Equipping future physicians to recognize a palliative approach to care: A mixed methods study on palliative care training needs in internal medicine residency

Abstract

Background

A palliative approach to care emphasizes holistic assessment and treatment planning for individuals with life-limiting illnesses. Despite Canadian national frameworks and competency guidelines, internal medicine (IM) residents often report limited exposure and comfort with palliative care.

Objective

The purpose of this investigation is to assess the training needs of IM residents at McMaster University and inform future curriculum development.

Design

A sequential mixed-methods design was employed. Both quantitative survey and qualitative interview data were reviewed together to develop recommendations for internal medicine curriculum planning.

Methods

Phase 1 included an online survey distributed to post-graduate years (PGY) 1 to 5 IM residents, assessing exposure, comfort, and preferences regarding palliative care education. Phase 2 consisted of semi-structured interviews with PGY4–5 subspecialty residents to explore perspectives in greater depth. Quantitative data were analyzed descriptively, while qualitative data underwent thematic analysis using inductive coding.

Results

Twenty-four residents completed the survey. While 54% rated palliative care as “very important” to their future practice, only 50% were satisfied with current training. Residents reported comfort with symptom management and communication but discomfort with outpatient resources and discussing artificial nutrition. Interviews with five senior residents revealed appreciation for early exposure and experiential learning but noted barriers such as limited role modeling and scheduling conflicts. Suggestions included mandatory rotations, case-based learning, and integration of community-based care.

Conclusions

IM residents value palliative care education and support its integration into residency training. Findings highlight the need for a structured curriculum that balances didactic and experiential learning, addresses identified gaps and promotes longitudinal skill development. Such efforts are essential to prepare future specialists to deliver comprehensive, patient-centered care.

Background

A palliative approach to care focuses on holistic assessment, and the development of a treatment plan with the goal of understanding patient’s symptom needs, psychosocial wellbeing, goals of care, and advance care planning when facing a life-limiting illness. When integrated early in the course of chronic illness, alongside disease-directed therapies, this approach is increasingly recognized as the standard of care for individuals with serious illnesses.^1,2 Research has shown that when focusing on this approach, patients do experience a better quality of life. ³ The Lancet Commission on Pallitive Care and Pain Relief, the Global Atlas of Palliative Care at the End of Life, and the Worldwide Hospice Palliative Care Alliance estimated that approximately 73·5 million people are in need for palliative care every year worldwide.^4,5

The World Health Organization has therefore identified a global need for national palliative care programs, resources and training through strong education programs for healthcare providers. ⁶ While the literature reflects increasing attempts to integrate formalized palliative care training into medical residency programs internationally, there remains a clear and ongoing call for additional research and educational initiatives.^6–9 In Canada, a National Framework on Palliative Care was published in 2018 highlighting the need and guidance towards better serving Canadians with palliative care needs. ¹⁰ The Framework sets out the collective vision for palliative care being accessible to all Canadians with life-limiting illness until the end-of-life. To establish the best models of practice, the Framework defines education as being one of the key areas of priority in achieving this goal. In 2019, the Canadian Society of Palliative Care Physicians (CSPCP) published a guidance document intended to describe palliative care competencies that specialists from disciplines other than palliative medicine should have upon completion of residency training. ¹¹ This document proposes core palliative education content for Canadian Universities in residency programs, all in line with international and national frameworks [Appendix A]. In short, the document suggests six domains for education priorities: Symptom management, communication, Advance Care Planning, psychosocial and spiritual care, end-of-life care and interprofessional collaboration.

Ongoing research continues to identify significant gaps in palliative care education in Canada, reflecting challenges observed globally.^12,13 One study has shown that many resident physicians feel inadequately prepared to identify and provide palliative care to their dying patients.^14–16 Among others, studies have shown that only 30% of internal medicine (IM) residents received 5+ hours of palliative care education and only 30% completed a palliative care rotation during their residency.^17,18 Importantly, despite this relatively minimal education/exposure to palliative care, 90% of IM residents agreed more education in palliative care should be a part of their training.

