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German Medical Education in Pain Therapy and Palliative Medicine

2002; Elsevier BV; Volume: 24; Issue: 1 Linguagem: Inglês

10.1016/s0885-3924(02)00427-x

1873-6513

Christoph Ostgathe, Friedemann Nauck, E. Klaschik, E. Duke Dickerson,

Pharmacological Effects and Toxicity Studies

To the Editor: Since the early 1800's, Germany has been a global leader in the development of analgesics used in pain therapy and palliative medicine. From the bench of Friedrich Sertürner in 1806, where morphine was first isolated, to the advent of Friedrich Hoffman's wonder drug aspirin in 1899, the development of methadone and the COX-2 inhibitors–the new generation of NSAIDs (e.g., meloxicam)–Germany has provided the world with the means for treating pain. However, like the rest of the industrialized world, Germany remains slow in implementing the necessary curriculum into medical schools to provide physicians in training with the appropriate knowledge to utilize pain medication in an effort to alleviate the unnecessary pain and suffering so many patients continue to endure as a result of an incurable disease. Although the tools have long been available, the best method to disseminate knowledge remains an enigma. Education is without a doubt the axis on which the world of pain therapy and palliative medicine revolves. Without education, any attempt to effectively (and efficiently) address this issue is counterproductive. Although medical educators acknowledge that medical students' attitudes, behavior, and clinical knowledge in the area of pain therapy and palliative medicine can be positively influenced by education,1Von Roenn J.H. Cleeland C.S. Gonin R. et al.Physician attitudes and practice in cancer pain management. A survey from the Eastern Cooperative Oncology Group.Ann Intern Med. 1993; 119: 121-126Crossref PubMed Scopus (721) Google Scholar the results of a 1998 international survey of 175 medical teaching institutions show that only 24% of the respondents (n = 117) have mandatory rotations in pain therapy and palliative medicine.2Oneschuk D. Hanson J. Bruera E. An international survey of undergraduate medical education in palliative medicine.J Pain Symptom Manage. 2000; 20: 174-179Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar This number is somewhat skewed as the United Kingdom clearly outweighs the rest of the respondents in offering mandatory rotations. Even more alarming, less than 3% of medical students participate in an elective rotation.2Oneschuk D. Hanson J. Bruera E. An international survey of undergraduate medical education in palliative medicine.J Pain Symptom Manage. 2000; 20: 174-179Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar To expect the medical community to treat something they know little about is questionable. Thus, education must serve as the essential building block in effective pain therapy and palliative medicine. In an effort to identify where on the “learning curve” Germany rests with regard to curriculum in pain therapy and palliative medicine, a survey was sent to 35 medical teaching institutions throughout the country. The survey, created by Doreen Oneschuk et al.2Oneschuk D. Hanson J. Bruera E. An international survey of undergraduate medical education in palliative medicine.J Pain Symptom Manage. 2000; 20: 174-179Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar and translated to German in our clinic, was used in an effort to maintain a “consistency” for comparative purposes. As expected, the survey confirmed a void in new learning with regard to pain therapy and palliative medicine in Germany. In contrast to the United Kingdom, well-known for its reputation as the “palliative care Mecca of the world,” Germany remained far from the “front of the class” with regard to mandatory and elective rotations. However, Germany did compare favorably to its Canadian and United States (USA) counterparts in the offering of formal lectures and educational reading material (Table 1).Table 1Comparison of British, Canadian, German and U.S. Medical Schools' New Learning Methods in Palliative MedicineMethod of New LearningBritishCanadianGermanU.S.Total Survey Respondents22143338Mandatory Rotation14 (64%)2 (14%)0anot approved (to date) by the German government for inclusion in the medical school curriculum (0%)4 (11%)Elective Rotation18 (82%)10 (71%)9 (27%)23 (61%)Formal Lectures17 (77%)10 (71%)20 (60%)23 (61%)Educational Reading Material13 (59%)7 (50%)14 (42%)16 (42%)a not approved (to date) by the German government for inclusion in the medical school curriculum Open table in a new tab A curriculum for palliative medicine for physicians and medical students3Hecker E. Nauck F. Klaschik E. Curriculum Palliativmedizin für Medizinstudenten und Ärzte in Palliativmedizin.in: Müller M. Kern M. Nauck F. Klaschik E. Qualifikation Hauptamtlicher Mitarbeiter, Curricula für Ärzte, Pflegende, Sozialarbeiter, Seelsorger in Palliativmedizin. 2nd ed. Pallia Med Verlag, Bonn1996: 7-17Google Scholar on the basis of international examples4MacDonald N. The Canadian Palliative Care Curriculum, The Canadian Committee on Palliative Care Education, 1991.Google Scholar, 5Palliative Medicine Curriculum Association for Palliative Medicine of Great Britain and Ireland 1992, Southampton.Google Scholar was created in 1996 and approved by the German Association for Palliative Care (DGP). However, German medical teaching institutions have not incorporated this curriculum into their teaching routine due to the fact that the German government must amend legislation as it relates to the education of physicians in training prior to implementation. Since forums for new learning (e.g., mandatory rotations, etc.) in the German medical school system have the luxury of national and federal control, once the governing authorities learn to appreciate and understand the merit of pain therapy and palliative medicine, the decision to incorporate the appropriate curriculum can be done with the proverbial “swipe of a pen.” While U.S. medical schools (n = 127) continue to lobby on “case by case, institution by institution” proposals for the inclusion of a palliative medicine curriculum, the German educational system could implement a new model of learning that integrates the ideas of pain therapy and palliative medicine into the training of physicians beginning with the first day of medical school. In summary, it appears the approval of a pain therapy and palliative medicine curriculum, to include mandatory and elective rotations by the German national and federal authorities is paramount. As formal lectures and educational reading material rival that offered in Canada and the USA, the ability to offer rotations of this nature is pivotal if German citizens in need of pain therapy and palliative medicine are to receive the quality of care they deserve. Dr. Dickerson's fellowship is funded by Boh- ringer Ingelheim GmbH.