Education is as an important factor in palliative care knowledge: results from a survey of physicians attitudes and knowledge in Palliative Medicine

Education is as an important factor in palliative care knowledge: results from a survey of physicians attitudes and knowledge in Palliative Medicine | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Education is as an important factor in palliative care knowledge: results from a survey of physicians attitudes and knowledge in Palliative Medicine Thais Ioshimoto, Danielle Ioshimoto Shitara, Gilmar Fernandes do Prado, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.20047/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Oct, 2020 Read the published version in BMC Medical Education → Version 1 posted 10 You are reading this latest preprint version Abstract Background: According to the Latin America Association for palliative care, Brazil offers only 0.48 palliative care services per 1 million inhabitants. In 2012, no accredited physicians were working in palliative care, while only 1.1% of medical schools included palliative care education in their undergraduate curricula. Aim: The aim of the study is to assess medical knowledge in end-of-life care, in order to identify key factors that could be useful in improving palliative care in Brazilian medical schools and residency. Design: Cross sectional study, conducted in São Paulo, Brazil. Students were invited to voluntarily participate in an anonymous and self-administered questionnaire survey. The latter included demographic information, attitudes, prior training in palliative care, prior palliative care experience and the 20-item Palliative Care Knowledge Test (PCKT). Participants: Physicians applying for the medical residency of the Federal University of São Paulo. Results: Of the 3086 subjects, 2349 (76%) answered the survey, 2225 were eligible for analysis while 124 were excluded due to incomplete data. Although the vast majority (99,2%) thought it was important to have palliative care education in the medical curriculum, less than half (46,2%) reported having received any education on palliative care. The overall performance in the PCKT was poor, with a mean score of 10,79 (± 3). While philosophical questions were correctly answered (81,8%), most participants lacked knowledge in symptom control (50,7% for pain, 57,3% for dyspnea, 52,2% for psychiatric and 43,4% for gastrointestinal problems). The high performance group (> 50% of correct answers) had received more training, showed more interest in learning, had a better sense of preparedness, as well as a higher percentage of experience in caring for terminal patients (p<0,001). Conclusions: Our study showed that Brazilian’s physicians lack not only knowledge, but also training in palliative medicine. Important factors to better knowledge in end-of-life care were prior training, previous contact with dying patients and prior medical residency. Corroborating the literature, training showed to be a key factor in overall knowledge. Therefore, medical schools and residency programs should focus on improving palliative training, especially those involving contact with dying patients. Internal Medicine Educational Philosophy and Theory education palliative care knowledge palliative care knowledge test (PCKT) palliative medicine medical residency developing countries Figures Figure 1 Full Text Supplementary Files STROBEchecklist.docx Palliativecarequestionnaire.docx Cite Share Download PDF Status: Published Journal Publication published 02 Oct, 2020 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Major revision 11 Mar, 2020 Reviewer # 2 agreed at journal 25 Jan, 2020 Review # 2 received at journal 25 Jan, 2020 Review # 1 received at journal 25 Jan, 2020 Reviewers invited by journal 20 Jan, 2020 Reviewer # 1 agreed at journal 20 Jan, 2020 Editor assigned by journal 09 Jan, 2020 Submission checks completed at journal 31 Dec, 2019 Editor invited by journal 31 Dec, 2019 First submitted to journal 23 Dec, 2019 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-10658","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":276178,"identity":"3f9b63ff-c919-45e8-bd91-cef3684c3b96","order_by":1,"name":"Thais Ioshimoto","email":"","orcid":"","institution":"Universidade Federal de Sao Paulo Escola Paulista de Medicina","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Thais","middleName":"","lastName":"Ioshimoto","suffix":""},{"id":276179,"identity":"3cbd4ce8-d314-44c6-9297-e6c37cf3e12b","order_by":2,"name":"Danielle Ioshimoto 