After recognizing this need, the McMaster University Department of Medicine, in conjunction with the Division of Palliative Care, is calling for the development of a palliative care curriculum for resident learners in the IM program. The goal is to equip future physicians with core palliative care competencies as they transition into specialty practice. The IM residency program provides training in IM-related specialties and subspecialties. Residents complete three consecutive years of postgraduate training in general IM (PGY1–3) before moving into subspecialties such as oncology, cardiology, nephrology, infectious diseases, gastroenterology, and general internal medicine (PGY4–6 and fellowship programs) among others. As part of a broader program of educational evaluation and development, this article presents data from a preliminary needs assessment of IM residents to better understand their comfort, exposure, and educational preferences regarding palliative medicine training within the IM residency stream. Based on the current literature, we hypothesized that IM residents at McMaster University will report lower levels of comfort and exposure to palliative care, but high interest in receiving additional training. This work supports better understanding of the learners’ perspectives, needs and was intended to inform towards efforts required to structure a palliative care curriculum aligned with Canadian national competencies to better prepare residents to deliver high-quality, patient-centered care in their future practices as specialists in the IM specialties and subspecialties. This work is presented to engage others to consider initiatives helping the WHO recognized need for global palliative care education initiatives.

Methods

Study design

A sequential mixed-methods two-phase study design was employed to better understand IM learning needs specific to palliative care. ¹⁹ Phase 1 involved a survey questionnaire distributed to PGY 1–5 IM residents, while phase 2 involved semi-structured interviews with PGY 4-5 IM subspecialty residents. Surveys were conducted first to understand general exposure and comfort with palliative care in this sample of learners. Interviews were conducted after survey responses were completed, to better understand experiences related to exposure and comfort with palliative care curriculum. Both quantitative and qualitative data were integrated and compared at the end of data collection and preliminary data analysis, to better understand resident experiences and comfort with palliative care. The aim of collecting both quantitative and qualitative data was to allow for deeper, richer inquiries. Surveys can often have more neutral responses, and the objective of including interview-based data was so further understand the context of IM training and exposure to palliative care curricula and provide potential explanations of why some questionnaire items may be rated more positive, negative or neutral. The GRAMMS reporting checklist ²⁰ for mixed methods investigations has been included [Appendix B].

Data collection

In Phase 1, an online survey was emailed to IM residents at McMaster University between June and July 2023. Research ethics exemption for this phase was obtained citing item TCPS2 [2022] Article 2.5 in June 2023, as this survey was considered as program development and planning. Respondents completed implied consent with survey completion. Survey questionnaire was developed by members of the author team (KC, JK) [Appendix C] and no undue influence existed between study team members and IM residents. Exclusion for survey participation included non-IM residents and residents who are not enrolled in a McMaster postgraduate training program. Key objectives included residents’ current view of the importance of palliative care education in their field, satisfaction with teaching received, perceived gaps in training, and preferred learning methods to address knowledge gaps. Additional questions focused on self-reported comfort level across palliative care topics, such as pain and symptom management, communication in palliative care, goals of care discussions, caring for dying patients, Medical Assistance in Dying (MAID) and knowledge about how to access palliative care resources. Surveys were emailed by IM education program administrators via email listserv and included consent for evaluation and dissemination of survey feedback and responses. LimeSurey^TM was used to create and distribute the survey and later exported to MicrsoftExcel for analysis.

Phase 2 involved interviews with IM residents using a semi-structured interview guide, developed from phase 1 findings. Participants were eligible for an honorarium for volunteering their time. Written informed consent was conducted prior to the scheduled interview, to explain the risks and benefits of survey participation. The interview guide consisted of questions and probes specific to their overall experiences in IM training and exposure to palliative care curriculum [Appendix D]. A purposive sampling approach was utilized to sample IM residents for a more detailed understanding of their education experiences specific to palliative care. Senior PGY4/5 residents were emailed with a study participation invite by program administrators. Investigators wanted to better understand their overall longitudinal journey in the residency programs and exposure to palliative care throughout their education blocks. Interviews were conducted via Zoom by two research team members, and audio-recorded with participant consent. Interviews were conducted until thematic saturation was achieved. ²¹ This phase of the study was approved by the Hamilton integrated Research Ethics Boards (HIREB 16728).

