The current system of providing palliative care in Japan is inadequate, although an increased number of medical institutions throughout Japan are establishing palliative care departments. According to the Hospice Palliative Care of Japan, only 244 hospitals in Japan, accounting for 2.6% of all hospitals in Japan, had a palliative care unit in 2012 (3
). In addition, the Ministry of Health, Labour and Welfare of Japan reported in 2008 that only 2.3% hospitals had a palliative care ward with palliative care specialists, and that only 4.2% hospitals with a palliative care specialist team and a palliative care ward were designated as cancer care hospitals. Under these circumstances, nonpalliative care specialists address various problems of patients with cancer in many hospitals. Many physicians do not feel comfortable treating incurable patients because their medical knowledge and technical skills are insufficient (4
). Nevertheless, clinical experience with such patients should be an essential part of medical education (5
). Palliative care skills are considered essential for all physicians who treat cancer, but the development of and the need for a primary palliative care skill set for physicians in training are not well established. Most medical schools in the USA do not emphasize on palliative care training as a requirement for graduation (6
) as much as those in Japan. Nevertheless, there is a documented need for palliative care training of doctors at the postdoctoral level, such as residents and fellows, in the USA (7
). In comparison with doctors in the West, few Japanese doctors believe that ‘I have enough knowledge and skills regarding palliative care’ or ‘I have received sufficient education about palliative care ’(10
). Of late, a project on palliative care education, called the PEACE project, is being performed for doctors at the postdoctoral level in Japan (14
). Although many doctors have received this training and have achieved results, nothing is compulsory.
Traditionally, surgeons have played significant roles in cancer care in Japan. They not only conduct surgeries and provide perioperative care, which are their primary tasks, but also provide endoscopic therapy, chemotherapy and end-of-life care in general wards (15
). Through these practices, they build good relationships with cancer patients by flexibly addressing various changes in a patient's clinical condition throughout the illness course. In contrast, as diversification continues in medical care, team care in which care providers share tasks is becoming mainstream. Unfortunately, the necessity of the team care approach for cancer patients has not been fully recognized (16
). There is concern that the current situation may hinder appropriate patient referral to a palliative care specialist team or patient transfer to a palliative care ward or another hospital with palliative care facilities. There is also a report stating that multidisciplinary teams provide more effective palliative care (16
) and that one of the most important tasks for the team is engaging surgeons with adequate knowledge on the patient's postoperative progress and the pathology of metastasized/relapsed cancer in this care.
Our hospital is the only medical institution in Japan that has made palliative care training compulsory for surgical residents. While some other countries conduct education programs and provide guidelines on palliative care for surgeons (17
), many differences exist between Japan and other countries. Surgeons in other countries mainly conduct surgeries, whereas Japanese surgeons take charge of patient right from making diagnoses and conducting surgeries to providing end-of-life care. We have made the palliative care training course compulsory for all residents since 2009. The entire training system for residents in the hospital is part of second-stage training after graduation from medical school. The surgical residents at our hospital in 2009 were in the fourth to ninth year after graduation, and half of them were specialists. All residents who participated in the palliative care training course had experience in end-of-life care, including pain control or care of terminal patients. However, none had received professional training in palliative care before participating in our course. In the questionnaire conducted before the course, up to 67% residents answered ‘I have no idea’ for the item concerning management with analgesic adjuvants, whereas only 1.7% residents gave this answer for the item concerning management with opioid and nonopioid analgesics. This is probably because the use of analgesic adjuvants for pain control is not popular in their previous medical institutions where they had practiced palliative care. In addition, many residents answered ‘I have no idea’ for items concerning management of malaise and control of refractory pain. None answered ‘I can perform this and explain to others’ for any of the questionnaire items except those concerning management of digestive symptoms. This may reflect the fact that there were many gastroenterological surgeons among the participants.
