# Teaching Palliative Medicine in the Medical School
Clerkship in France. A National E-Survey

Damien Klaeyle, Laurent Calvel, Elise Perceau-Chambard, Virginie Guastella,
Guillaume Economos, Adrien Evin

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## To cite this version:

Damien Klaeyle, Laurent Calvel, Elise Perceau-Chambard, Virginie Guastella, Guillaume Economos, et al.. Teaching Palliative Medicine in the Medical School Clerkship in France. A National E-Survey. Journal of Pain and Symptom Management, 2025, 70 (1), pp.80 - 88. 10.1016/j.jpainsymman.2025.03.027. hal-05393218

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Original Article

Teaching Palliative Medicine in the Medical School
Clerkship in France. A National E-Survey

<figure><img src="image_3.png" /></figure>

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Damien Klaeyle, MD, Laurent Calvel, MD, PhD, Elise Perceau-Chambard, MD, Virginie Guastella, MD, PhD, Guillaume Economos, MD, PhD, and Adrien Evin, MD, PhD

Nantes Université (D.K., A.E.), CHU de Nantes, Service de soins palliatifs et de support, Nantes, France; Supportive and Palliative Care Service (L.C.), Strasbourg University Hospital, Strasbourg Translational Medicine Federation (FMTS), Université de Strasbourg, Strasbourg, France; Institute for Cellular and Integrative Neuroscience (L.C.), CNRS UPR 3212 & Strasbourg University, ITI NeuroStra, France; Université Claude Bernard Lyon 1 (E.P.C.), UFR Lyon SUD-Charles MERIEUX, Hospices Civils de Lyon, France; Palliative Care Center of the Clermont-Ferrand University Hospital, Palliative Care Unit; CHU Louise Michel (V.G.), Cébazat, France; Neurodol Research Laboratory at the University Clermont Auvergne (V.G.), Clermont-Ferrand, France; ACCePPt Research Laboratory at the University Clermont Auvergne (V.G.), Clermont-Ferrand, France; Université Claude Bernard Lyon 1, Centre pour l'Innovation en Cancérologie de Lyon (G.E.), Oullins-Pierre-Benite, France; Nantes Université, Tours Université (A.E.), CHU Nantes, CHU Tours, INSERM, Methods in Patients-Centered Outcomes and Health Research, SPHERE, Nantes, France

Abstract

**Context.** There is considerable variation in the way that palliative medicine is taught allaround the globe. No comprehensive study has yet been conducted on the content of this teaching, particularly regarding clerkships and theoretical teaching (lectures, group teaching) in France. This would facilitate the standardisation of palliative care training throughout the country.

**Objectives.** The main objective of this study is to provide a comprehensive description of the theoretical and practical training in palliative medicine that is offered during medical school clinical yearsstudies in France.

**Methods.** We conducted an online specially designed survey of the 34 medical schools in France, that offer a complete second cycle of medical studies. It was sent to the head of teaching between February and April 2024.

**Results.** The response rate was 100%. In terms of clerkships, 30 institutions (88.24%) offer placements to second-cycle students (primarily in teaching hospitals) but for a limited number of their students. Thirty-three universities provided theoretical teaching, which is predominantly lecture-based (58.82%) or group-based (large group 38.24% and small group 47.06%). Moreover, we frequently observed a combination of different teaching methods, in particular group teaching and lectures (27%).

**Conclusion.** Training in palliative medicine during medical school in France varies widely. Practical training is available but limited in access, while theoretical training meets international standards but does not fully align with the EAPC objectives. Based on these results, the authors advocates for developing an access for all students to clerkships, and the development of theoretical teaching preferably in small groups in all universities. J Pain Symptom Manage 2025;70:80–88. © 2025 The Authors. Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

Key Words

Palliative care, palliative medicine, medical education, medical school, medical students

Key Messages

This study is the first to comprehensively examine the teaching of palliative care in French medical school clinical year programs. This study adds

that access to palliative care clerkships and theoretical teaching is heterogeneous, offered to small numbers of students and are not available in all universities.

