PSYCHO-ONCOLOGY, VOL. 4: 3 1 1-320 (1995)

SPECIAL ARTICLE

PALLIATIVE CARE TEACHING, WHAT CAN WE LEARN?

IAN E. HAIN=*?, CARRIE LETHBORG*$ AND MAX A. SCHWARZS 7 Lecturer, Department of Medicine, Monash University, Visiting Assistant Medical Oncologist, Alfred Healthcare

Group, Prahran, Victoria, Australia; f Assistant Lecturer, Department of Medicine, Monash University, Social Worker, Department of Oncology, St Vincents Hospital, Melbourne, Australia (previously employed in the

Infectious Diseases Unit (HIV/AIDS Service), Alfred Healthcare Group, Prahran, Victoria, Australia); 5 Clinical Associate Professor, Department of Medicine, Monash University, Head, Medical Oncology Unit, Alfred

Healthcare Group, Prahran, Victoria, Australia

SUMMARY Lack of palliative care education is being identified by many universities as a deficiency in their undergraduate medical teaching programme which requires urgent implementation into the undergraduate cumculum.

A comprehensive teaching programme in palliative care was devised and commenced at our institution at the beginning of 1991. This consists of seven one and half hour modules given to students in the last years of their course. The modules cover the broad range of aims of the course (as outlined) by using a diverse range of educational principles and methods and only a minimum of traditional non-interactive didactic teaching.

Students complete anonymous evaluation form at the completion of the course and responses from the medical students have been overwhelmingly positive. 89 percent of students rated the course ‘very useful’ or ‘extremely useful’. The students’ rating placed this course above all other components of their undergraduate teaching programme.

However, written comments from studeuts have provided us with even more significant insights into the importance of the programme, such as ‘why weren’t we taught this before’ and ‘I would like to see more space given to discussion on how to cope with the stress of the medical profession.’

The skills involved in palliative care are basic to good doctoring generally and we believe that this teaching programme could help form the basis for future medical undergraduate teaching programmes in palliative care.

BACKGROUND

Palliative care education has been targeted by leading universities in Australia and elsewhere as an area of major deficiency in mainstream medical teaching that requires urgent implementation into the undergraduate cumculum (Tattersall et al., 1986). However, the concepts embodied in this philosophy of care are central to medical care in general.

As the population ages, and cancer become more prevalent, the utilisation of increasingly limited health resources becomes a vital issue. With emphasis on domicilliary care where poss-

ible, the skills required to provide high quality and cost efficient care of dying patients are essential for all health professionals.

The traditional biomedical model that has formed the basis of all medical teaching has concentrated almost exclusively on the physical process of disease and not on the many aspects of the patient’s illness experience that contributes so powerfully to ‘quality of life’. Indeed, until recently, ‘response rates of the disease process’ and overall length of ‘survival of the patient’, the two measures of the success of treating disease, have been the major tools for evaluation o f new treatments.

*Authors to whom correspondence should be addressed: Dr Ian Haines, and Ms Came Lethborg, Suite 45 Cabrini Medical Centre, Malvem, Victoria, Australia 3144.

CCC 1057-9249/95/040311-10 0 1995 by John Wiley & Sons, Ltd.

312 I. E. HAINES ET AL.

Specific areas of deficiency in undergraduate and post graduate medical training in palliative :are. identified in recent literature have been:

psycho-social plan of assessment for all patients with cancer or other severe life threatening illnesses, and to be able to

2.

3.

4.

5.

In

The inadequate communication skills of doctors when conveying bad news, particu- larly telling affected patients (and their relatives) that they have cancer (Holland, 1989) or in discussing ethical issues to do with cancer (Parker, 1989). Lack of role models in palliative care and pain control. (Portenoy, 1992) and Weissman, 1988). Inadequate understanding of pain and symp- tom control amongst doctors, leading to a high rate of burnout among oncologists (Whippen and Cannellos, 1991), Abeloff, 1991). Lack of understanding of quality of life issues for patients (Weeks, 1992). Narrow definition of ‘medical success’ which suggests that only when a disease is cured has treatment been successful.

understand the interrelated nature of this suffering experience.

(b) To recognise the stages of illness and to be able to assign appropriate goals of management for each stage. To be able to recognise the patterns of the different psycho-social syndromes of patients with cancer.

