796 Journal of Pain and Symptom Management Vol. 41 No. 4 April 2011

Brief Report

Palliative Care Education in China: InsightInto One Medical UniversityXuan Jiang, MD, Zhongli Liao, MD, Jia Hao, MD, Ying Guo, MD,Yuanyuan Zhou, MD, Linhong Ning, MD, Jianying Bai, MD, Pengbin Zhang, MD,Chunlin Tang, MD, Xiaoyan Zhao, MD, and Hong Guo, MD, PhDThird Military Medical University (X.J., C.T.); Department of Gastroenterology (Z.L., Y.Z., L.N., J.B.,

P.Z., X.Z., H.G.) and Department of Cardiovascular Medicine (J.H.), Second Affiliated Hospital,

Third Military Medical University, Chongqing, People’s Republic of China; and Department of

Palliative Care and Rehabilitation Medicine (Y.G.), University of Texas M.D. Anderson Cancer

Center, Houston, Texas, USA

Abstract

Context. There has been an increase in the amount of palliative care available

in developing countries, including in China. However, palliative care is still verylimited, and it is not mandatory to teach courses on palliative care in Chinesemedical universities.

Objectives. To assess Chinese interns’ awareness of palliative care concepts.Methods. Using a questionnaire selected from an earlier Austrian study, interns

in a Chinese medical university were surveyed. All those surveyed had alreadybeen interns for at least six months.

Results. Four hundred interns from a Chinese medical university (response rate99.5%) were surveyed. Twenty-one percent were female (84 of 400), and theaverage age was 23 years. Approximately one-third (34.5%) of interns werefamiliar with the pain scale, and 31% of interns were familiar with the concept ofpain management. Only 7.5% of interns felt adequately trained in basic painmanagement, and 13% felt adequately trained to manage symptoms of dyingpatients. Seventy-seven percent of interns reported inadequate educationregarding discussion of death with patients and family members. More than 80%of interns felt that more education about palliative care should be included in thebasic medical curriculum and clinical intern training.

Conclusion. Palliative care education is inadequate from the perspective of theChinese medical interns. An improvement in the medical school curriculum isneeded. J Pain Symptom Manage 2011;41:796e800. � 2011 U.S. Cancer PainRelief Committee. Published by Elsevier Inc. All rights reserved.

Key Words

Palliative care, medical interns, survey

Address correspondence to: Hong Guo, MD, PhD, De-partment of Gastroenterology, Second AffiliatedHospital of Third Military Medical University,

Xinqiao Street, Chongqing, People’s Republic ofChina. E-mail: haojia2004@yahoo.com.cn

Accepted for publication: July 28, 2010.

� 2011 U.S. Cancer Pain Relief CommitteePublished by Elsevier Inc. All rights reserved.

0885-3924/$ - see front matterdoi:10.1016/j.jpainsymman.2010.07.012

Vol. 41 No. 4 April 2011 797A Snapshot of Palliative Care Education in China

Introduction theoretical knowledge of palliative care con-

Palliative care was initiated decades ago andadvanced rapidly in developed countries. In1997, a landmark report, ‘‘Approaching Death:Improving Care at the End of Life,’’ noted that‘‘Deficiencies in undergraduate, graduate, andcontinuing education for end-of-life care reflecta medical culture that defines death as failureand ignores care for dying people as a sourceof professional accomplishment and personalmeaning.’’ Since then, theU.S. Institute ofMed-icine has claimed that there have been majorimprovements in professional training and ac-countability on the part of medical educators.1

In recent years, there has been an increase inthe amount of palliative care available in devel-oping countries, including in China. However,this type of care is still very limited.2

It is not mandatory to teach courses on palli-ative care to students enrolled in the medicaluniversities of China. Students can select op-tional courses on palliative care for terminal pa-tients in only a fewmedical universities (CentralSouth University and Sun Yat-sen University ofMedicalSciences). In this article,we report a sur-vey of palliative care concepts among medicalinterns at the Third Military Medical University(TMMU), China, and compare the surveyresults with historical data.

MethodsSurvey Development

A previously published questionnaire wasused in the survey.3 The survey was composedof 12 questions (Table 1) covering the

Table 1Chinese Interns’ Respo

QuestionNumber Questions

Q1 Are you familiar with the concepts of palliative care? (Q2 Are you familiar with the concept of pain managemenQ3 Do you feel adequately trained in basic pain managemQ4 Are you familiar with pain scales? (T)Q5 Have you been involved in the care of dying patients?Q6 Are you familiar with the physical signs of the dying pQ7 Do you feel adequately trained to manage symptoms oQ8 Do you feel competent in talking about death to a terQ9 Have you been educated adequately to talk about theQ10 Have you witnessed your teacher discuss these issues?Q11 Do you feel adequately trained in delivering bad newsQ12 In your opinion, should more about palliative care be

T¼ theoretical knowledge of palliative care concepts; P¼ practicing virtual a

cepts (Questions [Q] Q1, Q2, Q3, Q4, Q7,Q9, and Q11) and confidence in practicing vir-tual aspects of palliative care (Q5, Q6, Q8, andQ10). An additional question (Q12) askedwhether or not there should be more palliativecare issues covered in the medical curriculum.