Address correspondence to: Adrien Evin, MD, PhD, Unité de Soins Palliatifs (5ème étage, aile Sud), Service Interdisciplinaire Douleur, Soins Palliatifs et de Support, Médecine intégrative, CHU de NANTES - Hôpital Guillaume et René

LAENNEC, Boulevard Jacques MONOD, 44093 NANTES cedex 1, France. E-mail: adrien.evin@chu-nantes.fr

Accepted for publication: 24 March 2025.
**Introduction**

*Global Context*

The World Health Organization (WHO) has identi-
fied training in palliative medicine as a priority area,
particularly given that only 14% of patients who require
palliative care have access to it.¹ In France, it is esti-
mated that 190,000 patients received palliative care in
2021, with the number rising to 450,000 by 2034.² This
means that all physicians will one day be required to
deliver palliative care. It is therefore very important
that medical students receive training in palliative med-
icine.

The development of training in palliative medicine
varies considerably from country to country, mainly
due to the uneven progression of palliative care prac-
tice worldwide.³ In Europe, the EAPC Atlas highlights
the availability of theoretical training for all undergradu-
uates in Austria, the UK, Belgium, Estonia, France, Ger-
many, Luxembourg, the Republic of Moldova and
Switzerland.⁴ In contrast, regions such as Asia,⁵ South
America,⁶ and Africa⁷ face significant difficulties in
accessing training, with less than 15% of physicians hav-
ing received training in palliative care. The United
States has seen a progressive development of palliative
medicine training over the past three decades, with a
primary focus on theoretical courses.⁸

Several studies have examined palliative medicine
training in Europe (United Kingdom,⁹ Switzerland,¹⁰
Austria,¹¹ and Germany¹²), Asia (Korea¹³ and other
countries⁵), South America (Colombia¹⁴) and the
United States,⁸ but none have been carried out in
France; moreover, there are many studies on theoreti-
cal teaching, but very few on both practical and theo-
retical teaching.

French Context

In France, the undergraduate medical training is
divided in two cycles; a basic cycle about medical scien-
ces and a deepened cycle (medical school clinical
year). This last one is equivalent to the Master's
degree¹⁵ and is based on a training framework led by
objectives. Those objectives are to develop clinical
skills, and to gain understanding of the physiopathol-
ogy process, pathology, therapeutic principles and pre-
vention. ¹⁶ They are assessed via the National Ranking
Examination that allows accessing postgraduate medi-
cal trainings in medical specialities.

Over the course of this deepened cycle, medical stu-
dents are initiated into the hospital environment
through clerkships and theoretical courses that are gov-
erned by the French Education Code. During the
above-mentioned clinical clerkships, they are responsi-
ble for carrying out routine medical procedures, keep-
ing observation records and participating in on-call
services. However, issuing prescriptions is not one of

their responsibilities. The curriculum is divided into
367 items, with six items dedicated to, multidisciplinary
and multiprofessional palliative care, the specific char-
acteristics of certain situations (paediatrics, intensive
care), global suffering, pain, ethics, death and bereave-
ment. It should be noted that the number of units does
not reflect their relative importance in the context of
National-Ranking Examination or in the context of stu-
dent learning.These elements are aligned with those
adopted by the European Association for Palliative
Care,¹⁷ which are as follows, palliative care, palliative
medicine (definitions, etc.), pain, neuro-psychological
symptoms (agitation, confusion etc.), management of
other symptoms (dyspnoea, nausea, etc.), ethics and
law, patient, family, and nonclinical caregivers perspec-
tives, and clinical communication skills.Although the
framework is similar, each institution is free to choose
the training it offers.¹⁸

As mentionned earlier, it's very likely that all physi-
cians will have to deal with palliative care as the num-
ber of patients affected by it increases. It is for this
reason that the government, through its multiyear
plans, has identified the necessity for palliative care
training. The 2015–2018 multiyear plan sought to
develop training for all professionals.¹⁹ This measure
was further specified by the 2017 interministerial
instruction,²⁰ which indicated in particular, the need
to set up clerkships in palliative care facilities for all sec-
ond cycle students. However, despite this instruction,
implementation varies widely across the country.²¹

Therefore, with the objective of acquiring knowl-
edge regarding the actual state of palliative medicine
training, a national survey was conducted targeting
French universities. The objective of this survey was to
describe the theoretical and practical training in pallia-
tive medicine that is provided during the second cycle
of medical studies in France.