(d) To be able to recognise, and where necessary, assist in the journey through the different coping strategies that pati- ents with cancer utilise.

(e) The principles of management of the most common and disturbing symptoms in advanced cancer.

(f) The principles of decision making in difficult ethical areas such as resuscita- tion orders and ceasing active treat- ment.

(c)

1991, in response to this gap in the medical (g) How to give bad news. curriculum, a Palliative Care Saining Programme was established at Monash University Medical School, Alfred Hospital, for all fifth year (the penultimate year) students. This was consequent to a prior pilot Programme initiated by our Oncology Fellow in 1990.

The 1991 Programme utilised aspects of the pilot Programme as well as some of the methods and modules used and evaluated at the Repatria- tion General Hospital, Heidelberg fifth year medical student teaching programme (Buchanan et al., 1990). The current Programme has built and expanded widely on these foundation courses, based on regular student feedback.

( 6 ) Principles of interviewing and counsell- ing dying patients.

(i) The spectrum of grief and bereavement and the ability to assess and manage the different psychological syndromes of patients.

(j) The options for places to care for pati- ents in the final stage of their illness.

(k) Recognition, prevention and manage- ment of stress in the professional carers.

(1) To see palliative care as a vital and potentially gratifying part of medical care.

METHODS AIMS

To teach:

1. The essential bio-psycho-social nature of palliative care assessment and treatment, a model which can be applied to the care of all severe chronic illness. The skills of palliative care as an essential part of quality medical practice for all family doctors and specialists. The attitudes and skills required for sound palliative care, as listed below:

(a) To be able to make an adequate bio-

2.

3.

The Programme consists of seven one and a half hour modules. Each module has been designed to be challenging and to be directly relevant to prac- tice. The course utilises methods of teaching that have been found to be effective and directly trans- ferable to personal experience. The educational principles and methods employed, include (a) ‘critical thinking’, (Halpern, 1991) and (b) ‘experiential learning’ (Kolb, 1991) as detailed in Table 1.

Within these theories, various methods have been used to teach important skills and principles and also to provide an experience of open discus-

PALLIATIVE CARE TEACHING 313

Table 1. Principles and methods of teaching

Educational theory Method used Skill learnt

Critical thinking Hypothetical discussion, role play, discussion of personal loss

Experimental Role play, learning hospice visit,

observed interview

Ability to critically reflect on personal resources

Ability to practice or observe a skill and reflect on personal ability

sion and reflection in the learning process. Table 1 shows the educational theories and methods used.

Using the methods of hypothetical discussion, role play and the use of student’s own ‘loss histories’, we are able to challenge them to look at the factors behind their responses. The skill of self reflection will enable students to be more prepared to tackle the many new and often stress- ful experiences awaiting them in their medical practice.

Learning through experience enables a powerful integration of theory and practice. For example in teaching the important skills involved with break- ing bad news’, we utilise the methods of theoretical discussion, followed by role play to practice the theory discussed, feedback and self reflection followed by modeling by way of a live patient interview in front of the student group. Students are further encouraged to practice com- munication skills in their hospice visit.

It has become apparent that these teaching strategies significantly contribute to the popularity of the Programme, creating an environment that encourages risk taking and open sharing in a way that is new to many students. The following quotes

from past students illustrate this point well;

‘I really enjoyed the whole course, especially the opportunity to talk about difficulties and emotions which you often don’t want to bring up because you don’t want to be too ‘different”,

‘It also helps you to share thoughts and ideas with your fellow students, that you wouldn’t get the chance to otherwise.’,

‘I found this course to be very helpful, there is nowhere else in this rotation (very little in the whole medical course) that provides discussion within a small group.’,

‘I especially liked the interactive teaching used for most of the sessions. In particular the bereavement session, which not only gave the opportunity to see a wide range of people handle grief, but also was valuable in focus- ing and harnessing my own feelings-for future patients.’,

‘Discussions help us to remember things rather than lists of instructions.’

MODULES IN THE CURRENT PROGRAMME

Using these theoretical frameworks, Table 2 shows the modules which make up the full Pro- gramme. As will be shown, these modules are presented over a period of 7 weeks, during the students medical rotation.

