suggested by a few of the residents,

could help to address this issue. In general, however, resi-

dents understood the value of being able to provide effective

palliative care now and throughout their careers. They there-

fore expressed a desire to improve their skills relating to

communication and symptom management and hoped to

learn about specific resources available to palliative patients

in the community. These identified learning priorities are

addressed within their current training program but could

continue to be strengthened in collaboration with palliative

care teams.

Our study, to the best of our knowledge, is the first qualita-

tive study to explore medicine residents’ palliative care-related

learning needs and thoughts about how to address those needs.

However, this study does have some limitations. Our findings

are limited to a relatively small sample size within a single

institution. However, this sample size appears to be consistent

with other qualitative studies that have looked at the experi-

ences of health care professionals engaged in end-of-life

care. 18-20

We know from previous research that within Canada, resi-

dents’ perceived level of competence, and their scores on

knowledge testing relating to palliative care vary across differ-

ent sites. 7

It is possible that residents’ training needs and pre-

ferences will also be expressed differently at different centers.

Further qualitative research with larger sample sizes within

different institutions would help provide greater depth of

understanding to our findings. It is also important to consider

the potential influence of the researchers on the design and

conduct of the study. The interviewer (SK) was a palliative

care resident during the study, which may have influenced the

types of questions asked and the nature of the responses given.

We observed that a few of the participants asked whether they

were giving the ‘‘right’’ answers to our questions, an indica-

tion that perhaps the depth of participants’ reflections was

limited by a desire to be perceived as competent in palliative

care to a fellow clinician. Equally important to consider are

the biases of the research team in the data analysis process. As

palliative care clinicians, both JR and SK are ideally equipped

to extract clinically relevant themes but also bring many

assumptions and biases relating to their own understanding

of palliative care and delivery of teaching methods. Having

the other 2 researchers participate not only allowed for added

expertise in qualitative methods but also rounded out these

biases and in the case of R.M., added a nonclinician

perspective.

Our findings have several important practice implications.

Currently, residents are able to learn from direct exposure to

palliative patients during their general medicine training and

from ongoing interactions with palliative care teams. Their

cumulative experiences allow their theoretical and technical

understanding of palliative care to evolve. However, our obser-

vation of a gap between their theoretical understanding and

their perceived ability to practice palliative care suggests that

perhaps bolstering the practice component should be our first

priority. Consistent with previous research, 21

all of the resi-

dents interviewed felt that a rotation in palliative care would

be useful, and many added their perspective that it should be

made mandatory. Accordingly, strong consideration should be

given to incorporating mandatory rotations in palliative care

within medicine training programs. In concert with such

efforts, opportunities for lecture-based learning can be

increased to supplement experiential learning. Finally, pallia-

tive care clinicians can further enhance residents’ learning by

seeking opportunities for informal teaching and direct observa-

tion and by identifying themselves as resources for learners,

possibly after-hours as well, if feasible.

Equipping medicine residents with the knowledge and expe-

rience that they need to provide palliative care throughout their

careers requires increased support from both internal medicine

and palliative care programs. Strong partnerships between the

two will be critical to the enhancement of existing educational

efforts.

Acknowledgments

The authors would like to thank Dr Jeff Myers and Dr Anita Chakra-

borty for their contributions to the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for

the research, authorship, and/or publication of this article: This study

was supported by the University of Toronto Division of Palliative Care

Collaborate Education Grant.

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