Evaluation of postgraduate family medicine trainee’s knowledge and attitude following an online Educational Module in Palliative Care: A descriptive study

Objectives: To identify improvement in knowledge and attitude of Family Medicine (FM) postgraduate trainees (PGT) towards Palliative care (PC) in order to provide effective care to the patients with advanced disease. Methods: A cross-sectional study was conducted over eight weeks from 1st July till 3rd September 2021 at Family Medicine Department, Aga Khan University Hospital (AKUH). PGT who willingly signed the written informed consent were enrolled in the study. Descriptive analysis, frequencies, proportions and thematic approach were used for data analysis. Data was analyzed using SPSS version 23. Results: FM-PGT were included in the study. Improvement in knowledge was observed in posttest scores along with positive change in their attitude and improved perception of level of confidence for managing PC patients. Overall assessment of PCM was positive. Conclusion: This PCM seems to be a useful tool for PC training in postgraduate medical education (PGME). This highlights some useful aspects for future applications in PC education and training.


INTRODUCTION
patients at home in the last 12 months of life. Most of them reported difficulties in pain and other symptoms management, dealing with families' emotional distress and psychosocial needs with their terminally ill patients. 9,10 It has been found that most young doctors do not have the required knowledge to provide effective end-of-life care. 11 There are structured PC training programs in developed world, but no such programs exist in Pakistan. Training in PC is challenging, as it has not been incorporated formally into undergraduate and PGT program. It is important to acquire knowledge, skills, and cultural sensitivity to provide long-term and effective PC. 12 Training needs of FM physicians in PC is vital and cannot be denied. 13 PC is much underdeveloped in low-middle-income countries and Asia Pacific region and its training is a ray of hope. 14 FM being the gateway of healthcare and the trainees being uncertain in managing PC patients highlights the need of this study in our population. 15 Online educational model has gained worldwide fame during Covid-19 pandemic hence affirms the online platform used for this module. [16][17][18][19] This module was organized to introduce basic training of PC among FM-PGT. PC being the emerging need of our community and FM-PGT being less confident in managing PC patients as found during their training assessments, mandates the need of this module integration in FM-PGME curricula.
The objective of this study was to highlight this need to improve PC in our population. The results from this study will help develop future PCM modules and training programs. This will provide a model that can be implemented at institutional level or nationally later which would help to address the PC needs. Physicians will be trained in providing basic PC and to reduce unnecessary suffering and improve the quality of life of patients and their families, who are dealing with a life limiting illness. To the best of our knowledge, no such study has been conducted in Pakistan earlier.

METHODS
This is a descriptive study to evaluate the effectiveness of PCM conducted over eight weeks commencing from 1 st July till 3 rd September 2021 at FM department of AKUH. FM-PGT who had given written informed consent were enrolled in the study.

Intervention: Phase-I: PCM Development
This module was planned to establish basic concepts of PC based on curricula of Palliative Medicine worldwide. After reviewing literature and discussing with PC specialists, PCM was formulated.

Phase-II: Implementation
The module was comprised of eight sessions, conducted once per week. This module was facilitated by multidisciplinary PC team including physicians, nurses and dieticians. It consisted of pretest, premodule need assessment, pre-reading material, MCQs, lectures and case-based discussions. Moodle e-learning platform was used. The module entailed 24 hours of classroom online teaching (synchronous), 24 hours of asynchronous engagement of the participants and two hours for pre-test, posttest, pre-module need assessment and post-workshop evaluation (Total of 50 hours).

Phase III: Evaluation
Evaluation was done by posttest MCQs, postmodule feedback and focus group discussion (FGD). Qualitative exploratory focus group methodology was adopted to gain a wide range of views, stimulate reflection and encourage discussion about PCM. It captured the impact of PCM on the knowledge, attitude, confidence level, experience, strengths and suggestions for improvement. Data collection and measures: All participants were informed about the module plan prior to the commencement of the study. Pre-module need assessment forms and pre-session MCQs were given to all trainees at the beginning of the module and before each session respectively. At the end of the module, PGT were requested to complete post-module feedback form and posttest consisted of MCQs.
The Principal Investigator conducted a FGD at the end of the module, which lasted between 60-90 minutes. A semi-structured interview guide was developed for FGD, supported by the literature and overarching research aims. PGT were asked to share their overall experience and feedback, which was recorded via digital recorder and later converted from voice to text and transcribed. The scores of this study were not included in academic performance assessment. Remedial sessions were arranged for those who scored less than 50%. Statistical analysis: Quantitative data was imported to SPSS version 23 for analysis. Descriptive analysis was done for all non-normally distributed data.

RESULTS
The total number of PGT participated in PCM were 16. Out of 16, three PGT dropped out due to their rural rotation.
The characteristics of module participants are shown in Table-II. Out of total 13 PGT, n=10(76.92%) was female and n=3(23.07%) was male and year of graduation varied from 2005 to 2019. According to the year of residency, n=5 PGT were from year I, n=5 from year II, n=1 from year III and n=2 from year IV have been enrolled in the study.

