Our study has elicited the experiences and preferences of GPs, PHCT members and CME providers with respect to undergraduate and postgraduate education in palliative care for GPs. Workplace learning has been suggested by participants as a complementary form of lifelong training, with its own specific requirements and conditions.
A first emerging theme is the wish for education to focus on clinical practice, in terms of format as well as content. Upon graduation, GPs do not feel fully prepared to deliver high-quality palliative home care as they lack clear insights in to what palliative care really entails and what will be expected of them in their practice. This reflects the intentions of coordinators of UK medical schools who formulate a concern towards a palliative-care attitude and an awareness of the palliative-care philosophy as an important topic of undergraduate education
. The lack of exposure and clinical experience during undergraduate education is mentioned as a major cause of insufficient preparation for practice in our study, confirming the results of a similar study in the UK
. The literature describes various ways of introducing practice experience in education with hospice rotation
[27–29]. Participants in our study, however, suggest that hospital/hospice training experience cannot easily be transferred to the specific requirements of home-based care. Therefore, it might be interesting to seek for ways of organizing practice rotation in primary care.
Expanding the undergraduate palliative-care curriculum enhances the perception of self-efficacy among students
. A valuable alternative, with possibly less impact on the organization of medical schools, might be to analyse the complete medical curriculum for ‘hidden palliative-care content’ (e.g. ‘therapy withdrawal in end-stage cardiac failure’ during lessons in cardiology) and fill in the gaps with a minimum of palliative-care courses
With respect to CME there were clear preferences for interactive, practice-based, small group sessions, thereby confirming literature suggestions on the efficiency of educational formats
[32, 33]. Unfortunately, as confirmed by a recent review, lecturing remains the primary way of education due to a lack of financial and practical support to provide more interactive training modules
. It is worthwhile, however, to make efforts to optimize CME sessions as it has shown the ability to enhance practice
. When questioned on the content of CME, GPs preferred it to mirror the complex reality of palliative home care, as is also suggested by the literature
[35–37]. With respect to the importance of communication training there was disagreement among the participants. While PHCTs and CME providers call for explicit and repetitive training in communication, GPs prefer to develop their own ways of communication through experience rather than through training sessions. The latter contrasts with the literature, which refers to the positive effects of training on doctors’ communication and promotes interactive training sessions
[38, 39]. This might be due to the GPs’ reluctance to engage in role-play sessions
. The educational outcomes have been shown to be enhanced by practice reinforcement
Workplace learning is the second theme of interest emerging from the results. Practice reinforcement is easily accessible in the case of bedside teaching
. This is in line with participants’ preferences for learning by doing. All participants preferred this way of learning to classroom-based learning, especially when addressing GPs’ on-the-spot learning needs. Both GPs (who can be considered the ‘learners’) and PHCT nurses (who can be considered the ‘teachers’, since they are more experienced than the GPs) acknowledge this. The literature on workplace learning (WPL) indicates that this is a reciprocal relationship (both are learning from each other), but the focus of our study was limited to the learning experiences of GPs
[42, 43]. Participants in our study see WPL as a valuable way of learning, both for practical issues (hands-on training) and for honing a holistic, person-centred attitude towards palliative care (PHCT nurses acting as a ‘role model’). Although the literature supports the idea that a palliative-care attitude should preferably be acquired early in undergraduate medical education in order for GPs to be well-prepared for practice
[35, 44], participants in our study declare that the PHCT nurses’ role modelling changed their attitude towards palliative patients.
Learning through collaboration offers different ways of learning (e.g. implicit learning, disseminating tacit knowledge) through different learning activities (e.g. observation, receiving feedback) which are difficult to incorporate in CME sessions. Both ways of learning are therefore complementary
[17, 45]. Opinions on the effectiveness of WPL, however, differ among the participants: while GPs were convinced of the enduring change in competences after a learning experience in a PHCT, the PHCT nurses doubted the effectiveness of it, having witnessed GPs raising the same problems and questions over and over.
A third important theme is the GPs’ self-perception of the tasks and position towards palliative care during interprofessional collaboration. Our study results indicate that palliative care is an integral part of primary care and GPs are willing to make efforts for it, although workload can sometimes limit the GPs’ involvement
. Gibbins equally concluded that palliative care is ‘part of being a doctor’ and that the same skills are needed for primary care in general, which is pleaded for in other publications as well
[25, 46]. PHCTs are a major support for GPs when care becomes too complex. Newly qualified doctors seek support from nurses and the palliative-care team and not from their usual medical team
[26, 47]. Our study confirms and extends this observation to experienced practicing doctors.
GPs state that they learn from the PHCT nurses through collaboration. Creating opportunities for shared learning and education is a clear indicator that a good partnership between specialist palliative-care services (e.g. PHCTs) and generalists has been established
. In our study, the PHCT nurses are willing to take up this responsibility. Professionals positioning themselves as learners, can learn from the more experienced colleagues positioning themselves as learning facilitators
[21, 49]. As the learner must show a willingness to learn, the facilitator must show a willingness to share knowledge and expertise
. The overall concepts of personal identity and professional identity influence the way professionals engage in their work and consequently in workplace learning
[51–53]. This means that job perception (the way you define your job and task responsibilities) and self-conception as a practitioner are important
The literature shows that for feedback to be effective, it should be authoritative
. Our study shows that authority does not necessarily need to be diploma-based but can also originate from expertise.
An emerging suggestion from some CME providers was to train some interested GPs who can act as an informal reference for their colleagues. In Belgium and other countries there is a lot of experience with formal reference physicians in palliative care who are easily accessible. Some GPs might hesitate to take this ‘official route’ and might prefer to consult a fellow colleague.
Further research is needed to gain insight in the interaction between GPs and PHCT nurses to enhance interprofessional workplace learning.
This study’s greatest strength lies in the integration of the views of all parties involved in palliative home care: GPs, PHCTs and CME providers.
Some limitations have to be mentioned, such as the fact that GPs in Belgium have been used to working with PHCT for many years. This might have influenced their views on learning through collaboration with these teams. Generalizing their views on health-care providers to those from countries without these traditions must be done cautiously. Two different sampling strategies were used: CME providers and PHCT members responded to an invitation to participate in a mail survey, whereas GPs were recruited through a convenience sample of two peer groups. We do not think this has had a major impact on the results since the diversity of participants from CME providers and PHCT members guarantees a broad view on the topic. As for the GPs, since the two groups as a whole agreed to participate, proponents as well as opponents of palliative-care education were present. The predominance of males in the GP groups might have had an influence but reflects the male predominance in the GP workforce (at the time of our study, there were twice as many male GPs in Belgium as female GPs). Fourth, the differing probing questions in the various focus groups might seem to interfere with the analysis of the results but in our view they served to elicit different viewpoints (participants from different backgrounds) on the same topics. The same moderator led all the focus group discussions and ensured that the same topics were discussed in all focus groups. The viewpoint of our study participants may not be representative of the current situation at medical schools (since some participants graduated many years ago) but the expectations they articulate on undergraduate education are probably representative as they were based on current daily work needs (which will always be the patients’ care needs).
In summary, after finishing their undergraduate education, GPs feel unprepared to deliver high-quality palliative care. They also feel insufficiently supported by official CME providers to keep up palliative-care competences. To address their on-the-spot learning needs (induced by specific patient care needs) they turn to PHCTs. While collaborating with these teams, workplace learning occurs. Further research is needed to clarify the dynamics and efficiency of this kind of workplace learning.