Module One deals with the principles of pallia- tive care. Following introductions, the session begins with students reading a letter published in The Journal of the American Medical Association titled ‘Its Over Debbie’ (Young, 1988). This letter deals with a case study of a young woman suffer- ing from end stage ovarian cancer as told by an American House Officer. The case provides many areas for discussion including medical goal setting, symptom management, communication.

Table 2. Modules for current programme

Module 1 Module 2 Module 3 Module 4 Module 5 Module 6 Module 7 Module 8

~ ~~

Principles of palliative care The illness experience Communication skills Symptom management Hospice visit Bereavement Options for the care of the dying Stress management in medicine

1st week 2nd week

3rd & 4th week 4th week 5th week 6th week 7th week 7th week

3 14 I. E. HAINES ET AL.

skills and medical ethics. The principles of Pallia- tive Care are interwoven throughout this discussion and are thus presented in a logical framework incorporating student comments.

Module Two was developed to challenge stud- ents to look at the experience of illness, or what it is like to be living with a life threatening disease. The session begins with a discussion of the bio- psycho-social model of care, incorporating the many aspects of the individual response to illness (including the impact on families and carers) The module utilises a video entitled ‘On The Edge of Being’ (Yorken Drazen and Fruchtman, 1993) which includes interviews with six Physicians who have lived through either their own experience of cancer or that of some one close to them.

The practice and personal wisdom of these individuals suggest the possibilities and the expec- tations of an expanding role for the medical practitioner, the need to assist patients to partici- pate in their own health care and redefines the meaning of success in the care of people with life threatening illnesses. The video is followed by a discussion of the intervention strategies available to work with patients who are struggling with the emotional responses to their illness, and utilises the presenters’ own case examples.

The Third Module deals with communication skills, specifically with the skill of breaking bad news. Students are divided into groups of four and given roles of either doctor, patient, spouse/ partner, or observer. Each student is given some information about their respective roles and is asked to role play a scenario of the doctor giving the patient an unexpectedly poor diagnosis.

The emphasis in this session is not on the per- formance of any student but on the experience of giving and receiving bad news. A large proportion of this session is spent on sharing these experi- ences and discussing alternative ways of medical information giving. A step by step approach to a doctor/patient interview is provided at the end of the discussion.

This Module also incorporates a live interview of a cancer patient, usually with end stage disease. The interview illustrates some of the suggestions of the step-by-step approach as well as one doc- tor’s own personal style. The patient is usually not known by the doctor and is a young person, com- parable in age to the students themselves, if possible. Apart from providing an example of effective patient/doctor communication the inter- view provides students with the experience of one

patient’s journey and is often a very powerful experience for all concerned.

Module Four deals with symptom control, especially the management of pain. This session, by necessity, is the most didactic session and provides information about the methods and pharmacology involved in effective symptom management for patients receiving palliative care. As noted previously much of this session looks at pain management and challenges beliefs about pain assessments and the use of analgesia such as morphine.

Module Five incorporates a visit to Bethlehem Hospice a 98 bed inpatient facility and outpatient domiciliary palliative care service. The visit involves an introduction to hospice based care including the philosophy of care in such centres. Students are then encouraged to visit with inpati- ents and to talk to them about their personal experiences.

Module Six begins with a brief discussion about the hospice visit and logically progresses into a discussion about bereavement. Students and lec- turers sit in a circle and share each others personal loss histories including their perceptions about how the bereavement was handled, their experi- ence of being told about the death, the funeral and their observations about how others coped.

Individual and common experiences are brought together in the theoretical part of this session which presents a number of principles about working with people who are experiencing ber- eavement. We have found that the principles presented have usually been mentioned within an experience of one of the students and thus is easily consolidated into their learning. The use of students’ own personal and often painful experi- ences is a deliberate one. A self knowledge of personal trigger points is vital to the ability to practice ongoing effective care of patients as well as the self preservation of the health care professional.

The Final Module has three components. To begin with any unfinished business that was not dealt with in either the previous, or indeed any of the other modules, is briefly discussed. This is followed by a short discussion concerning the options for the place of care for patients who are receiving palliative care. This section provides information on three options for care including home with support from a community based palliative care service, inpatient care in an acute hospital setting and inpatient care in a hospice

PALLIATIVE CARE TEACHING 315

setting. The advantages of each setting are dis- cussed, including the students personal views on where students would choose to die and why. This discussion assists in making the topic real and relevant to their own context.