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Pizzoni","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYBADHjCZUAEkmJkbSNFyBqSFkTgtEMDYBibxazFvP2O64eOOOzLy/YePPXg4rzaavx2o5UfFNpxaZM7kmN2ceeYZD2PDsXSDxG3Hc2ccZmxg7DlzG6cWCYYcs9u8bYd5mBl7zCQStx3LbQBqYWZsw6OF/w1ECxszD1DLnGO58wlqkYDawsMG0tJQk7uBsJZnZTdntj3jkeBhS5NIOHYgdyNQy0G8fuFP3nbjY9sde1CISf6oqcudd/7wwQc/KnBrYWDgMAASB2C8w2DyAHalMMD+AFlNHX7Fo2AUjIJRMCIBAIvnWpM2JvOJAAAAAElFTkSuQmCC","orcid":"","institution":"Universidade Federal do Rio Grande do Sul","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Raymon","middleName":"","lastName":"Pizzoni","suffix":""},{"id":276182,"identity":"c35e8846-a7d3-4ef1-b9e6-21dc8f74e100","order_by":5,"name":"Rafael Hennemann Sassi","email":"","orcid":"","institution":"Universidade Federal do Rio Grande do 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16:29:23","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":124624,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEchecklist.docx","url":"https://assets-eu.researchsquare.com/files/23e309f7-765b-4b83-982b-c91d5fd901cb/v1/STROBE checklist.docx"},{"id":321890,"identity":"1cb478c6-d066-42c5-ad48-14c188e7fad9","added_by":"auto","created_at":"2020-01-03 16:29:22","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":19506,"visible":true,"origin":"","legend":"","description":"","filename":"Palliativecarequestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/23e309f7-765b-4b83-982b-c91d5fd901cb/v1/Palliative care questionnaire.docx"}],"financialInterests":"","formattedTitle":"Education is as an important factor in palliative care knowledge: results from a survey of physicians attitudes and knowledge in Palliative Medicine","fulltext":[{"header":"Full Text","content":"\u003cp\u003eThis preprint is available for \u003ca href='/article/rs-10658/latest.pdf' target='_blank'\u003edownload as a PDF\u003c/a\u003e.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"education, palliative care, knowledge, palliative care knowledge test (PCKT), palliative medicine, medical residency, developing countries","lastPublishedDoi":"10.21203/rs.2.20047/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.20047/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Background: According to the Latin America Association for palliative care, Brazil offers only 0.48\npalliative care services per 1 million inhabitants. In 2012, no accredited physicians were working in\npalliative care, while only 1.1% of medical schools included palliative care education in their\nundergraduate curricula.\nAim: The aim of the study is to assess medical knowledge in end-of-life care, in order to identify key\nfactors that could be useful in improving palliative care in Brazilian medical schools and residency.\nDesign: Cross sectional study, conducted in São Paulo, Brazil. Students were invited to voluntarily participate in an\nanonymous and self-administered questionnaire survey. The latter included demographic\ninformation, attitudes, prior training in palliative care, prior palliative care experience and the 20-item\nPalliative Care Knowledge Test (PCKT).\nParticipants: Physicians applying for the medical residency of the Federal University of\nSão Paulo.\nResults: Of the 3086 subjects, 2349 (76%) answered the survey, 2225 were\neligible for analysis while 124 were excluded due to incomplete data. Although the vast majority\n(99,2%) thought it was important to have palliative care education in the medical curriculum, less\nthan half (46,2%) reported having received any education on palliative care. The overall\nperformance in the PCKT was poor, with a mean score of 10,79 (± 3). While philosophical questions\nwere correctly answered (81,8%), most participants lacked knowledge in\nsymptom control (50,7% for pain, 57,3% for dyspnea, 52,2% for psychiatric and 43,4% for\ngastrointestinal problems).\nThe high performance group (\u003e 50% of correct answers) had received more training, showed more interest in learning,\nhad a better sense of preparedness,\nas well as a higher percentage of experience in caring for terminal patients (p\u003c0,001).\nConclusions: Our study showed that Brazilian’s physicians lack not only knowledge, but also\ntraining in palliative medicine. Important factors to better knowledge in end-of-life care were prior\ntraining, previous contact with dying patients and prior medical residency. Corroborating the\nliterature, training showed to be a key factor in overall knowledge. Therefore,\n medical schools and residency programs should focus on improving palliative training,\nespecially those involving contact with dying patients.","manuscriptTitle":"Education is as an important factor in palliative care knowledge: results from a survey of physicians attitudes and knowledge in Palliative Medicine","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-01-03 16:29:22","doi":"10.21203/rs.2.20047/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-03-11T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-01-25T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-01-25T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThank you for the opportunity to revise this manuscript.