Introduction
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In the course of revising the Medical Licensure Act (ÄApprO; 07/2009), palliative care as the care of severely and terminally ill patients was incorporated as a 13th cross-disciplinary (Q13) subject in the mandatory undergraduate curriculum. Providing proof of teaching in the subject of palliative care will be obligatory starting from the beginning of the final year (´practical year´) in August 2013, i.e. at the latest by the time of registering for the second part of the medical examination in October 2014. At present, the German faculties are facing the challenge of implementing appropriate teaching structures by that point in time, given that only 6 universities offered a mandatory course in palliative care in 2008 \[[@R1]\].

The formal conditions with respect to the the implementation as well as the curricular context were described in detail elsewhere \[[@R2]\], \[[@R3]\], \[[@R4]\], \[[@R5]\], \[[@R6]\], \[[@R7]\].

In context of the bi-annual surveys of the German Medical Students\' Association (Bundesvertretung der Medizinstudierenden in Deutschland e.V., bvmd), conducted for the first time in 2006 and last amended in the year 2008 \[[@R1]\], very diverse teaching concepts in palliative care - ranging from a complete, mandatory curriculum with graded exams to no teaching at all in an explicit palliative care context - became evident.

As a result it becomes apparent that the medical faculties will begin or continue the implementation process for the new teaching subject under very different starting conditions. Accordingly, the formal implementation of Q13 as a compulsory subject within the required implementation deadline will be a substantial challenge for individual faculties in view of structural and particularly content-related questions which may arise.

The aim was not only to bring transparency to the present implementation process, but also to support those faculties with less didactical experiences with respect to teaching and examining palliative care contents. Therefore, the bvmd survey of 2010 - approximately half a year after the revision of the Medical Licensure Act - thoroughly questioned the current situation of palliative care teaching as well as the conceptual planning and future development of the respective faculties.

These concepts and developments should be the focus of this contribution.

Methods
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Since 2006 the bvmd conducts a bi-annual survey of all medical faculties in Germany with respect to the current state of teaching in palliative care. Based on an online questionnaire used by the bvmd in the year 2008 in order to evaluate the current state of palliative care teaching, an expanded version of this questionnaire was developed that aims to compile conceptual and structural as well as curricular and examination-related plans and future developments at the respective faculties.

Apart from the bvmd as project manager, different professional associations cooperated in this survey (German Association for Palliative Medicine DGP, German Association for Haematology and Oncology DGHO, German Cancer Society DKG, and German Association for the Study of Pain DGSS). The questionnaire was piloted at the universities of Munich LMU (n=4), Göttingen (n=10) and Jena (n=8), and was uploaded online for one month (HTML- document) with an inviting cover letter to all faculties, starting on 01.05.2010.

In the case of non-response, the respective Deanery was contacted by telephone.

The data was assessed using a PHP script exported in SPSS.

The survey comprised general information regarding the faculty and teaching structures, extended questions regarding the implementation of the Q13 requirements, the scope of the course, the curricular content, the didactics and examinations, the inclusion of students in planning, the presence or planned establishment of a Chair or professorship, the qualification of the person in charge of palliative care teaching, the participating medical disciplines and external co-operating partners.

Selected results of this publication were presented at the congress of the European Association for Palliative Care (EAPC) in 2011 \[[@R8]\], and at the congress of the DGP in 2010 \[[@R9]\].

Results
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Response rate
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The response rate was 86% (31 of 36 faculties).

Status of implementation
------------------------

Prior steps in the implementation of the palliative care as a mandatory subject were described at 21 sites. In the current survey 2010, two of the 31 participating faculties reported to have no teaching activities so far with respect to palliative care (see figure 1 [(Fig. 1)](#F1){ref-type="fig"}).

Timing
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The majority of faculties aim to introduce the Q13 as a compulsory subject as of the summer semester 2011; at three faculties this is due to take place as of the summer semester 2012, a year before the latest possible date.