The major section of this module looks at stress management for health professionals. Students are given out quotes from the book ‘Mamed to their Careers’ (Gerber, 1983) which interviews Ameri- can medical students and doctors at different stages of their careers. A common theme throughout these quotes is that at each stage of the medical career there are various sacrifices that are neces- sary in order to move on to the next stage. These sacrifices are often made, based on the justification that the next stage will be easier. However, this idea is reiterated in the book. by interns, specialists and older doctors alike. Students begin to realise that these occupational stressors are largely inher- ent in the profession and that decisions about developing a balanced life style must begin now and be a conscious one, as it will not happen without their own effort.

Many of the concepts that have been discussed throughout the course including holistic care, quality of life, team work and the duty of self care are repeated and discussed again in light of the students own life-styles and plans for the

future directions of their careers. Issues concem- ing the difficulties of workload pressures, the emotional component of health care, and the variety of role models in the development of their professional self are also discussed in this session. Various solutions to these issues are suggested and worked through as a closing point of the course.

Handouts provided to all students during the course are: 1. Principles of Palliative Care. 2. Management of Cancer Pain (Sigma Public-

ation). 3. Golden Rules of Management of Cancer

Pain. 4. Detailed Synopsis of Principles of Manage-

ment of Cancer Pain. 5 . Principles of Bereavement. 6. Management of Symptoms of Cancer other

than Cancer Pain. 7. Counselling Cancer Patients.

PHASES IN COURSE DEVELOPMENT

The combination of disciplines in facilitating the Programme not only models the importance of both the medical and the psycho-social aspects of

Table 3.

Phase one

Phases of course development

Module 1. Principles of palliative care Module 2. Communication skills/breaking bad news Module 3. Symptom control Module 4. Bereavement/evaluation

inclusion of a social worker

Module 1. Principles of palliative care Module 2. Experience of illness Module 3. Communication skills/breaking bad news Module 4. Symptom control Module 5. Bereavement Module 6. Debriefing/options for community care/stress management/evaluation

changes as a response to evaluation results

Module 1. Principles of palliative care Module 2. Experience of illness Module 3. Communication skills/breaking bad news Module 4. Symptom control Module 5. Hospice visit Module 6. Bereavement Module 7. Debriefing/options for community care/stress management/evaluation

Phase two

Phase three

316 I. E. HAINES ET AL.

health care, but has enabled the growth and development of the curriculum itself. Table 3 shows the three phases that the course has taken following the inclusion of a social worker and in response to the needs of the student group. These phases illustrate the importance of both the multi- disciplinary expertise in teaching the principles of holistic care and of ongoing evaluation of the needs of the students themselves.

METHODS OF EVALUATION

An evaluation form is completed before students leave the final session. (see Table 4.)

As this Table shows, the Programme has been evaluated by short questionnaire, incorporating a scale to measure the perceived usefulness of each session. This format allows us to measure the importance each session to each student and

Table 4. Hospital 5th year medical rotation

Evaluation form. Evaluation for introduction to palliative care. Monash School of Medicine, Alfred

Session one: Debbie story and discussion Principles of palliative care

Session two: The experience of illness: video discussion

Session three: Communication skills/role play Discussion

giving ‘bad news’ ~

Sewon four: Patient interview Pain and symptom control

Session five: Hospice visit

Session six: Beareavement

own experiences theoretical

Session seven: Options for discharge Stress management

self care

Overall rating

Comments

1 2 3 4 5

Code: 1. Not useful at all, 2. Not really useful, 3. Somewhat useful, 4. Very useful, 5. Extremely useful

PALLIATIVE CARE TEACHING 317

provides us with useful data about specific modules.

Results show that overall, the Programme is considered by 89% of students to be either a ‘Very Useful’ or an ‘Extremely Useful’ component of their training (see Table 5.) . While this score is most encouraging, it has been the written com- ments from students that have provided us with the most insight into the importance of this Pro- gramme. The most common issues raised in this section of their evaluation forms are discussed.

A . ‘Why weren’t we taught this before?’

Some introductory components of the bio-psycho- social approach to health care are referred to early in the medical cumculum prior to palliative care training in fifth year. Yet, comments indicate that the integration of these concepts as being seen to be relevant to possible practice situations has not yet occurred. One possible reason for this could be the learning stage of the students themselves, with 5th year providing the first real experiences of direct patient contact for students and thus present- ing many new practice based situations on which to reflect.