Data analysis

Descriptive data analysis of survey responses included frequencies of categorial variables and Likert-scale survey responses. Interview transcripts were anonymized and deidentified by a research assistant. Interviews were coded using an inductive, descriptive approach by labelling ideas and generating codes with thematic descriptive analysis.^22,23 Similar codes and ideas were then grouped into broader categories to better understand IM experiences with the palliative medicine curriculum. After transcribing the interviews, the analysis began with familiarization and identifying initial codes that describe residents’ narratives and experiences. These initial codes were then grouped together and organized into broader themes that reflect underlying meanings. This approach allowed the research team to move beyond surface-level responses to interpret how residents construct their understanding of palliative care, offering insights that can inform curriculum improvements and support professional development. Rigor was achieved through iterative engagement with data, reflexivity, and contextualization. When the research team immersed themselves with interview data, transcripts became increasingly familiar, followed by generating codes inductively while maintaining an audit trail of analytic decisions. Reflexivity allowed for self-awareness of the team’s bias and influence with coding and interpretation, as consensus meetings created a trusting space to question each other’s assumptions and further enhance interpretation. Contextualization ensured inductive topics and themes were understood within the settings in which participants’ experiences occurred. Transferability provided rich, thick descriptions of participants’ experiences and situating topics and themes specific to IM training and whether palliative approach to care was acknowledged and applied during training. Credibility was strengthened through peer debriefing across the research team during consensus meetings and constant comparison to refine codes and themes. This coding approach emphasized interpretation, transparency, and ensured findings were both trustworthy and meaningfully grounded in residents’ accounts. ²⁴

Data from both surveys and interviews were integrated at the end of the data collection period. The study team (KC, AG, JB) reviewed priority topic areas that required greater training across both surveys and interviews, to make recommendations for IM curriculum. Facilitators and barriers to palliative care training were also outlined to better understand context and develop education methods to best overcome limitations in the current program.

Results

Phase 1: Survey results

A total of 24 residents completed the survey, with a total response rate of 20% from the cohort of internal medicine residents. Most respondents were between the ages of 25 to 29 years and attended McMaster University for their medical education (Table 1). Residents ranged from 1 to 3 years postgrad, in a core internal medicine training program, and were not in a previous residency program before internal medicine.

Table 1.

Survey respondent demographics.

Participant background	N (%)*
Age
20-24	1 (4%)
25-29	18 (75%)
30-34	4 (17%)
35-39	0
40+	1 (4%)
Medial Education School
McMaster University	14 (58%)
International Medical Graduate	3 (13%)
Western University	1 (4%)
University of Toronto	1 (4%)
Queens	1 (4%)
University of Saskatchewan	1 (4%)
Year of Residency
PGY-1**	6 (24%)
PGY-2	8 (33%)
PGY-3	6 (24%)
PGY-4	4 (16.7%)
Residency Program Type
Core IM***	19 (79%)
Palliative Fellow	2 (8%)
GIM fellow****	1 (4%)
Critical Care Fellow	1 (4%)
GI fellow	1 (4%)

*total N = 24.

**PGY= postgraduate year.

***IM=internal medicine.

****GIM= general internal medicine.

Participant exposure to palliative care during medical undergraduate training was mostly via large group activities, workshops, and selective/elective rotations. During residency, most exposure was during didactic teaching, clinical rotations, and online resources. Residents were mostly satisfied to very satisfied (50%) in their satisfaction with palliative care curriculum and considered palliative care to be very important (54%) to their future (Table 2).

Table 2.

Satisfaction with palliative care curriculum.

​	N (%)*
Satisfaction with current Palliative Care Curriculum
Very Dissatisfied	0
Dissatisfied	3 (12.5)
Neutral	9 (37.5)
Satisfied	7 (29.2)
Very Satisfied	5 (20.8)
No Answer	0
How important residents feel palliative care is to their future
Not important	0
Low importance	0
Neutral	1 (4.2)
Important	10 (41.7)
Very Important	13 (54.2)
No Answer	0

*Total sample n=24.

When participants were asked about their exposure to palliative care, most palliative care curriculum items were just right (Figure 1). Participants identified minimal exposure to the following items: awareness of outpatient resources in the local community, identifying determinates of health and barriers to providing palliative care, addressing psychosocial and spiritual needs of patients and families, and discussing issues related to artificial nutrition and hydration.

