JOURNAL OF PALLIATIVE MEDICINE

Volume 10, Number 3, 2007 Brief Reports

© Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2006.0188

Survey of Palliative Care Concepts

among Medical Interns in India

PARAG BHARADWAJ, M.D.,1 M.S. VIDYASAGAR, M.D.,2 ANJALI KAKRIA, M.D.,2

and U.A. TANVIR ALAM, M.S.3

ABSTRACT

Background: Medical knowledge, if theoretical, will fade away if not reinforced especially if not clin-
ically implemented. We conducted a survey study amongst interns to assess awareness and confi-
dence of common palliative care issues. Undergraduate medical education in India is a 41/2-year
course. This is followed by a 1-year internship before the new physician can practice independently.
Aim: To compare the level of awareness in palliative care concepts among interns to that of fi-
nal-year medical students at Kasturba Medical College, Manipal, India.
Materials and Methods: Forty-four interns participated in a survey study. The data were collected
after the survey and the responses were analyzed. We compared these data with those obtained from
conducting the same survey among medical students.
Results: The reported theoretical knowledge of palliative care concepts was better than the level
of confidence in performing practical aspects of palliative care. The interns, overall, did not out-
perform the students.
Conclusion: Before this survey, we hypothesized that interns in India would have low levels of
self-reported understanding of palliative care and its components. We were hoping to see an im-
provement in knowledge and confidence with training. In contrast, there was not much of an im-
provement but rather a decline in some areas. From this, we conclude that when medical students
become interns, they need reinforcement of knowledge and more hands-on experience.

INTRODUCTION burden of disease, but access to modern treatments is

limited. A case in point is the population with human

P ALLIATIVE CARE is a developing field in the West-

ern world. The focus is to help patients with var-
ious facets of their very being that play an important
role in the alleviation of their symptoms and level of
comfort.
The development of palliative care is limited in the
developing world. India has a population of 1.02 bil-
lion.1 The life expectancy at birth is 64.7 years com-
pared to 77.8 years in the United States.2 Mortality
from various diseases is high. There is a tremendous
immunodeficiency virus (HIV). Currently, India is es-
timated to have the highest population with HIV in-
fection in the world.3 Twenty-five percent of the pop-
ulation is below the poverty line.2 Seventy-five percent
of the patients with cancer are diagnosed in the ad-
vanced stages4 when there are no therapeutic options.
The case to have a strong palliative care component
in the health care system cannot be overemphasized.
Approximately 1 million people in India experience
cancer pain every year.5 It is estimated that fewer than

1Palliative
Care Program, Cedars-Sinai Medical Center, Los Angeles, California.
2Department of Radiation Oncology, Kasurba Medical College, Manipal, India.
3Department of Orthopedics, Queen Elizabeth Hospital, Gateshead, United Kingdom.