In addition to the timing of the programme in the medical course, the skills taught, such as those involved with self disclosure, grief counselling and breaking bad news are purposely presented in a safe environment that is conducive to learning and risk taking. This course was developed in such a way as to encourage group cohesion and gradual development of trust and support within the group itself. Group leaders have attempted to model open

Table 5. Student rated evaluation of each session and the course as a whole, averaged over a four year period.

1

WK 1 WK2 WK3 3% WK4 3 90 WK5 1% WK6 WK7 Overall

2 3

1% 36% 5% 30% 4% 31% 2% 35% 3% 25 % 2% 11%

11% 7%

4 5

49 % 13% 47% 17% 40% 24% 27% 35% 55% 15% 49% 38% 34% 52% 51% 42%

Code: 1. Not useful at all, 2. Not really useful, 3. Somewhat useful, 4. Very useful, 5. Extremely useful. Number of students approx 300 in 4 years

communication by sharing practice experiences which have been both successful and not so suc- cessful and by providing positive feedback for participation at all levels. One student described this environment as a ‘refreshing human oasis’.

Further student comments indicate the need for increased opportunities for this kind of forum to be available within their training including, the opportunity to practice skills, to discuss reactions to incidents and to receive positive feedback in relation to such risk taking. As one student put it, ‘I really believe that this course is extremely important-it is one of the few times that we as medical students are allowed to talk about our own experiences, feelings and opinions and are listened to.’ And another, ‘It is great to have someone actively encouraging us to look further than medi- cine. I found (the session on Stress Management) very valuable-I wondered if I was the only person in the medical profession who wanted more.. . There should be a course such as this that runs throughout the medical course.’

B. ‘I’d like to see more space given to discussion on how to cope with the stress of the medical profession’ An awareness of the pressures on medical profes- sionals has well and truly begun by 5th year (Saul and Kass, 1969). The pressure to perform, to be seen to be professional, and the pressure to ‘cope’ with difficult emotional situations is clearly articu- lated at this early stage in the medical ‘career’. Indeed, according to Weinstein (1983), ‘During their education, one third of medical students seek professional counselling because they suffer anxiety and depression, secondary to academic pressures or because they feel emotional distance from others.’

The inclusion of a session on stress manage- ment was met with a powerful response. ‘I found it incredibly difficult to deal with some of the issues on the wards (especially oncology)’ noted one student, ‘and felt that there had been no real attempt to deal with this up until now.. . problems dealing with our own emotions and feelings of inadequacies in doing so interferes enormously with ability to develop any kind of skills in this area’. Another comment stated, ‘I think having sessions and talking about patients or personal experiences is very helpful, perhaps it should be a regular session for interns.’

Such responses indicate the need for not only

318 I. E. HAINES ETAL.

ongoing education on stress management but some consideration of the culture which creates such stress. Other quotes further support the need to acknowledge the issues relating to stress and the development of skills to prepare for ongoing challenges:

‘Excellent! First time in the course where the tutes not only tried to teach us, but to help us help ourselves and at least initiate our thoughts as to how to cope in ourselves when we help others.’,

‘The final session.. . . makes us look at ourselves and re- evaluate the way we pursue our careers to make sure that we don’t ‘burn out’ prematurely.’,

‘This is a very useful course especially the last session which we can discuss freely about how life would be for a doctor. Knowing what the future is like helps to relieve a lot of stress.’,

‘This is the only time we’ve been asked to look after ourselves, I think it’s good.’,

‘The course in general is very worthwhile-as we are able to think about these issues k f o r e we have to deal with them professionally.’

C . The Apprenticeship Model The point at which theory becomes integrated into practice is a crucial ‘moment’ in the development of the medical professional. This step, from student to doctor, is influenced largely by the role models each student is exposed to. According to Praise and Meers (1986) medical education in hospitals is ‘conducted according to the appren- ticeship model, with the consultant’s ‘masters’.

This apprenticeship model indicates that the relationship between the student or intern and the resident is a learning relationship where the stud- ent observes, practices and integrates into their own professional persona. However, Praise and Meers go on to describe this relationship as ‘limited in scope’ because the consultants, ‘as heads of the hierarchy, are expected t o make broad clinical management decisions, leaving the management of the patients’ personal and emo- tional needs to the lower. members of the hierarchy, e.g. . . . nursing sisters and social workers.’