Sample RecruitmentTMMU is a major medical university estab-

lished in 1954 in southwest China, with a classsize of approximately 500 students. The curric-ulum at TMMU, like most other medical uni-versities in China, comprises four years ofcourse work on basic and clinical sciencesfollowed by one year of clinical internship.The internship involves rotations in surgery,internal medicine, obstetrics and gynecology,and other departments, consisting of threemonths each. For this study, medical universityinterns from TMMU were surveyed. Thisgroup had no mandatory education in pallia-tive care. We randomly approached 400 in-terns and asked them to complete the surveyvoluntarily after a meeting. Ten to 15 minuteswere allotted to complete the survey. Thosewho were unwilling to participate in the surveywere allowed to leave.

Statistical AnalysisDescriptive analysis was used.

ResultsA total of 402 questionnaires were distrib-

uted to the interns and 400 of them were re-turned. Among the interns surveyed, 84 were

nses to Survey

% Chinese Interns WhoResponded Yes (n¼ 400)

T) 77t? (T) 31ent? (T) 7.5

34.5(P) 54rocess? (P) 60.8f the dying patient? (T) 13minally ill patient? (P) 27.5se issues? (T) 13(P) 62? (T) 21included in your curriculum? 84.5

spects of palliative care.

798 Vol. 41 No. 4 April 2011Jiang et al.

female (21%). The average age of the internswas 23 years.

The survey results are presented in Table 1.In the theoretical part, 77% of the Chineseinterns considered themselves familiar withthe concept of palliative care (Q1). However,only 31% were familiar with the concept ofpain management (Q2), only 7.5% felt ade-quately trained in basic pain management(Q3), and 34.5% were familiar with the painscale (Q4). Additionally, only 13% of the Chi-nese interns felt adequately trained in manag-ing symptoms of dying patients (Q7).

Regarding communication, only 13% of theChinese interns believed that they had beeneducated adequately to discuss death with a ter-minally ill patient (Q9), and only 21% felt thatthey were adequately trained in delivering badnews (Q11).

In the practical training area, 54% of theChinese interns were involved in the care ofdying patients (Q5), 60.8% were familiar withthe physical signs of the dying process (Q6),27.5% felt competent in talking about deathto a terminally ill patient (Q8), and 62% hadwitnessed their teacher discussing death witha terminally ill patient (Q10). In the opinionof 84.5% of the Chinese interns, more pallia-tive care education should be included in theircurriculum (Q12).

DiscussionThe modern palliative care practice in devel-

oped countries is well established. The WorldHealth Organization (WHO) considers pallia-tive care to be the active compassionate careof patients at a time when the goals of cureand prolongation of life are no longer achiev-able. The WHO has called for training institu-tions to make palliative care compulsory incourses leading to basic professional qualifica-tions. According to a WHO document, pallia-tive care comprises six parts, which aredescribed by O’Neill and Fallon.4 Our studyprimarily assessed the skills needed for themanagement of pain and other symptoms(Q1eQ7), whereas Q8eQ11 addressed thecommunication aspect of terminal care. Thisarticle does not effectively assess the spiritualcare or social support aspects.

A previous study by Pohl et al.3 using thesame questionnaire has shown that 80% of

Austrian interns were familiar with the conceptof palliative care (Q1). In fact, 96% were famil-iar with the theoretical concepts of pain man-agement (Q2), 50% were familiar with basicpain management (Q3), 91% were familiarwith the pain scale (Q4), and 25% were famil-iar with symptom management (Q7). As ourdata indicated, most Chinese interns (77%)thought that they were familiar with the con-cept of palliative care (Q1), but in fact, mark-edly lower percentages were familiar withthe theoretical concepts of pain management(31% for Q2), basic pain management (7.5%for Q3), the pain scale (34.5% for Q4), andsymptom management (13% for Q7). Theseobservations indicate that although the Chi-nese interns understand broad concepts, theydo not possess the knowledge and skills thatwill enable them to act in practical circum-stances. The concept of the pain scale is easyto grasp, and it should be integrated into thelist of vital signs. Once becoming aware ofpatients’ pain, physicians are more motivatedto treat it or learn how to treat it.Pohl et al.3 reported that 93% of the

