Journal of Pain Management & Medicine

The Need to Integrate Palliative Care in Undergraduate Medical Training: A Reflection in Developing Countries

Emilia John^1*, Carnel John², William Kerti³ and Feruie Thomson^{4 1}Department of Medicine, Porto University, Portugal
²Pain and Palliative Care Unit, Maputo Central Hospital, Maputo, Mozambique
³Department of Anesthesiology, Vanderbilt University, Nashville, United States of America
⁴Department of Medicine, Universidade Eduardo Mondlane, Mozambique
^*Correspondence: Emilia John, Faculdade de Medicina Porto University, Rua Dr. Plácido da Costa, 4200-450 Porto, Portugal, Email:

Received: 21-Sep-2021 Published: 12-Oct-2021

Introduction

According to the World Health Organization (WHO), “PC is an integral approach that promotes the quality of life of patients and their families, who face diseases that threaten the continuity of life, through the prevention and relief of suffering. It requires early identification, correct assessment and appropriate treatment for pain relief and other physical, psychosocial and spiritual problems, ” from the diagnosis of an incurable disease to the period of mourning of the family [1].

Access to health care is a major challenge in Low- and Middle- Income Countries (LIMCs). PC remains limited, inaccessible or even absent in these countries and its availability is urgency. The difficult access, lack of trained and specialized professionals, late detection of some pathologies and the inaccessible and / or insufficient treatment options contribute to high mortality [2].

Pain and Palliative Care Education in Mozambique

In 2014, the World Health Assembly Resolution on PC called for all countries to incorporate the provision of PC into their national health system in order to guarantee their access to all who need it, but the intended results have not been achieved [1].

Although not established as a medical specialty in Mozambique, since 2012 there has been a National Palliative Care Policies, a training curriculum, and a reference manual, which provides for the implementation of this care at all levels and the whole society [3]. PC should be introduced as soon as possible in patients with severe disease, following early guidance for symptom control, aiming to improve their quality of life, satisfaction for caregivers, and reducing costs related to the patients´ hospitalization [4,5].

The lack of implementation of PC education in undergraduate medical curricula is considered to be one of the most important barriers to effective PC integration in health systems in Africa [2].

In a cross–sectional study between August 2018 and July 2019 on 146 students from Eduardo Mondlane University (EMU) and Unilúrio University, we found important gaps in pain and PC general knowledge, oncologic pain management and end of life issues. In these 2 medical schools there was no specific discipline on pain and PC. However, at EMU students reveled to have pain and PC´s modules during their training, and in these 2 universities, students informed also that they did not receive enough information about common symptoms´ control in PC, as pain, dyspnea, vomiting, constipation, and cachexia. More than half of the participants said that they did not learn communication tools and medical posture to give bad news to patients and family members during training.

Overview of Knowledge and Palliative Care

In 2004, the WHO recommended that governments include PC in training curricula for health workers at all levels.

The provision of PC should not be performed only by specialized professionals. However, there are PC actions, also known as general or primary PC, which are composed of therapeutic measures without curative intent, practiced by professionals without specific preparation, as a way to minimize the deleterious effects of the disease on patients' well-being [6].

Although it is a recognized medical specialty, the PC curriculum was not introduced into the undergraduate training of different medical schools or, where it was introduced, it does not offer enough tools to support future PC practices [7].

The universities take the responsibility of integrating and training on PC into undergraduate and postgraduate education. Uganda and South Africa included PC in the undergraduate curriculum. Countries such as Namibia, Botswana, Malawi, Tanzania, and Kenya are in the process of its implementation. However, each country is doing it at a different level of integration. The first postgraduate PC diploma and degree in the region was developed in 2001, at Cape Town´s University, and PC certificate courses occurs in Uganda, South Africa, Kenya, Zambia, Swaziland, and Botswana amongst others [8].

There are large disparities between countries related to pain and PC discipline in medical schools which may contribute to increased therapeutic futility and suffering of patients [9,10].

Discussion

Symptom´s control, end-of-life issues and death

The introduction of theoretical contents into the university curriculum and the consolidation of student theory and practice may be crucial for better symptomatic patients´ control and EoL issues. The overload of physical and psychological symptoms is similar in chronic terminal cancer and non-cancer patients, so the approach to undergraduate education should be prioritized [11].

“Unrelieved pain” drastically decreases with the involvement of inter and multidisciplinary teams. The lack of trained professionals and the growing trend in the prevalence of cancer and cancer pain are imperative factors for the education of health professionals in the management of pain and other symptoms [12].

Pain is one of the most frequent and serious symptoms experienced by patients in PC needs. Opioid analgesics are essential for treating the pain associated with many advanced progressive conditions. However, many students do not know the WHO´s “ladder” for pain management.It is important to educate physicians regarding PC and to emphasize EoL issues, particularly during the last years of medical training and in the beginning of their professional activity [13].

Training can help medical students to be more aware of palliative issues, to face their own fears about death and its process and to establish a positive attitude towards this reality. In addition, it can help them to integrate PC into their future work and to approach them with a sense of competence and tolerance, leading to better interactions with EoL patients and their families or caregivers [14].

Faced with EoL issues, some professionals were uncomfortable, powerless, suffering, and sometimes fearful when faced to death and dying process, and this may reflects a lack of preparation for coping with death. It is important that the training model implemented by most medical schools is not only aimed at preserving life, and in quality care focused on the disease, but rather on the individuality of the human being. And this training gap has negative consequences for the patient-physician and family-physician relationship [7,15].

PC limits the physical and emotional suffering of patients and family members, however, its approach at the end of life is a psychological challenge for health professionals. Health education and training in health students can support them in this transition, helping them to deal with it. Many health professionals and students report being unprepared to deal with care at the end of life [16].

When and how to introduce pre-graduate education in palliative care?

In a meta-analysis that evaluated when to introduce the PC curriculum, it was defended that it must be articulated with the years of the program. The timing of the intervention varied but it tended to be in the third year of the students' course. Some of studies did not specify a year level however; they found that there was no need to introduce PC in the first preclinical years [17].

Undergraduate medical education should be transformed to help students to make the transition from a healing approach to care, and this teaching should involve not only teaching materials, but also teaching strategies and methods, interprofessional education focused in psychosocial aspects and EoL care [18].

Knowledge of the concept of PC and the principles that guide it are important in clinical practice because most of the therapeutic decisions and guidance of patients passes through the notion of this knowledge and consequently less suffering of the patient with futile treatment.

Conclusion

Most students reported difficulties in dealing with issues related to symptoms´control, mainly in pain treatment as well as in EoL issues due to the lack of a specific curriculum on medical students addressing pain and PC, as well as practises issues related to EoL. The inclusion of CP as mandatory content during undergraduate training remains an urgent and unmet need. There is a need for representative studies to better assess training programs and integrate the CP curriculum.

Declarations

Competing of interest

None.

Funding

No funding to the research.

Acknowledgements

Author Emília Pinto thanks the support of the Calouste Gulbenkian Foundation through the doctoral scholarship received and the Ministry of Health of Mozambique.

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