Figure 1.

Exposure to Palliative care curriculum and competencies.

Participants identified comfort with the following items: collaborating with interprofessional team members, effective communication, caring for the dying patient and their family, assessing pain and symptoms, and providing a palliative approach to care. Residents were uncomfortable with awareness of outpatient resources in the local community, identifying determinants of health and barriers to palliative care, and discussing artificial nutrition and hydration (Figure 2).

Figure 2.

Rating comfort with palliative care curriculum items.

Fifteen residents (62.5%) expressed current knowledge gaps and twenty-one (87.5%) would prefer more palliative medicine training as a part of their educational experience. Additional topics for learning included; awareness of outpatient resources, discussion of artificial hydration and nutrition, assessing and managing common symptoms, and addressing spiritual needs (Table 3).

Table 3.

Topics for additional learning.

Topic of interest	N (%)
Awareness of outpatient palliative care resources in your community (such as home supports, hospice care, Medical Assistance in Dying (MAID), grief and bereavement services)	20 (19.4)
Discussing issues related to artificial nutrition and hydration	18 (17.4)
Assessing and managing pain and other common symptoms in palliative patient populations (e.g., constipation, nausea and vomiting, dyspnea, delirium, and insomnia)	12 (11.7)
Addressing psychosocial and spiritual needs of patients requiring a palliative approach to care and their families	12 (11.7)
Identifying determinants of health and address barriers impacting palliative care provision for an individual patient and the population served	11 (10.7)
Providing palliative care approach	8 (7.8)
Actively engaging in advance care planning, goals of care discussions and decision making with patients who would benefit from a palliative approach to care, using bioethical and legal frameworks	8 (7.8)
Communicating effectively with patients, families and other informal caregivers (including breaking bad news, discussing prognosis)	6 (5.8)
Participating in care of dying patient in uncomplicated cases	4 (3.9)
Collaborating as a member of an interprofessional team to provide palliative care	4 (3.9)

Residents preferred more clinical rotations to improve exposure, as well as academic half-day sessions and boot-camp style workshops (Table 4).

Table 4.

Learning method preferences to increase palliative care education.

Education method	N (%)
Clinical Rotation	15 (26.3)
Academic Half Day Sessions	12 (21.1)
Boot camp, workshop style	11 (19.3)
Case based learning with practice and expert feedback	11 (19.3)
Self directed learning with optional mandatory modules	2 (7.0)
Self directed learning with mandatory reading	2 (3.5)
Self-directed learning with mandatory online modules	1 (1.8)
Self-directed learning with optional reading	1 (1.8)

Phase 2: Interview data

Five residents were interviewed in more detail, specifically their experiences in internal medicine and palliative care exposure during training. Residents were PGY4-5s across a range of subspecialties, such as cardiology, respirology, geriatrics and infection disease. Resident experiences with palliative care curriculum included formal training and palliative care education, comfort with providing palliative care and transition to practice.

Formal training and palliative care education

Residents valued the importance of palliative care education, especially early exposure during CORE internal medicine blocks. Learners expressed positive experiences and always “taking something away.” Experienced, mature residents preferred less didactic teaching and suggested this more appropriate for junior leaners, “I always find that didactics can run a little bit dry like they’re helpful to have as resources. Physically having to like do those conversations as sort of trial runs. Would obviously be the ideal.” [Participant 1] One resident specifically commented on the necessity of mandatory palliative care training, “I don’t think it is a bad idea to have at least a bit of mandated palliative care time. It’s the type of thing like, it’s good for you, but you don’t know what’s good [for you].” [Participant 4] Difficulties experienced with formal training, included subspecialist physicians who do not have a strong understanding of a palliative approach to care and trying to schedule a “full block” of palliative care rotation during other competitive blocks within the subspecialty.