654
PALLIATIVE CARE EDUCATION IN INDIA
3% of the needy have access to palliative care.6 Iron-
ically, India is one of the largest suppliers of morphine
to the world.2 The idea is not to paint a grim picture
but to share with the readers the magnitude of the prob-
lem.
A common observation is that there is lack of
awareness in the medical field about the concept and
scope of palliative care in taking care of patients. To
our best knowledge, there are a few select medical
school in India that have palliative care in their un-
dergraduate curriculum. We decided to conduct a
survey study among medical interns at Kasturba
Medical College, India, to assess awareness. At the
time this survey was conducted, palliative care was
not being taught at the institution. We also compared
the results to a similar survey conducted among med-
ical students.
Medical school training in Kasturba Medical Col-
lege, like all other medical schools in India, comprises
41/2 years of training followed by 1 year of internship.
Students take the final exam after the first 41/2 years.
The first 11/2 years comprise basic sciences. During
the next 3 years, the students regularly attend clinics
with the clinical component gradually transitioning to
be stronger with the progression of training. Internship
is purely clinical with no scheduled lectures. Intern-
ship involves rotations in surgery, medicine, obstetrics
and gynecology, and social and preventive medicine
consisting of 3 months each.
MATERIALS AND METHODS
A panel of physicians developed a questionnaire
that each agreed would be the best to administer. The
panel comprised physicians board-certified in pallia-
tive medicine and those with experience in this field
in India. The strategy was to administer the simplest
survey in a setting that would ensure maximum par-
ticipation. We considered the fact that there was no
palliative care education at the time the survey was
conducted.
Our assumption was that interns had very limited
knowledge of the concept of palliative care and its ba-
sic components, e.g., pain management, care of the dy-
ing patient, etc. This would be the first survey the in-
terns would ever participate in. We kept the questions
very simple and the responses as yes/no. We took the
trainee attitudes into consideration. Taking into ac-
count all the factors mentioned above, it was decided
that a survey would be the best way to gauge the pur-
pose of the study. There is no Institutional Review
Board (IRB), but permission was obtained by the
655
physician administrator of the medical college to con-
duct the survey.
We requested that the interns fill out the survey
after an interns meeting. Fifteen minutes was allot-
ted to complete the survey. We chose this method
to ensure a good response rate. Those who were not
willing to participate in the survey were allowed to
leave. There were a total of 80 interns. On the day
the survey was conducted, 44 (55%) interns attended
the meeting. None of the interns declined to partic-
ipate. The focus was the participant’s level of edu-
cation. Therefore, no other data regarding the par-
ticipants, e.g., gender, age, etc., was collected. The
intention was to assess the responses as a percent-
age of positive and compare them to those of the
medical students to see if there was an expected im-
provement in knowledge and confidence. The in-
tention was to eventually make a case of training in
palliative care during the internship year. The ques-
tions of the survey and the responses of both the in-
terns and students are shown in Table 1.
RESULTS
Eighty-two percent of the interns indicated that
they were familiar with the concept of palliative care
compared to 86% of the students responding posi-
tively to the same question. Sixty-eight percent of
the interns were aware of the different types of pain
compared to 85% of the students. Only 4.5% of the
interns felt they were adequately trained to treat the
different kinds of pain whereas 13% of the students
felt the same. Eighteen percent of the interns were
aware of pain assessment tools/scales compared to
10% of the students. Thirty-six percent of the
trainees witnessed care of a dying patient while only
20% of the students had the same experience. Fifty-
five percent of the interns were familiar with phys-
ical signs of the dying process compared to 38% of
the students. Only 9% of the interns felt confident
in managing the symptoms of the dying patient ver-
sus 10% of the medical students. Fourteen percent
of the interns were themselves comfortable talking
about death to their patients when 29% of the stu-
dents reported confidence in doing the same. Forty-
five percent of the interns had witnessed a teacher
talk to a patient about the terminal nature of their
disease while 29% of the students had had a similar
experience. Four and a half percent of the interns felt
adequately trained in delivering bad news to a pa-
tient with a terminal disease while 15% of the stu-
dents felt the same.
656 BHARADWAJ ET AL.

TABLE 1. QUESTIONS AND COMPARISON OF THE SURVEY TO ASSESS PALLIATIVE CARE

CONCEPTS AMONG MEDICAL STUDENTS AND INTERNS IN INDIA

Y N %Y Y N %Y
Students Interns

1. Are you familiar with the concept of 96 15 86 36 8 82

palliative care?
3. Are you familiar with the different types 94 17 85 30 14 68
of pain?
4. Do you feel adequately trained in 14 97 13 2 42 4.5
managing differnt types of pain?
5. Are you familiar with any of the pain 10 101 10 8 36 18
assessment tools/scales?
2. Have you witnessed the care of a 22 89 20 16 28 36
dying patient?
6. Are you familiar with the physical signs 42 69 38 24 18 55
of the dying process?
7. Do you feel adequately trained to 11 100 10 4 40 9
manage symptoms of the dying patient?
8. Are you comfortable talking about 32 79 29 6 38 14
death to a terminally ill patient?
9. Have you witnessed your teacher 32 79 29 20 24 45
discuss the terminal nature of the
patient’s disease?
10. Do you feel adequately trained in 16 95 15 2 42 4.5
delivering bad news (terminal
diagnosis) to the patient?