Comments from students seemed to agree with this notion. For example, when asked ‘What are the factors which impinge on your skill develop- ment in palliative care?’; one student noted, ‘the

attitude of some senior medical staff in finding it less important’, and another ‘this is about the only time in which patients thoughts and feelings are discussed instead of symptoms and signs,’, and ‘I think student discussions expressing their own feelings are very helpful-this is not done very much in the medical course.

As clinical teachers attempting to help equip medical students to work in difficult emotional situations, these comments are of concern. While we attempt to prepare students to think things through for themselves, the pressure of the hospi- tal culture may well work against our aims. It seems important: that all staff working in teaching hospitals critically evaluate their own practice and ask how their actions are seen by those who will conclude, ‘so that’s what a doctor (or other health care professional) does’. It is imperative that all staff involved with medical students see their practice being observed, for the important influence that it: has. The following quotes give some indication of the messages students are already noting about the ‘culture’ of medicine at this early stage of their career;

‘I think this has been an enriching course-actually focused on the more human and emotional aspect of medicine which is often left out or not discussed during ward rounds or tutorials.’,

‘Overall this course was valuable because of the new ground that was covered and I felt like each week I THOUGHT about things I hadn’t before.’,

‘It was worthwhile focusing on death and other areas which are still seen by medicine as failures to some extent and are therefore not talked about much.’,

‘It has been particularly valuable having clinical teach- ing about social and emotional issues in medicine during a clinical term, there is too much of a tendency to pigeonhole these issues into a ‘community medicine’ part of our course. This sort of course should be encouraged, particularly during terms which are more emotionally hostile, such as surgery.’,

‘... about the only subject where patient’s thoughts and feelings are discussed instead of symptoms and signs, which is inspiring.’,

‘ ( I was) able to stand back from the weekly demands and look at how it was all affecting us. Showed that we need to consider feelings/health/experiences not just of the patients but of ourselves-made me feel more at ease with myself and my perceived incompetence at not knowing ‘everything’.’

PALLIATIVE CARE TEACHING 319

‘Good to get something different during the week, amongst all the pathology.’

CONCLUSION

The tenets promoted within the philosophy of palliative care provide the basis for understanding the illness experience and ways in which we can respond to the suffering involved with this experi- ence. Indeed, as Professor I Maddocks (1989) notes, the skills involved in palliative care are basic to good doctoring generally. Yet, this concept, basic to the provision of quality medical care, is an area that continues to be lacking in medical cumcula.

Throughout the four years this current pro- gramme has been taught, the students themselves have taught us a great deal about the educational needs of the next generation of doctors. The results from feedback about our programme indicate that students acknowledge the importance of this area of skill, in addition to their other training. They also acknowledge the discrepancy between this training and the messages they receive about the culture of medicine in practice. The success of our programme is based on both the perceived relevance of the subject matter by the students themselves. and on the methods of teaching which are seen to be refreshing, effective and challenging in a way that many students have not experienced before. These messages, about content and methods need to be taken into account for future planning in medical education generally.

From a patient perspective, there is a growing expectation that medical practitioners will provide a service that takes into account both the disease and its impact on the persons life. Indeed, as Kash and Holland ( 1990) states, ‘...to enable staff to give more sensitive and compassionate care, consequently would have a positive effect on the patients perceptions about the human aspects of care.’. This additional requirement is also an added stressor and does not allow for such a detached method of practice as might have been the case in the past. Given this, we have a respon- sibility to prepare our future doctors for the skills to find the balance between empathy and self preservation.

The end results of this teaching Programme will not be apparent until the students graduate and are faced with the very situations that we have

attempted to prepare them for. Indeed, the very confidence that grows when students feel they are being provided with such preparation is an end in itself, as the following students noted;

‘I thought this course was very helpful in that it helps us to think our way through situations we will have to deal with later but which were never prepared for.’,

‘I always felt very uncomfortable about this area but now I think I could cope better.’,

‘This has been the best thing we’ve done all year. It puts a lot of things into perspective. It also helped me understand a lot of my feelings regarding patients, i.e. whenever a patient was dying I always felt the need to give the impression that everything would somehow be all right (denial on my part), now 1’11 be more able to deal with my discomfort of ‘bad news’, and be more honest with the patient.’ (Note that Breitbart (1993) finds that counter transference issues, such as this student notes, are commonly found to be stressors for health care professionals working with cancer patients)

It was most gratifying to hear one of our early students, now a second year resident, say that the first time he was asked to go and tell a family that their loved one had died, he paused with fear and then remembered our session on ‘Breaking Bad News’, and walked into the room with an addi- tional confidence.

