Addressing a Long-felt Need: Introducing Palliative Care for MBBS Students in the New Competency-Based Medical Education Curriculum
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It is not death I fear to face but dying–ROBERT LOUIS STEVENSON
There are an estimated 2.5 million people living with cancer in India, with every year about 700,000 new cancer cases registered. It is estimated that in India, the total number of people who need palliative care is likely to be around 5 million people a year.
Every year, a meager number of specialists in palliative care are added to the country from handful of centers that offer specialist palliative medicine training. Hospitals and hospices offering palliative care are few and cannot cater to the numbers of patients who flock to them. Unhappily, several more patients are forced to go without any palliation, since medical graduates and nonspecialty doctors are not trained in administering basic palliative care. The Medical Council of India recognized palliative care as a postgraduate specialty in 2010. Currently, postgraduate courses are offered only in Tata Memorial Hospital, Mumbai; GCRI, Gujarat; and AIIMS, Delhi.
Formal teaching of palliative care in the undergraduate MBBS years falls into a no-man's-land and remains largely neglected. Palliative care is not taught as a subject during MBBS education. A large number of MBBS students have largely remained ignorant of what palliative care means and even fewer have actually seen it practiced.
It is heartening to see that from August 2019, the new CBME curriculum for MBBS students, introduced by the Board of Governors (formerly known as the MCI) will include an introduction to palliative medicine. The introduction of the competency-based medical education (CBME) and the Attitude, Ethics, and Communication Module (AETCOM) to the MBBS students heralds a welcome introduction to palliative medicine and the principles of palliative care. The new undergraduate medical education program is designed with a goal to create an “Indian Medical Graduate” (IMG) possessing requisite knowledge, skills, attitudes, values, and responsiveness, so that he or she may function appropriately and effectively as a doctor of the first contact of the community while being globally relevant. The stress on palliative care and its importance begins from defining the role that the IMG is expected to play in the society. As a clinician, he is expected to understand and provide preventive, promotive, curative, palliative, and holistic care with compassion. The clinician is also expected to be competent in pain and distress alleviation and rehabilitation and palliation.
CBME is based on a strong horizontally and vertically integrated curriculum, and the palliative care competency framework has been skillfully woven into it under various subject specialties as well as within AETCOM. The curriculum design spells out the competencies and also suggests pedagogy styles and assessment practice. The competencies needed for the palliative care approach are at the level of the minimum competencies that are expected of all health and social care professionals. The areas covered, however, are enough to pique the interest of a student who would want to pursue palliative medicine as a specialist.
The domains of palliative care dispersed throughout the CBME MBBS curriculum include the basics of palliative care, pain management, ethical and legal implications, communication skills, teamwork, and professionalism. Palliative care competencies are spread across various subject disciplines such as pharmacology, community medicine, surgery, anesthesia, gynecology, and even radiotherapy. Samples of competencies listed relate to the anatomical correlates and physiologic principles of pain, cancer pain and its management, the pharmacology and use of drugs in the management of pain, the principles of pain management in palliative care, and the principles of pain management in the terminally ill. Some of the competencies which address the core principles of palliative medicine like breaking of bad news, demonstrating the importance of confidentiality, and respecting the preferences of patients when choosing curative and palliative therapy will be taught by psychiatrists.
Several cases in the AETCOM module provide a parallel and re-enforced learning experience. These cases pertain to basic skills in communication and clinical interactions, professionalism, ethics related to treatment decision-making, patient-centered care, and issues at the end of life. Furthermore, the new concept of electives within the CBME curriculum gives scope for the student to obtain a clinical placement within a palliative care setting where skills of patient assessment, communication, and multiprofessional working can be developed alongside management of the advanced chronic disease.
Assessment methods in palliative care education may be formative or summative and may be integrated into a particular teaching module or may be stand-alone. Assessment methods should be congruent and complement the threads running through the curriculum, including syllabus, learning objectives, and teaching methods.
Summative assessments in the theory examination will be through long questions, short notes, and multiple-choice questions. In the clinical examination, students will be assessed through OSCE or by assessing the clinical skills using a tool like mini-CEX. The case-based OSCEs will be used to assess the skills in communication, ethics-based decision-making, understanding the legal aspects, etc., Formatively, students will be assessed using journal entry for the learning portfolio, case reflection, and demonstration of communication using a role play.
There is need for skilled and experienced educators to teach Palliative medicine to MBBS students. There must be more capacity building programs and faculty development programs to train the trainers to teach students ethical, social, and emotionally sensitive materials while taking care to not to preach one's own opinions and beliefs. Specific aspects of the course may be taught by subject experts, for example, pain management and spiritual care. Curriculum governance is also required to oversee the logistics of the program implementation and assessment.
In conclusion, a much-awaited need of the society has been addressed by the new CBME curriculum. India can hope to see a steady growth of palliative care services to improve the quality of life of both patients and families of Indians living with serious and chronic illness.