\nThis qualitative study aimed to analyse medical education as an \"[...] important factor in palliative care knowledge [...]\" by submitting an ad hoc questionnaire and the PCK test. The topic is certainly important in a historical moment in which, lacking specialist professionals, it becomes at least necessary to disseminate the concepts useful for developing a 'palliative approach' to care.\nIn my opinion, the use of terminology consistent with the main objectives of this research is the fundamental question to be addressed in this manuscript. Currently, the definition of 'Palliative care' characterizes them as holistic and therefore including, in addition to the physical problems, also the psychic, spiritual and social aspects regarding patient and/or caregiver. Moreover, this clinical-care model is provided for months/years during specific and recognized disease trajectories (cancer vs. non-cancer) [Murray SA, Kendall M, Mitchell G, et al. Palliative care from diagnosis to death. Bmj 2017; 356: j878. 2017/03/01. DOI: 10.1136/bmj.j878] along which patients experience different stages of disease (stable, unstable, worsening, end of life) [Mather H, Guo P, Firth A, et al. Phase of Illness in palliative care: Cross-sectional analysis of clinical data from community, hospital and hospice patients. Palliative Medicine 2018; 32: 404-412. 2017/08/16. DOI: 10.1177/0269216317727157].\nIn different sections of the study, the terms \"Palliative care\", \"End-of-life care\", \"Palliative medicine\" seem to be used as if they were synonyms. My suggestion is to choose the terms that most effectively represent what you want to analyse (physical aspects/symptoms and end-of-life care) and use them all along the manuscript.\n\nTitle\nThe title mentions 'Education is an important factor in palliative care knowledge [...]', but it is my opinion that the content of the tools used in this study (questionnaire regarding training and attitudes, PCK Test), allowed to investigate almost exclusively the aspects related to the physical problems at the end-of-life phase of a patients' illness trajectory. I therefore consider it more appropriate to specify these two aspects already in the title to better detail the results obtained. From here on, the text should uniformly refer to end-of-life care rather than palliative care in general, as well as physical rather than holistic aspects of care.\n\nBackground\nThe bibliography to support what was stated in the first sentence of the first paragraph is missing.\nThe reference [6] refers to palliative care needs in patients with chronic conditions only in a single Nation of western Europe, and in my opinion it would be better to use more comprehensive (continental) epidemiological references.\nIn the first sentence of the third paragraph, the terms 'palliative care' and 'end-of-life care' are used inconsistently as synonyms.\nIn the fourth paragraph, concerning the objectives of the study, I expect the clear statement that the aspects analysed in the study specifically concern the physical problems and the patients' end-of-life phase.\n\nMethods\nI would suggest to rewrite the second sentence considering the use of a coherent terminology as already expressed above.\nIn the second sentence of the Questionnaire section, in my opinion, it is necessary to specify 'End-of-life palliative care'.\n\nDiscussion\nIt's my opinion that the first paragraph should be rewritten by emphasizing the mainly physical aspects of the end-of-life phase. Moreover, it could be discussed how this multi-professional palliative care 'approach' can be very useful to facilitate the transition from a paternalistic (medical-centric) to a 'patient centered' model of care. Another not negligible topic, which I expect will also be addressed, concerns the setting in which this study was conducted (hospital or residential), excluding the home setting where most of the patients with palliative care needs are probably present.\nWhat is written in the fourth sentence of the third paragraph is not relevant with respect to the objectives of the study as redefined above. The aforementioned systematic review referred to the population with chronical-degenerative diseases who demonstrate palliative care needs practically throughout their disease trajectory [Murray SA, Kendall M, Boyd K, et al. Illness trajectories and palliative care. Bmj 2005; 330: 1007-1011. 