Principal Researchers: Dr Rodger Charlton (Medical School) and Dr Michael Bevan
Start date: 1 January 2007
Completion date: 30 April 2007
The aim of the project was to ascertain the nature of medical education in the care of dying from 1930 to 1970 with a focus on Birmingham medical school and whether this can further inform current thinking about palliative care training and so the care of the dying.
Palliative care is a new specialty following the pioneering work in establishing the modern hospice movement of the late Dame Cicely Saunders, founder of St Christopher’s Hospice in London in 1967. During the research period (1930-1970) keywords in the care of the dying included: pain, dying, death, cancer, incurable, hospice, chronic illness, hopeless, terminal and palliative. In order to test the hypothesis that doctors at Birmingham medical school were not adequately prepared to undertake the equivalent of modern day palliative care the project undertook a review of the literature, a search of the medical school archives, and oral history interviews with 10 doctors who graduated prior to 1970 and 5 members of the public. The transcripts of the interviews were analysed looking for recurrent themes. The results supported the hypothesis. The medical school archives showed no evidence of such teaching. The literature review and interviews concurred and also supported the hypothesis. The following themes were identified:
(1) No teaching in the care of the dying.
(2) Training has improved enormously since from being entirely rudimentary.
(3) The lack of training led to problems after qualification.
(4) A lack of communication with the patient about the truth of their illness resulted in a ‘conspiracy of silence’ which contrasts with current patient-centred medical education.
(5) Nurses played a key role in care and patients usually died at home.
(6) Pain relief did not feature largely in patients’ care.
(7) Many patients prior to the NHS may have gone without palliative care for financial reasons and so it was not necessarily a central part of doctors’ work and training.
Three areas of medical education that changed shortly after the study period were: attitudes towards death, communication skills and openness with patients, and curriculum development. It was concluded that potential exists for further in depth research to ascertain what factors influence medical curriculum change and the factors that facilitate home care for the dying.
The anticipated outcome was to ascertain whether the research could further inform current thinking about palliative care training and so what could be learnt for clinical practice today.
This project has been important in medical education research as it sought to ascertain the factors which influence changes in a medical curriculum. Is it the students, the patients, the public, clinicians, medical teachers, research, the media or pioneers? This is unclear but the literature review and the interviews would suggest pioneers such as Cicely Saunders through the modern hospice movement. Observational studies of medical practice can influence change in medical education and should be published as the literature review illustrated. A ‘before’ and ‘after’ article would be of interest to students and so in this case a publication is planned in the next 6 months in the Birmingham Medical School magazine, the Queens Medical Magazine, which may be a catalyst for further teaching in palliative care at the medical school.
Research in palliative care has changed from personal views and subjectivity to rigorous scientific studies and so objectivity which continues to direct medical education in this field. It was, however, the observations of the early pioneers who influenced change in training from a lack of training to a significant contribution. If dying patients suffer distress it suggests that training is inadequate. Current literature suggests that this continues to be the case in several circumstances and studies such as this should be published to stimulate further changes in medical education. Publication of this project as a paper in a peer reviewed journal is planned during the next 12 months.
Most care was provided at home and research now shows this is where most people would wish to die if given the choice. However, the majority of people now die in hospital. Why was dying at home achievable during the research period and not now? This is an area for change and its implementation is part of new end-of-life care pathways. The reasons for the change are not clear. Further history of medicine research will have much potentially to contribute to this process.