The purpose of palliative care is to mitigate pain in most cases, suggesting that pain control is a pillar of palliative care. However, prior therapy with analgesics had already been initiated in many patients before they were referred to the palliative care department. The cases that were already consuming nonopioid or opioid analgesics for moderate-to-severe pain accounted for up to 70%, indicating that most initial pain treatments were administered by surgeons and medical oncologists, and that most cases referred to the palliative care department were those in whom pain control with nonopioid and opioid analgesics was not effective or those in whom the analgesics caused intolerable adverse effects. Therefore, residents participating in the training course needed to introduce analgesic adjuvants and/or make changes in the administration routes or doses of prior opioid analgesics more frequently than introducing nonopioid or opioid analgesics for moderate-to-severe pain. As a result, the residents learnt how to introduce analgesic adjuvants and use opioid analgesics appropriately. The overall symptom improvement rate was 89.1% during the training course. Some cases that showed no improvement were those for whom complete symptom evaluation at baseline was not possible because of delirium or those who did not respond to any analgesic.
Results of the questionnaire analysis revealed that before participating in the course, the proportion of residents who answered ‘I can perform this and explain to others’ or ‘I can perform this with support’ did not exceed 50% for any item. However, the figure increased after the course and exceeded 75% for all items, including pain control.
The training course included home-based palliative care training that involved traveling with doctors or nurses to visit patient's homes. In the questionnaire administered after training, >80% residents answered ‘I gained necessary knowledge and skills’ or ‘the experience will change my approach to home care’. Specifically, many of the residents answered that they were going to change their methods while working with visiting physicians, communicating with visiting nurses, preparing treatment protocols and during various other processes associated with home care. The questionnaire results showed that the course helped residents understand the significance of good communication with visiting physicians and the effective use of home-care by recognizing concerns and backgrounds of home-care patients. They also understood the actual situations and difficulties in providing home care, such as shift timing and medical equipment limitations. While participating in this training course conducted at our hospital, which is one of the designated cancer care hospitals in Japan, they experienced the reality of home-based palliative care with their own eyes.
All residents answered ‘Yes, very much’ or ‘Yes’ when asked whether the course would be useful for their future clinical practice. The training period was 4 weeks, which may be relatively short, but we can say that it was fruitful for the participating residents. We expect that after acquiring palliative care knowledge and skills through this professional training course, these resident surgeons will provide cancer patients with better medical care aimed at mitigating their physical pain and providing mental comfort. However, the training may be insufficient with regard to caring for special patients, which requires greater expertise. Therefore, we need to arrange resident supervision by palliative care specialists or extend the course to include this training.
The primary responsibility of surgeons is to apply their expertise to cancer care and fully utilize their knowledge and skills in cancer surgery and chemotherapy. Oncological surgeons build trusting relationships with cancer patients by performing various activities based on sound palliative care knowledge and skills. In a sense, they may become role models for surgeons in other fields. Although there is still room for improvement, the surgical residents answered that it was a meaningful course, that they gained practical palliative care knowledge, and that the experience would change their home-care approach after the training course. This training course appears to be a significant step forward for all surgical residents and course planners at the hospital.
Questionnaires form an important data collection method in a number of situations (19
), and they have been used extensively in a variety of studies. There are two basic goals (20
) of a questionnaire design. The first is to obtain information relevant to the survey purpose and the second is to collect this information with maximal reliability and validity. The reliability of an instrument can be measured objectively using Cronbach's alpha, which is the most widely used objective measure of reliability. Cronbach's alpha was developed by Lee Cronbach in 1951 (21
) to provide an internal consistency measure of a test or scale; it is expressed as a number between 0 and 1. A reliability analysis is conducted to determine questionnaire reliability, and internal consistency of the items is measured using Cronbach's alpha coefficient. A questionnaire is considered to represent a measure of high internal consistency if the total alpha value is >0.7 (22
). The reliability of the questionnaire was supported by its alpha value of 0.78. However, the sample size was too small to evaluate validity, and this was only a single cross-sectional study. It will be necessary to refine the validity and reliability of this scale in the future with more data from diverse samples and more critical scrutiny of validity (23
In conclusion, we reported the first mandatory training course at a specialized cancer institute in Japan in Japan, which educates surgical residents on palliative care for cancer patients. The surgical residents took charge of an average 7.66 cases during the course, and the purpose of care in most cases was to mitigate pain. The residents were mainly learnt how to use opioids appropriately and when and how to introduce analgesic adjuvants. In addition, they learnt to mitigated the physical pain of cancer patients and provide mental comfort through this professional palliative care training course.