Methods

Population

A total of 33 universities in France offer a medical
program. Three of them have two medical schools and
offer different programs (Lyon, Montpellier, and
Saclay), and two of them have incomplete curricula at
the time of the study (Antilles and La Réunion). The
study encompassed 34 French medical schools with a
complete second cycle in medicine (Supplementary
material 1) and different programs.

Cross-sectional Data Collection

Data collection was conducted via an online ques-
tionnaire on the LimeSurvey software®. The link to
the questionnaire was distributed via email, using the
mailing list of the National College of Teachers for
University Training in Palliative Care (CNEFUSP). The initial distribution of the questionnaire occurred on February 22, 2024, with subsequent targeted reminders sent throughout March and April of the same year. Data collection ended on 30 April 2024.

If an establishment had provided more than one answer, we contacted them to obtain further information about the differences between the different answers.

## Questionnaire Design

The questionnaire was developed in collaboration with AE (initial of one of the authors) drawing upon existing preliminary work conducted by the CNEFUSP - Collège National des Enseignants pour la Formation Universitaire en Soins Palliatifs (French National College of University Palliative Care Teachers) - (without publication), and the content of the 2017 interministerial instruction.²⁰ The survey was divided into two sections: the first section addresses the practical aspects of training, including clerkships, multiprofessional meetings, and other pedagogical methods; the second section focuses on theoretical training, encompassing lectures, group courses, optional teaching units, video capsules, preparation sessions for national dematerialized exams, and other methods. We chose to survey the distribution of instruction in the 4th, 5th, and 6th years in order to get as accurate a picture as possible of the distribution of theoretical hours.

A preliminary version of the questionnaire was tested by palliative medicine teaching referents at five universities, including Nantes, Tours, Strasbourg, Clermont-Ferrand and Lyon. The draft questionnaire required two rounds with the experts involved in writing it. There were 6 experts, including a former student representative, a pedagogy expert, 5 palliative medicine teachers, and 4 PhDs with experience and training in questionnaire development.

The questionnaire consisted of 45 questions, some of which are open-ended and the majority of which are closed (in Supplementary material 2), in this case the questions were multiple choice or simple choice. The questionnaire has been designed to avoid incomplete response fields.

## Ethical and Legal Aspects

The survey methodology was validated by the ethics committee of professional conduct and scientific integrity from Nantes University on January 22, 2024 (reference no. 22012024-2).

Participation in the questionnaire was considered to constitute agreement to participate in the study.

## Statistical Analysis

The analysis and processing of the results were conducted using the LimeSurvey software® and by

exporting the results to Microsoft Excel 2016®. Data were analysed using descriptive statistics. The data collected will be described by descriptive statistics median (interquartile range) for non-Gaussian continuous data and number (%) for categorical variables.

## Results

All medical schools surveyed responded, achieving a 100% response-rate without missing data.

In detail, we received 38 responses, but 4 of these were double responses, and in the event of a discrepancy between the answers, clarification was obtained from the city's palliative medicine teaching manager.

## Practical Training

Thirty establishments (88.24%) provide practical training such as clerkships, multidisciplinary meetings, or other forms of practical training (Table 1). The majority of universities provide clerkship opportunities in palliative care units, with many also offering placements in palliative care consultation team or regional pediatric palliative care teams. There are no opportunities for clerkships in day hospitals. Additionally, none of the establishments offer clerkships in nursing homes or via structures other than those mentioned in the questionnaire. These placements constitute a component of the hospital services offered to students, with only a limited number of students participating (with the exception of one establishment, Fig. 1). 1%–10% of students take part in these clerkship programs, which are optional in 13 institutions and required by the faculty in 17 other institutions.

With regard to multiprofessional meetings, these are offered in establishments that also offer clerkships.