2005/04/30. DOI: 10.1136/bmj.330.7498.1007], and not only in the end-of-life phase.\nThe content of the fifth sentence of the same paragraph refers to a study on the issue of euthanasia that falls outside the objectives pursued in this study.\nIn the first sentence of the fifth paragraph, and throughout the manuscript, I expect the term \"palliative medicine\" to be replaced by \"end-of-life care\".\nThe fourth sentence of the fifth paragraph does not help the discussion as it refers to the 'general practitioners' who typically belong to the main actors providing care in the home setting. I also suggest to replace the term 'specialists', referring to palliative care physicians, with 'experts' or 'specialised', considering that this 'medical specialization' still does not exist in the clinical practice.\n* Are the methods appropriate and well described?: **Unable to assess**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **Not relevant to this manuscript**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"editorInvitedReview","content":"","date":"2020-01-25T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThis is an interesting paper which describes the knowledge and attitudes of physicians in Sao Paulo applying to residency programs. The large number of participants as well as how this study reflects the lack of knowledge and skills in Brazil merit to be disseminated.\nHowever, there are several issues that I think need to be addressed before:\n\n1. In the methods section, the authors need to specify which residency program or programs the participants were applying to. If to different residency programs, it would be valuable to know any differences among groups.\n2. Authors should state the reasons as to why they selected the The Palliative Care Knowledge Test (PCKT) over other tests (ie Palliative Education Assessment Tool - PEAT).\n3. The terms terminal patient, patients with progressive, non curable conditions are used interchangeably to refer to persons needing palliative care. This needs to be revised and a single term used throughout the text for consistency and to avoid confusion. I suggest using person with palliative care needs, which is more consistent with evidence that indicates that palliative care benefits patients with acute and chronic conditions, as well as when it is applied early in the course of the disease.\n4. There are several grammar and spelling mistakes that need to be addressed. Several terms need to be revised: Contagious for communicable, persons for people and \"graduate\" in Table 1 refers to \"undergraduate\".\n5. In the Methods section, specify how the second set of questions was developed. Was it based on another tool or were these developed jointly by the authors?\n6. The results show that roughly the same number of students fell in the \"good\" and \"bad\" categories. This could be a result of how the groups were distributed and should be mentioned and discussed in the text.\n7. I would like to see also a statement in the Discussion section that would show how this study could not only benefit the advancement of palliative care education in Brazil but also in Latin America.* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"reviewersInvited","content":"","date":"2020-01-20T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-01-20T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-01-09T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-12-31T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-12-31T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2019-12-23T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"753811ff-7b49-4f5c-b075-94e79b354111","owner":[],"postedDate":"January 3rd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":46647,"name":"Internal Medicine"},{"id":46648,"name":"Educational Philosophy and Theory"}],"tags":[],"updatedAt":"2020-10-04T15:02:37+00:00","versionOfRecord":{"articleIdentity":"rs-10658","link":"https://doi.org/10.1186/s12909-020-02253-8","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2020-10-02 12:00:00","publishedOnDateReadable":"October 2nd, 2020"},"versionCreatedAt":"2020-01-03 16:29:22","video":"","vorDoi":"10.1186/s12909-020-02253-8","vorDoiUrl":"https://doi.org/10.1186/s12909-020-02253-8","workflowStages":[]},"version":"v1","identity":"rs-10658","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-10658","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}