The Development of a Knowledge Tool:

For Rapid Assessment of Palliative Medicine & End of Life Knowledge in Medical

Students

Alyson Brodeur, MD

Pippa Hall

Lynda Weaver

Objectives:• Develop a quick, easy to use assessment tool

• Important for tool to be specific and to have ecological validity (content relative to medical students)

• Identify possible uses for tool– needs assessments– evaluate educational initiatives– stimulate discussion

The Palliative Care Quiz for Nursing (PCQN)

• Ross MM, McDonald B, McGuinness J. The palliative care quiz for nursing (PCQN): the development of an instrument to measure nurses’ knowledge of palliative care. Journal of advanced nursing. 1996:23;126-137.

– Dieckmann L, Zarit J, Gatz M. The alzheimer’s disease knowledge test. The Gerontologist. 1988: 28(3); 402-407.

– Pratt, CC, Wilson, W., Benthin, A., Schmall, V. (1992). Alcohol problems and depression in later life: Development of two knowledge quizzes. www-

distance.syr.edu/ageans2.html

Development - Stage One

• Advisory committee - To establish– key knowledge areas

– determine appropriate format & level of difficulty

– generate items

• Ontario palliative undergraduate network - common educational objectives for students in an undergraduate medical curriculum - draft report 2004

Development - Stage One

• Literature Review (ongoing)– current knowledge tools/quizzes

– Databases = Cinahl & Medline

– Search Terms • (palliative or hospice or terminal care or terminal illness or

dying or end of life) AND ( (curriculum or education & evaluation or knowledge & evaluation) OR(knowledge or education & need assessment or tool or tools or test or testing or questionnaire) ) AND ( (medical resident or medical student) OR (undergraduate and (medicine or medical) )

Development - Stage One

• Biswal BM, Zakaria A, Baba AA, Ja’afar R. Assessment of knowledge, attitude and exposure to oncology and palliative care in undergraduate medical students. Medical journal of malaysia. 2004:59(1)78-83.

• Burge F, McIntyre P, Kaufman D, Cummings I, Frager G, Pollett A. Family medicine residents’ knowledge and attitudes about end-of-life care. Journal of palliative care. 2000:16(3);5-12.

• Dionne L, Dionne A. Global exchange: a questionnaire to medical students on palliative care and euthanasia. Journal of palliative care. 1996:12(2);39-46.

Development - Stage One• Fischer SM, Gozansky WS, Kutner JS, Chomiak A, Kramer A.

Palliative care education: an intervention to improve medical residents’ knowledge and attitudes. Journal of palliative medicine. 2003:6(3);391-399.

• Jackson WC, Connor PD, Tavernier L. Antemortem care in an afternoon: a successful four-hour curriculum for third-year medical students. American journal of hospice & palliative care. 2002:19(5)338-342.

• Oneschuk D, Fainsinger R, Hanson J, Bruera E. Assessment and knowledge in palliative care in second year family medicine residents. Journal of pain and symptom management. 1997:14(5);265-273

Development - Stage Two

• Consultation beyond the advisory group• Assessment:

– small group (8-12 individuals)

– palliative medicine physicians, fellows, nurses and pharmacists

– assessed knowledge tool on two different occasions

– goal - assess clarity, relevance, level of difficulty, accuracy

– end result = two questions significantly changed

Development - Stage Three

• Test-Piloting– Family Medicine academic half-day

– PGY-1 & PGY-2

– Response rates• PGY-1 = 100% (n = 17)

• PGY-2 = 70% (n = 8)

– Mean scores (out of 6)• PGY-1 = 3.4

• PGY-2 = 2.3

Residents’ Assessment of Tool

• The majority of residents thought the quiz was a fair tool for assessing fourth year medical students’ knowledge

• Most residents assessed the level of difficulty as average– 61% average

– 35% difficult

– 4% easy

Development - Stage Three

• Test-piloting– University of Ottawa - fourth year medical students

– Location = MCCQE review lecture

– Class size = 125

– 90 students in attendance

– Response rate 67%

– Incomplete = 5

– Assessment based on 50 responses

Medical Students - Year 4

• Mean Score = 1.8 Mode = 1.0

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Series1

Question Number

% Correct

Question OneMrs. X is taking Long-Acting Morphine tablets 30 mg by mouth every 12

hours for her pain, which has been well controlled. She is now dying, and unable to take anything by mouth. The appropriate change in medication should be:

a) 10 mg sc q4h

b) 5 mg sc q4h

c) 5-10 mg sc q4h prn only

d) crush the tablets, dissolve them in water, and administer same medications bucally

38% of students identified the correct answer

Question Two

Which of the following opioid medication has serious consequences if given for chronic pain management?

a) methadone

b) hydromorphone (Dilaudid)

c) fentanyl patch (Duragesic)

d) meperidine (Demerol)

56% of students identified the correct answer

Question ThreeSally has developed signs of toxicity on morphine (some confusion,

hallucinations, myoclonus) and the cancer in her bones is still causing pain. She is taking 200 mg of morphine per day. To improve her symptom control, you can:

a) switch to another strong opioid, such as hydromorphone

b) add a different, long acting opioid such as the fentanyl patch

c) add a neuroleptic, such as haloperidol

d) (a) and (c)

28% of students identified the correct answer

Question Four

Joe was prescribed an opioid for severe pain, due to metastatic prostate cancer, 2 days ago. The medication has made him feel very nauseated. The most appropriate antiemetic which has its main effect on the chemoreceptor trigger zone is:

a) dexamethasone (Decadron)

b) haloperidol (Haldol)

c) dimenhydrinate (Gravol)

d) scopolamine patch

0% of students identified the correct answer

Question Five

Mr. Y. has end-stage COPD. Despite optimum medical management he remains short of breath. To improve his symptom control, you can start:

a) a fan for his face

b) an opioid (e.g. morphine)

c) a neuroleptic (e.g. chlorpromazine)

d) all of the above

38% of students identified the correct answer

Question Six

You have just written a prescription for hydromorphone (Dilaudid) for a patient. You must also write a prescription for a laxative. The best choice is:

a) a stool softener, such as docusate sodium

b) an enema, if needed

c) a bowel stimulant, such as senna derivatives

d) a glycerine suppository

18% of students identified the correct answer

Development - Stage Four

• Reassess– Item Difficulty

– Item Clarity

– Total number of Items

• Determine – Item Discrimination

– Face Validity

– Test-retest Reliability

Development - Stage Four

• Determine if responses vary in accordance to level of education and experience

• Further comparison of test results for family medicine residents and fourth year medical students

• Identify frequent misconceptions