## Theoretical Training

A single institution does not provide any teaching modality to all second-cycle students (Table 2). Theoretical teaching is mainly provided in the form of lectures (58.82%), with few hours of teaching per year (<5 hours per year in most institutions). When any other form of teaching is used, it is also of short duration, be it group lessons, video capsules or lessons to prepare for the National Ranking Examinations. With regard to the distribution of theoretical courses between lectures and group courses (large and small), it is observed that some institutions offer only lectures (29.41%), large groups (14.71%), or small groups (17.65%). In instances where multiple pedagogical approaches are employed, these may include lectures and large (5.88%) or small (11.76%) groups, a combination of both (8.82%), or all three (8.82%). Finally, the majority of courses are scheduled to occur during the fifth year.
<table><caption>Table 1
Type of Practical Training Propose in French Medical School</caption><thead><tr><th colspan="2">Teaching Modality: Practical Training<sup>a</sup></th><th>Number of Medical School n Total = 34</th></tr></thead><tbody><tr><td rowspan="2">One or more practical teaching modality<br/>Clerkship</td><td>Number of universities</td><td>30 (88.24%)</td></tr><tr><td>Structure</td><td>30 (88.24%)</td></tr><tr><td rowspan="10">Place</td><td>Palliative care unit</td><td>30 (88.24%)</td></tr><tr><td>Mobile team (adult/children)</td><td>23 (67.65%)</td></tr><tr><td>At home hospital</td><td>2 (5.88%)</td></tr><tr><td>Identified beds for palliative care in a no specific palliative unit</td><td>15 (44.12%)</td></tr><tr><td>Outpatient Consult</td><td>6 (17.65%)</td></tr><tr><td>University Hospital</td><td>30 (88.24%)</td></tr><tr><td>Other public hospital</td><td>13 (38.24%)</td></tr><tr><td>Private not-for-profit healthcare establishment</td><td>11 (32.35%)</td></tr><tr><td>Private for-profit healthcare establishment for profit</td><td>1 (2.94%)</td></tr><tr><td>Liberal medicin</td><td>1 (2.94%)</td></tr><tr><td rowspan="2">Obligatory in the model</td><td>Mandatory</td><td>17 (50%)</td></tr><tr><td>Optional</td><td>13 (38.24%)</td></tr><tr><td rowspan="2">Length</td><td>Like classical clerkship<sup>b</sup> Median (IQ) by weeks</td><td>25 (73.53%) 6 (4;7.25)</td></tr><tr><td>Less than other clerkship Median (IQ) by weeks</td><td>5 (14.71%) 1(1;1.25)</td></tr><tr><td>Participation rate</td><td>percentage of promotions involved in clerkships</td><td>1–10 (1–10;11–20)%</td></tr><tr><td rowspan="6">Multiprofessional meeting</td><td>Number of universities</td><td>6 (17.65%)</td></tr><tr><td rowspan="2">Obligatory</td><td>Yes</td><td>2 (5.88%)</td></tr><tr><td>No</td><td>4 (11.76%)</td></tr><tr><td>Number of meetings required</td><td>1</td><td>5 (14.71%)</td></tr><tr><td rowspan="2">Participation rate</td><td>>1</td><td>1 (2.94%)</td></tr><tr><td>percentage of promotions involved in multi professional meeting Median (IQ) %<sup>c</sup></td><td>11–20 (1–10; 61–70)%</td></tr></tbody></table>

## Lectures

The proportion of students participating in courses varies considerably according to the modality. Based on data from lectures over the 3 years, we estimate the median attendance to range between 20 and 30% (IQ 10–20; 65–75).

## Group Course

The rates of attendance for group courses with active student participation vary according to the teaching method and the year of the course. In the clinical case study, participation in large groups (>25% of the graduating class) increased from the fourth to the sixth year, up to 85%–95% (IQ 70–80; 100%). For small groups (<25% of the graduating class), it also increased to 65%–75% (IQ 30–40; 90%–100%) in the sixth year.

## Optional Course

Eleven establishments (32.3% of establishments) offer optional course units with one establishment offering two. These courses involve 10%–20% (IQ 1–10; 10%–20%) of students in these establishments. They focus mainly on ethics and palliative care (six have “palliative” in their title and three “ethics”). They are mainly offered in the fifth and sixth years (72% of optional course units). The quantity of instruction

varies, but is typically in excess of 20 hours (63% of optional course units).

## Other Form of Teaching

Educational establishments are free to propose alternative forms of teaching. Two instances arose in which proposals were made for the introduction of Objective Structured Clinical Examinations (OSCEs). One institution also reported that OSCEs constituted another form of group teaching.