Y, number yes; N, number no; %Y, percentage yes.

DISCUSSION smaller percentage of interns responded positively to

This is, to our knowledge, the first such study con-
ducted among interns in a medical school. Possible at-
titudes of the medical interns were taken into account
in the study design. Although conducted after a Interns
association meeting, interns were given the option to
not participate in the study. The total number of in-
terns was 80, of whom 44 participated in the meeting
and the survey. We got data from a good percentage
(55%) of the interns at the institution. More interns
participated than expected from a mailed survey. In-
terns are posted in different hospitals at distant loca-
tions. Perhaps that was the reason for the lack of full
attendance. We actually assumed a smaller number
would be present. The response rate is similar to the
survey conducted among students (58%). This
strengthens the validity of the data compared because
no further statistical analysis was intended. Although
the findings of the study, in our opinion, are interest-
ing by themselves, it is the comparison of the results
of the survey among the two groups that makes the re-
sults even more interesting.
We were surprised by the fact that there was not
much progression of the trainees in their knowledge
and clinical confidence. We compared the results of
the interns survey versus the medical students. A
being aware of the concept of palliative care compared
to the students, but this difference could be considered
insignificant. However, there was not a substantial in-
crease as one might expect. Fewer interns were aware
of the different types of pain when compared to stu-
dents. A valid argument could be that the knowledge
was theoretical and the trainees were not able to re-
tain it, due to lack of reinforcement in the clinical
wards. Interns were, however, more aware of differ-
ent pain scales than the students. They were less con-
fident in treating pain. This, once again, is likely due
to the knowledge being theoretical with inability to ap-
ply it practically or just the lack of reinforcement. As
expected, more interns witnessed the discussion of the
terminal nature of the patient’s disease, were exposed
to the care of the dying patient, and were familiar with
the signs of the dying process. However, interns did
not feel more comfortable in managing the symptoms
of the dying patient. They were also less confident in
delivering bad news. The arrogance ignorance para-
dox7 is a stronger possibility when reviewing the bet-
ter performance of the students compared to the in-
terns.
The drawbacks of the study include a few questions
being too general. The group of interns who attended
the meeting on the day of the survey may have been
PALLIATIVE CARE EDUCATION IN INDIA
more competent than those who did not attend. Kas-
turba Medical College is among the top 10 medical
schools in India.8 The authors are confident in stating
that the level of awareness in other institutions might
not be at par with the results obtained in this institu-
tion. Many students transfer to other hospitals during
internship and likewise new interns transfer to Kas-
turba Medical College for internship. Therefore, there
was a possibility that the sample could include interns
who did not train at the medical school. Having said
that, this group of interns were all from Kasturba Med-
ical College. We had to, indeed, make many assump-
tions while planning and conducting this survey. This
is because of the reasons mentioned in the methodol-
ogy section.
The results of this survey make a strong case of im-
proving this facet of medical training, i.e., palliative
care. An identified deficiency creates a need to im-
prove. We hope to conduct a more objective study in
the near future to evaluate the knowledge base further.
One goal is to make a case to introduce palliative care
during internship training in the institution and in oth-
ers as well. The other is to encourage more research
and papers being published from this region. Finally,
we hope that with this paper we can share the current
state of need for palliative care versus the sharp con-
trast of lack education in this field.
657
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Address reprint requests to:
Parag Bharadwaj, M.D.
Palliative Care Program
Cedars-Sinai Medical Center
8700 Beverly Boulevard, Room 2802
Los Angeles, CA 90048
E-mail: paragbharadwaj@hotmail.com