Austrian interns were involved in the care ofdying patients (Q5), 76% were familiar withthe physical signs of the dying process (Q6),56% witnessed their teachers discussing deathwith the patients and their relatives (Q10),40% felt competent in talking about death toa terminally ill patient (Q8), and 19% felt ade-quately trained in delivering bad news (Q11).Our data also showed that 54% of the Chineseinterns were involved in the care of dying pa-tients (Q5), 60.8% were familiar with the phys-ical signs of the dying process (Q6), and 62%witnessed their attending physicians discussingdeath (Q10). Unfortunately, only 27.5% of theChinese interns felt competent in talkingabout death (Q8), 13% felt adequately trainedin talking about death (Q9), and 21% felt ad-equately trained in delivering bad news (Q11).In the southwest area of China, patients with

late-stage cancers typically choose to die athome or in nearby hospitals. Meanwhile, doc-tors working in local community hospitalshave less adequate knowledge of palliativecare (data not shown). A large portion of fi-nancially challenged dying patients usually isdischarged home for economic reasons.While these patients are dying at home,most do not have access to hospice care and

Vol. 41 No. 4 April 2011 799A Snapshot of Palliative Care Education in China

are even less likely to receive physician visits;this could be why a lower percentage of theChinese interns were exposed to the care ofdying patients.

In recent years, tension between physiciansand their patients has been escalating for vari-ous reasons.5 Because the topics about progno-sis and death are very sensitive ones, whichmay result in strong emotional reactions, in-terns are generally discouraged from discus-sing disease processes with patients and theirfamilies.

Most Chinese interns expressed the desire toinclude palliative care in their curriculum.However, in addition to concept and theory,they also could benefit from bedside teachingof palliative care specialists. Because palliativecare rotation is not a choice in the electivesin our university, establishing a palliative caredepartment in a medical university is essentialto provide training and clinical experience formedical students and interns.

Data in the Chinese cancer registry showthat the five-year overall survival rate for allcancer patients is only 35.64% (http://www.tj.xinhuanet.com/shkj/2007-05/31/content_10170176.htm), which compares unfavorablywith a five-year overall survival rate of morethan 66.0% in the United States (http://www.seer.cancer.gov/statfacts/html/all.html).The low five-year survival rate in China iscaused by several factors: a majority of newlydiagnosed cancer patients are in advancedstages of disease, as in other developing coun-tries,6 and many patients refuse surgery, che-motherapy, or radiation therapy because offinancial and other reasons. The low five-yearsurvival rate of cancer patients suggests thata larger proportion of patients would need pal-liative care and symptom control during theirend-of-life care. There are about two millionpeople in China suffering from cancer pain.Because cancer-related pain is one of themain causes of depression, 80% of cancer pa-tients’ attempted suicides are related to severepain. Cancer pain management has becomea public health issue.7,8 Pain and symptommanagement are urgently needed.

An early study regarding pain managementindicated that, although efforts had beenmade over the past 10 years and the evaluationof cancer-related pain had progressed notably,a few doctors still used placebos to assuage

cancer pain. This shows that medical staff donot believe that cancer patients have pain orunderestimate their pain.9

In China, most medical school graduates willfind jobs after their internship and will be-come resident physicians. Later, they will be-come attending physicians in rural areas,county hospitals, or city hospitals, providingprimary care or specialist services. Only asmall number of medical university graduatescontinue to study in an academic setting.Therefore, most physicians in nonteachinghospitals rely on the knowledge and trainingthey received while in medical school and dur-ing their internship. If the knowledge andtraining are not provided, they are unlikelyto provide optimal care when they encounterdying patients in their practice. Future studiesto evaluate palliative care concepts and prac-tice in attending physicians in different prac-tice settings can further elucidate the actualquality of care provided to patients.

Unfortunately, as in most developing coun-tries, palliative care has not been recognizedas an important specialty in China, especiallyin poor areas. A survey of experienced Chineseurban physicians showed that a significant num-ber of these physicians did not feel competentin symptommanagement.10 There was a sugges-tion that undergraduate study, by providing the-oretical teaching, clinical observation, andinternship, should aim to provide death educa-tion as a compulsory course. Attention shouldbe given not only to the quality of life but alsoto strengthening palliative care.11

Because oncologists commonly treat dyingcancer patients who need supportive care, ef-fective symptom management, and friendlyhospice care,10 it is essential to establish a palli-ative care department to provide training andclinical experience for medical students andinterns in each medical university. Further-more, there is a need to develop continuingmedical education with specific case discus-sions and demonstrations to help build educa-tion programs and gradually introduce moreeffective care for the dying.12 In addition, tech-nologies, policies, organizations, and publiceducation will all have a role to play in helpinghealth professionals acquire new knowledge,improve their existing skills, and continuallyimprove their abilities to care for dyingpatients.

800 Vol. 41 No. 4 April 2011Jiang et al.

Although the results reported here shedlight on the current status of palliative carein China, they are not without shortcomings.Among them, the most serious is probablythat the data from the questionnaires werebased on self-evaluation. The population selec-tion for the questionnaires is limited to oneclass from one institution. Further tests ofthe knowledge of pain and symptom controlwould reflect more accurately the actual levelof understanding. Future studies in multiplemedical universities and in different regionsof China are needed to confirm this finding.Nevertheless, this study is the first in Chinato provide a unique perspective of palliativeeducation in a major medical university.

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