## Discussion

This study reveals a significant diversity in the theoretical and practical teaching of palliative medicine in France. Access to palliative care clerkships is heterogeneous and offered only to small numbers of students. Theoretical teaching is not available at all universities, and when it is, it is often delivered with large numbers of students. These findings may be attributed to the fact that the teaching of palliative medicine has been gradually structured in various universities, with organizational choices that have been the subject of discussion specific to each establishment, in the absence of a national framework for theoretical teaching and the relatively recent universitarisation of the discipline.

<footnote><sup>a</sup>No other practical courses were reported in the second cycle.</footnote>

<footnote><sup>b</sup>Duration varies from university to university, typically one or two months.</footnote>

<footnote><sup>c</sup>Divided into 10 classes of 10%.</footnote>
<figure><img src="image_4.png" /><figcaption>Fig. 1. Participation in clerkships (%) by establishment.</figcaption></figure>

Practical Training

Although practical training is a common component of palliative medicine teaching, it is offered to a relatively small number of students (1%–10%) and appears to be more of a supplementary opportunity than a fully integrated part of the curriculum, as an clerkship with a general practitioner might be,²² even though the benefits of clerkship learning have been proven.²³⁻²⁵ If the duration of the clerkship is the same as that of a standard clerkship (in other medical specialties), and therefore includes another proposed placement among the other clerkship opportunities, then the duration is similar. On the other hand, if it is a shorter placement, it lasts one week, which is similar to what was reported in the study by Noguera et al.²⁶ Furthermore, the placements on offer are mainly palliative care units and mobile teams at university hospitals. 57% (17/30) of the placements were considered compulsory, but only with a small number of students (1%–10% of the graduating class) because it was

imposed on a small number of students. This can be explained by the compulsory nature of the rotations (regardless of the medical service) and not by the obligation to do a palliative care rotation. A number of factors need to be taken into account, in particular the number of students in the country, which is close to 10,000 per year (based on the number of candidates for the National Ranking Examination 2023), and the difficulties in finding suitable placement locations. Furthermore, as the EAPC's European Atlas points out,⁴ the fact that there are only associate professors (6 in 2019) and no university professors of palliative care could limit the development of training. The absence of a specialty and the fact that it is structured as a sub-specialty can also make practical training more complex.