Comfort with providing palliative care

Participants were comfortable with the palliative approach to care, as residents at this stage understand a given disease trajectory within their subspeciality better. Initial symptom management and combined subspecialist clinics with palliative care all facilitated comfort and learning, “At the end of the day, you just need to have more goals of care conversations.” [Participant 3]

Difficulties experienced during training included not being aware of community-based supports and resources when planning care and discharge, “I feel like one of the things that was missing was the practical aspects in terms of resource management in terms of things that are available.” [Participant 5] Comments about not seeing the “dying process” or later stages of disease was difficult in their rotations, and difficulty in seeing a decline in function overtime for chronic disease-based specialties, “We rarely see the beginning [of the disease] in [core IM]. We get them when they’re sick, we have a pretty good idea of the middle and we don’t often see the end, but sometimes we do. In [subspecialty] training, I’ve seen all of it.” [Participant 3].

Transition to practice

During this block, residents felt comfortable with providing a palliative approach to care. Residents were unsure of how long to best monitor patients along their disease trajectories, and what is available and feasible when consulting specialty services within an outpatient or community setting. Applying palliative care principles as a consulting subspecialist without being the most responsible physician was a unique challenge during transition to practice. Residents reported difficulties with navigating systemic barriers and limitations to set realistic goals for patients when they are not directly managing overall care, “…following up on ‘palliative’ patients can be challenging because of how busy outpatient clinics can be even if an outpatient of yours is having some trouble with that need sort of an urgent assessment and it can be very difficult because as some sub specialty wait times are they can balloon it can be very difficult to get patients in.” [Participant 4] In busy outpatient clinics, timely follow-up for palliative patients is often difficult, compounded long wait times that can delay assessments and further limiting time to engage in discussions specific to treatment goals and care planning.

Discussion

Both junior and senior medicine residents recognized and validated that palliative care is central to IM specialties and subspecialties education. This goes is in line with other published literature highlighting the fact of high acceptance and support for palliative care education in medical trainees^17,18,25 and suggests curriculum development being both appropriate and feasible.

Residents reported feeling comfortable with applying a palliative approach to care, including assessing and managing pain and other symptoms. Both survey respondents and interview participants noted feeling confident in communication, interprofessional collaboration, and involvement in end-of-life care. This likely reflects the cumulative impact of undergraduate and early postgraduate palliative care education, as captured in our survey findings. Previous studies have similarly shown that formal palliative care education is associated with increased confidence and a higher frequency of applying a palliative approach to care.^25–27

In alignment with prior research, ²⁸ participants advocated for the integration of core palliative care competencies into the residency curriculum. Our findings show strong support for didactic academic half-day sessions, particularly during the junior years of training. Priority topics were identified based on the 2019 guidance document from the CSPCP (Appendix A). ¹¹ These included symptom management, especially artificial nutrition and hydration, and goals-of-care discussions. Similar learning objectives for core palliative care topics have been identified in a European survey that assessed experts’ opinions on educational goals required for comprehensive palliative care training. These findings demonstrate substantial overlap with the learning objectives outlined in the 2019 CSPCP guidance document and suggest a broad international consensus regarding the essential components of palliative care education. Nonetheless, concerns were raised that didactic sessions alone may be insufficient for teaching complex communication skills particularly when advancing more into specialty practice. Fischer ²⁷ reported that while didactic education is the most commonly implemented form of palliative care training, it has recognized limitations. Similarly, a U.S.-based survey of neurology residency program directors found that didactic teaching of palliative care topics may be inadequate on its own and suggested the need for more interactive or experiential learning approaches. ²⁹ While a mandatory palliative care rotation was discussed in semi-structured interviews by some senior residents in the interviews, this was also discussed diversely due to time constraints and competing curriculum responsibilities. Altogether, senior residents mentioned case-based learning as a good educational method compared to traditional didactic teaching. Most importantly, seeing superiors conduct adequate examples of comprehensive goals of care discussions was stressed as an excellent learning model to develop communication skills. However, it was also highlighted as a barrier particularly when there was no expert role modeling from supervisors experienced. Learning in the clinical environment is reported to depend largely on the demonstration of clinical competence, personal attributes, and teaching skills modeled for the learner. ³⁰ When developing a palliative care curriculum, it is therefore important to identify and support opportunities for case-based teaching within the clinical setting.

Some senior residents reported a decline in the frequency of goals-of-care discussions during subspecialty training over time. While goals of care discussions appear to occur more frequently during the earlier years of training, they tend to become less common as residents advance and gain specialty-specific knowledge. This “drift” away from core palliative care values highlights the need for longitudinal integration of communication skills across all stages and specialties of training, including among faculty members. Pennarola ²⁵ found that frequent practice of sensitive communication skills fosters development and increases confidence—an observation supporting our vision of longitudinal practice.