Curriculum
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15 faculties reported to rely on a teaching curriculum; at seven sites, the curricular content is being based on the DGP and the EAPC recommendations. Eight faculties reported to already have compiled an independent curriculum. Despite having commenced the implementation process, six faculty sites do not have a comprehensive curriculum yet. 10 of the 31 responding faculties did not provide information regarding the presence of a curriculum for palliative care teaching.

7 faculties reported to have drawn upon a catalogue of learning objectives.

14 faculties aim to provide 21-40 course hours (Lehrveranstaltungsstunden, LVS); 3 faculties aim for 11-20 LVS, and at 2 faculties merely 5-10 LVS are intended (see figure 2 [(Fig. 2)](#F2){ref-type="fig"}). 12 faculties provided no information. In contrast, the DGP recommends -- in line with the European Standards -- up to 40 LVS. "A range of 20 course units under the direct leadership of a palliative care department i.e. of a corresponding Chair should however not be undercut" \[[@R6]\].

Didactics
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17 faculties responded regarding this issue (multiple answers permitted). Intended teaching methods include:

lectures (at 16 of 17 sites)seminars (16 of 17)case discussions (14 of 17)bedside teaching (13 of 17)teaching with simulated patients (8 of 17)e-learning (6 of 17)

Examinations
------------

17 faculties responded regarding this issue (multiple answers permitted). Intended teaching methods include:

multiple-choice questions (11)oral examinations (8)OSCE (4)homework (3)

Students
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At 18 of 31 faculty sites students are being involved in the implementation process.

Main responsibility
-------------------

At the time of recording, an independent Chair for palliative medicine existed at the eight universities Aachen, Bonn, Erlangen, Göttingen, Cologne, Munich LMU (with the associated endowed professorships paediatric palliative care, social work in palliative care, and spiritual care), Mainz, and Witten / Herdecke (with the Chair for paediatric palliative care and paediatric pain therapy).

In addition, six further faculties (Freiburg, Homburg, Jena, Lübeck, Rostock and Tübingen) reported that they are taking concrete steps in the planning of a Chair for palliative medicine.

Statements were made by 19 faculties regarding the qualification of the respective person in charge (multiple answers possible):

specialization in the field of palliative care, at 10 sitesspecialization in the field of palliative care with more than two years of clinical experience in palliative care, at 15 sitesteaching experiences in palliative care, at 9 sitesstructured postgraduate qualification, at 11 sites.

At two sites, no special qualification requirements were demanded.

Participating professions and medical disciplines
-------------------------------------------------

19 faculties responded regarding this issue (multiple answers permitted, see table 1 [(Tab. 1)](#T1){ref-type="fig"}):

External co-operating partners
------------------------------

17 faculties responded, concerning questions pertaining to external co-operating partners (multiple answers permitted). Co-operations are made particularly with specialized outpatient palliative care teams (SAPV; n=13), outpatient hospice services (n=11), inpatient hospices (n=10), general practitioners (n=9) or other hospitals (n=8), but also with medical specialists (n=5), other faculties (n=4) or other institutions (n=2).

Implementation of teaching dependent upon the existence of a Chair
------------------------------------------------------------------

Six of the eight faculties that by now have an established Chair in palliative medicine stated they have already implemented compulsory courses in palliative care. On the other hand, only nine of the remaining 23 participating faculties without a Chair provide compulsory courses. Thus, the degree of commitment is significantly higher at sites with an independent Chair.

Discussion
==========

By expanding the bi-annual survey of the bvmd, that describes the current state of palliative care teaching in Germany, and by ascertaining the plans of the German medical faculties with respect to Q13 implementation, the various ideas and curricular concepts at the medical faculties should be made more transparent.

The 2010 survey confirmed the different "starting positions" of the various faculty sites -- ranging from faculties with a complete organisational and curricular infrastructure to those faculties without any form of specific palliative care teaching.