There are, as always, many other topics that could be covered more fully in this teaching Programme, such as belief systems and religions, multi-cultural perspectives and a more thorough overview of the various specialties involved with treatment for palliation. However, what we have attempted to do thoroughly, in the time available was to introduce the important concepts involved with this philosophy of care, and to this end we believe we are achieving very positive results. It seems fitting to conclude with words from an early student which summarises what we have attempted to do and the impact this course can have in the preparation of our future doctors;

‘I have thoroughly enjoyed this course. It has been really useful to me as a person and I believe the impact it’s made will be camed through to my interactions with patients in the future. One of the best things was giving me a different perspective on death, demystifying it taking away the fear. Thanks for the insight.’

320 I. E. HAINES ET AL.

REFERENCES Abeloff, M. D. (1991) Burnout in Oncology-

Physician Heal Thyself, J . Clirz. Oncol. 9,

Buchanan, J., Millership, R., Zalceberg, J., Milne, J., Zimet, A. and Haines, I. (1990) Medical education in palliative care, Med. J . Australia, 152, 27-29.

Breitbart, W. (1993) The stress of caring for the cancer pain patient, For the cancer-related pain management guideline panel, Memorial Sloan Kettering Cancer Center, New York, 3-4.

Gerber, L. A. (1983) Married To Their Careers: Career and Family Dilemmas in Doctors Lives, Tavistock, New York, NY.

Holland, J. C. (1989) Now We Tell-But How Well?, J . Clin. Oncol., 7, 557-559.

Halpem. D. (1991) as quoted in A Handbook for Field Educators in Social Work arid Social Welfare. The Field Education Manual Project Group, Charles Sturt University (Publishers), p. 18

Kash, K. M. and Holland, J. C (1990) Reducing stress in medical oncology house officers, in Educating Competent and Humane Physicians, (Hendrick, H. C. and Lloyd, C. (Eds)) Bloomington, Indiana University Press, 18

Kolb, D. A. (1991) as quoted in, A Handbook for Field Educators in Social Work and Social Welfare, The Field Education Manual Project Group, Charles Sturt University (Publishers) p. 20.

Maddocks, I. (1989) The teaching of palliative care to medical students, Cancer Forum, 13(1), 25.

1721- 1723.

Parker, L. M. (1989) Doctor Patient Communication and Ethical IssuesJ. Clin. Oncol., 7, 1820-1 183.

Portenoy, R. K. (1992) Cancer pain: from cumculum to practice change, J . Ch i . Oncol., 10, 1830-1831.

Praise, I. and Meers, G. )1986) Low morale in public hospitals, New Doctor, 39, 18-20.

Saul, V. and Kass, T. S. (1969) Study of anticipated anxiety in a medical school setting, J . Med. Educ., 44,526-532.

Tattersall, M. H. N., Langlands, A. O., Simpson, J. S. and Forbes, J.F. (1986) Undergraduate education about cancer in Australia, Cancer Forum, 11(2),

Weeks, J. (1992) Quality of Life Assessment: perfor- mance status upstaged?, J . Clin. Oncol., 10,

Weinstein, H. A. (1983) Committee on well-being of medical students and house staff, J . Med. Educ., 58, 375.

Weissman, D. E. (1988) Cancer pain eucation: A call for role models, J . Clin. Oncol., 6, 1793-1794.

Whippen, D. A. and Cannellos, G. P. (1991) Burnout syndrome in the practice of oncology. Results of a random survey of 1000 Oncologists, J . Clirz. Oncol., 9, 1916-1920.

Yorkin Drazen, R. and Fruchtman, R. (1993) On The Edge Of Being. When Doctors Confront Cancer, (Video) Cerenex Pharmaceutical’s.

Young, R. K. (Ed), (1988) It’s over Debbie, JAMA, Jan 8,272-273.

53-56.

1827-1829.