Senior medicine specialty residents emphasized that their confidence in managing illness-related symptoms and disease trajectories improved with clinical experience. However, they expressed greater comfort in hospital settings than in outpatient environments, particularly with respect to coordinating care and follow-up. This may be influenced by variability in the structure and availability of community-based palliative care resources. A potential strategy to address these challenges could involve fostering collaboration between family medicine and specialty programs to bridge communication gaps between inpatient and outpatient services. This integration could strengthen the continuity of care and enrich residents’ training experiences in practicing a collaborative approach. A 2021 systematic review by Canadian authors ³¹ examined the impact of receiving palliative care in hospital settings and the transition to community-based care. The review highlighted the poor methodological quality of available study designs and findings, suggesting a need for more rigorous and systematic approaches, including opportunities for randomized controlled trials around this topic.

Several limitations must be acknowledged. The small sample size and qualitative nature of the analysis limit the generalizability of our findings. Recruitment and interview participation challenges also limited the study. We further acknowledge the limitation of sampling from a single institution. Although only five interviews were completed, an inductive coding approach revealed recurring themes, suggesting thematic saturation and highlighting the appetite for increased palliative care education among IM residents at our institution. Although our findings are consistent with prior studies, our reliance on survey data means that the results are based on self-reported confidence and perceived knowledge. Additionally, selection bias may be present, as residents with a pre-existing interest in palliative care may have been more likely to participate and rate its importance highly. Moreover, our survey and interviews did not collect and report participants’ gender. Therefore, we cannot discuss whether there are gender-related differences in the trainees reported confidence levels. The intent of the survey was to conduct a needs assessment of IM resident experiences, therefore pilot testing and survey validation was not conducted. Despite these limitations, our findings support the conclusion that formal palliative care education within the internal medicine curriculum is highly valued by residents and is perceived as an area of ongoing need.

The findings of this study have several important implications for postgraduate medical education. First, the strong acceptance of palliative care education across internal medicine resident trainees at our Canadian university aligns with the WHO’s global call for strengthened education initiatives focused on core palliative care competencies. When designing a curriculum, our data suggests the use of educational strategies that combine foundational didactic teaching with case-based discussions, experiential learning, and explicit role modeling in clinical settings may better address the complex communication and decision-making skills required in palliative care practice. Faculty development initiatives may also be necessary to ensure consistent and high-quality role modeling across specialties. Future studies should evaluate the effectiveness of longitudinal, multimodal palliative care curricula on both learner outcomes and patient-centered measures. Additionally, research exploring barriers to sustaining palliative care practices during subspecialty training, as well as interventions to support outpatient and community-based palliative care education, would be particularly valuable. Multi-institutional and mixed-methods studies with larger sample sizes could further enhance generalizability and inform national standards for palliative care education in internal medicine training programs.

Conclusions

Residents’ feedback supports the creation of a formalized, integrated palliative care curriculum that accommodates existing scheduling demands while ensuring the development of core competencies. Addressing these needs will be essential in preparing residents to deliver comprehensive, patient-centered care across the spectrum of illness.

ORCID iD

Ashlinder Gill https://orcid.org/0009-0006-3412-1179

Ethical considerations

Hamilton Integrated Research Ethics Board granted the survey as quality improvement ethics exemption, citing item TCPS2 [2022] Article 2.5. No reference number was provided, as an email verification was provided for full board ethics exemption for program evaluation and local program development. No conflict of interest or undue influence existed between students and the study Principal Investigator. The qualitative interview portion of this project was granted full ethics approval on December 29 2023 (HiREB 16728). This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.

Consent for publication

All participants were recruited following approved protocols, and written informed consent was obtained prior to inclusion. Participants also provided explicit consent for the publication of anonymized data. Participants were aware and informed their responses would be summarized and included for evaluation purposes. Specifically, interview participants provided informed consent prior to participation, to be audio recorded, and for anonymized, deidentified data to be included for analysis and dissemination.

Data Availability Statement

Anonymized, deidentified data is available from the corresponding author upon reasonable request.*