On the other hand, the variety of implementation requirements also mirrors the different teaching intensities that are intended: quantitatively, in terms of course hours (LVS), as well as qualitatively, in terms of the teaching formats.

As such, the faculties have specified that lectures and seminars will be the main format of teaching; however, bedside-teaching, simulated patient training and other, more elaborate teaching formats will also be offered.

Similarly, most of the faculties that responded planned to use multiple choice questions as the preferred format of examination; however, some faculties intended to use more elaborate, partly oral or practical, examinations. With respect to the selected teaching and examination formats, the question arises whether a subject that does not only aim to convey specialised knowledge but also intends to convey a therapeutic attitude of empathy towards severely and terminally ill patients, should rely predominantly on lectures i.e. respective multiple choice questions \[[@R10]\], \[[@R11]\], \[[@R12]\]. In view of the organisational and structural demands resulting from the new legal requirements, it might to be expected that many faculties may employ more general teaching and examination formats as a temporary solution.

However, more individualistic, differentiated and authentic - but more extensive and mentoring teaching and examination formats would be desirable.

By aspiring more complex teaching and examination formats, the necessity for labelling a clear, coordinating responsibility, ideally in the form of an independent Chair for the subject of palliative medicine, becomes evident. Particularly in light of the results of our survey regarding the degree of responsibility, it can be surmised that the presence of a Chair is likely to be the main force for the implementation of the legal requirements of undergraduate palliative care teaching.

It is encouraging, though, that a high percentage (58%) of faculties reported to involve students in the implementation process. This should not only be deemed as a good starting position for constructive teamwork between teachers and students, but may also be interpreted as a sign of considerable interest of students regarding palliative care issues.

The variety of co-operating occupational groups and specialist disciplines that were found in our survey mirrors the multifaceted and multi-professional aspect of palliative care. It also serves however to emphasise the great complexity in the coordination of student teaching in Q13.

This study presents a range of limitations. Only 31 of 36 faculties took part in the survey, despite being repeatedly contacted by telephone, and despite extensive support of the project by those medical associations that share responsibility for palliative care.

A majority of the questions that regard the future planning of the faculties was answered by merely 17-19 of the participating faculties. Methodological problems such as the absence of mandatory fields, as well as content-related aspects such as the absence of well-defined curricular contents or examinations, could contribute in the sense of a negative response. As a result, fully representative statements cannot be made based on the present study, for instance with respect to curricular contents, details of teaching methods or examinations. At most, tendencies can be formulated.

Moreover, in this publication the term "Chair" was used in a common, non-juridical understanding of a university-based leading position, implying distinct tasks in teaching and education, research and patient care. It does not take into account the subtle nuances of the respective professorships, even though the degree of independence of a professorship might have an influence on the positioning of palliative care at a university setting.

Moreover, this survey could not make any statements regarding the quality of teaching in palliative care but could only describe organisational and structural aspects and objectives related to curriculum and teaching and examination didactics.

Nevertheless, this study can contribute impulses and ideas to the implementation of palliative care teaching, given the requirements for implementing the cross-disciplinary subject Q13, and might therefore contribute to a transparent, uniform and future-oriented implementation process in Germany.

Note
====

B. Ilse and J. Hildebrandt contributed equally to the publication.

A project of the federal representation of medical students in Germany (bvmd) and the German Association for Palliative Medicine (DGP), in co-operation with the German Association for Haematology and Oncology (DGHO), the German Cancer Society (DKG) and the German Association for the Study of Pain (DGSS)

Acknowledgement
===============

With genuine thanks to Mrs. Kristina Kluziok for her programming work and to Mrs. Reena Rick for translating the manuscript.

Competing interests
===================

The authors declare that they have no competing interests.

![Involved professions](ZMA-29-47-t-001){#T1}

![Participating faculties and status of implementation](ZMA-29-47-g-001){#F1}

![Distribution of the faculties based on their LVS aim for Q13 (n = 19)](ZMA-29-47-g-002){#F2}