Pre-module need assessment:
Regarding the objectives, most of the PGT stated that they wanted to learn basics of PC, improve communication skills, find areas of research, provide effective and continuity of care to patients with advanced illness, and refer to appropriate specialty when required. PGT mentioned that learning PC is important because it would help them to manage patients with PC needs. Important themes identified were "symptoms management" "counselling skills", and "polypharmacy" in PC.
Most of the PGT n=12(92.3%) perceived that PC is about "neither hastening death nor prolonging suffering, while only one n=1(7.69%) of them perceived that it's about "giving up on active treatment". Majority of the PGT n=9(69.23%) strongly agreed that PC is important for Family Physicians. While n=4(30.7%) agreed with the statement.
Similarly, n=8(61.53%) PGT strongly agreed that this module would increase their level of confidence in managing patients with advanced illness. While n=5(38.46%) agreed with the given statement. Post-module evaluation: Majority of the participants n= 9(69.23%) agreed that the program objectives were achieved while n=1(7.69%) participants did not agree at all. On other hand, n=3(23.07%) participants agreed that only some objectives have been achieved. The most useful sessions identified by PGT were "symptoms management" and "communication skills".
The knowledge gained with this module was reported to be excellent by n=4(30.7%), and good by n=8(61.5%) while only n=1(7.69%) participant found it very good.

Residency level
Year I Year II Year III Year IV   1: where x-axis shows residency year and y-axis shows pretest and posttest scores.

Numbers in each year
Level of confidence in managing patients with terminal illness reported by module participants was mostly "good" and "very good".
PCM organization was reported to be excellent by n=4(30.7%) PGT, very good by n=8(61.5%), while =1(7.69%) reported it as good. Regarding the usefulness of this module in their clinical practice, n=7(53.8%) PGT reported that module was very good, n=5(38.46%) reported good while only n=1(7.69%) reported it to be excellent.
Most of the PGT suggested that module would have been more effective if it could be tailored according to Family Medicine context with more physical and skills sessions including role-plays. The strengths of the module were "communications skills", "symptoms management", "learning from the skilled faculty" and "organization of the module" as reported by the PGT. Overall assessment was marked as very good by 50%, excellent by 35.7% and good by 14.29% of study participants. Pretest and posttest score: The pretest score was 61.5% and posttest score was found to be 73.46% with improvement of 12%. The pretest and posttest scores among different residency years are shown in Fig-1. There was increase of knowledge of 12% overall and each level of residency year as shown in the bar chart. Focus Group Discussion: Participants rated PCM as a good experience overall. They appreciated the innovative idea of introducing PCM into Family Medicine core curriculum. The activity was "well organized" and it was like "putting the pieces together". Sessions were "very informative" and "helpful". Sessions on symptom management and counselling skills were stated as strengths of this module. Some sessions like oncological ailments and nutrition were regarded as beyond the scope of FM. Initially, the perception about PC was end-of-life care but after attending this module, participants understood that it's about a "holistic care" of advanced illnesses with empathy and patients' wellbeing physically, socially and mentally. The beauty of PC lies in taking "care of caregivers". Most trainees recognized the need for skills session including breaking bad news and few in-person interactive sessions. Some of them liked the idea of online sessions, as one of the speaker was able to deliver the session from outside the country and those trainees who were on their rural rotations got benefit from that too. Role-plays during the sessions got huge appreciations.

DISCUSSION
This study emphasizes the vitality of introduction of PCM in curriculum of concerned specialties like FM which will enable physicians to take care of this huge vulnerable population of our country. The results of this study reveals improvement of knowledge by 12%, increased level of confidence in managing patients with advanced diseases and overall assessment for the module was marked as good and very good by most of the participants. These outcomes are comparable to other studies for online educational intervention, such as those reported about symptoms management at the end-of-life. [17][18][19][20][21][22][23][24][25] Most of the participants assigned a score of "good and very good" to the usefulness of educational content in their clinical practice. The content and organization of the module was wellreceived.
Education using an e-learning platform had a positive impact as mentioned by a few participants. Although majority of the participants expressed the need of more physical and skills sessions including roleplays, but also realized the need of the online platform to facilitate the trainees on their rural and elective rotations. Further studies and skill-oriented training programs with long-term follow up evaluations may address these issues.
The findings of this study reflect the educational and training need of the PGT regarding PC. Family Physicians being the first point of care for several people can provide effective care if trained properly, so training need is of utmost importance. This module can be a useful resource for PC physicians and experts to develop capacity of family physicians in the field of Palliative medicine and should be offered to other physicians interested in PC education soon. There is a need to design further educational programs and interventions and evaluate their impact on patients, families and health care providers on local, regional and national levels.

Limitations:
The study sample size was small. Due to Covid-19 pandemic and unavailability of few PGT, all the sessions were conducted online. Skills sessions could not be conducted physically as well.

CONCLUSION
This online module on PC had positively influenced PGT in this study by bringing a significant change in their knowledge and attitude. This module can be a useful resource for PC Physicians and experts to develop capacity of Family Physicians in the field of Palliative Medicine and should be offered to other physicians interested in PC education in the near future. There is a need to design further educational programs and interventions and evaluate their impact on patients, families and health care providers on local, regional and national levels.