In other specialties²⁷,²⁸ and other countries,²⁹ it has been shown that the added value of practical training influences the choice of specialty. The opportunity to undertake a palliative care clerkship may therefore
<table><caption>Table 2
Theoretical Training</caption><thead><tr><th colspan="3">Teaching Modality: Theoretical Training</th><th>Number of medical School<br>n Total = 34</th></tr></thead><tbody><tr><td rowspan="10">At least one theoretical teaching modality<br>offered to the entire graduating class</td><td rowspan="10">Lectures</td><td>Number of universities</td><td>33 (97.06%)</td></tr><tr><td>4th year Training time</td><td>20 (58.82%)<br>4 (11.76%)<br>2 (5.88%)<br>1 (2.94%)</td></tr><tr><td>5th year Training time</td><td>20-30 (10-20; 65-75)%<br>9 (26.47%)<br>4 (11.76%)<br>3 (8.82%)</td></tr><tr><td>6th year Training time</td><td>20-30 (20-30; 50-60)%<br>6 (17.65%)<br>1 (2.94%)<br>1 (2.94%)</td></tr><tr><td>Participation rate Median (IQ)<sup>a</sup></td><td>60-70 (10-20; 80-90)%<br>13 (38.24%)<br>100 (50-230)</td></tr><tr><td>Number of universities</td><td>12 (35.29%)</td></tr><tr><td>Group size Median (IQ)</td><td>1 (2.94%)</td></tr><tr><td>Teachoursing modality</td><td>1 (2.94%)</td></tr><tr><td>Clinical case studies</td><td>1 (2.94%)</td></tr><tr><td>Flipped classroom<br>teachoursing</td><td>1 (2.94%)</td></tr><tr><td rowspan="10">Large group<sup>b</sup> (&gt;25%<br>graduating class)</td><td>Number of universities</td><td>1 (2.94%)</td></tr><tr><td>Group size Median (IQ)</td><td>16 (47.06%)<br>20 (9.25-42.5)</td></tr><tr><td>Teachoursing modality</td><td>3 (8.82%)</td></tr><tr><td>4th year Training time</td><td>13 (38.24%)</td></tr><tr><td>5th year Training time</td><td>2 (5.88%)<br>0 (0%)</td></tr><tr><td>6th year Training time</td><td>2 (5.88%)<br>1 (2.94%)<br>2 (5.88%)<br>0 (0%)</td></tr><tr><td>Participation rate Median (IQ)<sup>a</sup></td><td>10-15 hours</td></tr><tr><td>Number of universities</td><td>10-15 hours</td></tr><tr><td>Group size Median (IQ)</td><td>10-15 hours</td></tr><tr><td>Teachoursing modality</td><td>10-15 hours</td></tr><tr><td rowspan="10">Small group<sup>b</sup> (&lt;25%<br>graduating class)</td><td>Number of universities</td><td>16 (47.06%)<br>20 (9.25-42.5)</td></tr><tr><td>Group size</td><td>3 (8.82%)</td></tr><tr><td>Teaching modality</td><td>1 (2.94%)</td></tr><tr><td>4th year Training time</td><td>18 (52.94%)</td></tr><tr><td>5th year Training time</td><td>5 (14.71%)<br>80-90 (40-50; 100)%</td></tr><tr><td>6th year Training time</td><td>12 (35.29%)<br>45-55 (25-35; 65-75)%</td></tr><tr><td>Participation rate Median (IQ)<sup>a</sup></td><td>10 (29.41%)<br>75-85 (55-65; 100)%</td></tr><tr><td>Number of universities</td><td>1 (2.94%)</td></tr><tr><td>Group size Median (IQ)</td><td>1 (2.94%)<br>1 (2.94%)</td></tr><tr><td>Teachoursing modality</td><td>1 (2.94%)</td></tr><tr><td rowspan="10">Video capsule</td><td>Number of universities</td><td>1 (2.94%)</td></tr><tr><td>5th year Training time</td><td>3 (8.82%)<br>1 (2.94%)</td></tr><tr><td>4th year Training time</td><td>18 (52.94%)<br>5 (14.71%)</td></tr><tr><td>5th year Training time</td><td>12 (35.29%)<br>45-55 (25-35; 65-75)%</td></tr><tr><td>6th year Training time</td><td>10 (29.41%)<br>75-85 (55-65; 100)%</td></tr><tr><td>Participation rate Median (IQ)<sup>a</sup></td><td>10 (29.41%)<br>75-85 (55-65; 100)%</td></tr><tr><td>Number of universities</td><td>1 (2.94%)</td></tr><tr><td>Group size Median (IQ)</td><td>10-15 hours</td></tr><tr><td>Teachoursing modality</td><td>10-15 hours</td></tr><tr><td>4th year Training time</td><td>1 (2.94%)<br>3 (8.82%)</td></tr><tr><td>5th year Training time</td><td>1 (2.94%)<br>1 (2.94%)</td></tr><tr><td>6th year Training time</td><td>1 (2.94%)<br>1 (2.94%)</td></tr></tbody></table>

<footnote><sup>a</sup>Divided into 10 classes of 10%.</footnote>

<footnote><sup>b</sup>Group teaching with an active learning modality (in comparison with lectures).</footnote>

<footnote><sup>c</sup>Conference (1), Multi choice question session (1), presentation preparation (1), palliative concept presentation (1), objective structured clinical examination (1).</footnote>

<footnote><sup>d</sup>Exchanges on professional situations (1), interprofessional teaching (1).</footnote>

<footnote><sup>e</sup>No video-capsule teaching in 4th and 6th year.</footnote>
influence the choice of specialty at the end of under-
graduate medical training.

Interprofessional work is an integral part of pallia-
tive care.³⁰ However, when we asked about the opening
up of multiprofessional palliative care meetings to stu-
dents, the response was still rather low, which can be
explained by the fact that these meetings are only
attended during clerkships in palliative care units and
by the lack of formalisation of these meetings. It is to
be hoped that the universitization of the paramedical
professions will facilitate interdisciplinary teaching
(theoretical and practical).

Theoretical Training

In our study, we observed considerable heterogene-
ity between establishments, a finding that is consistent
with observations in other European countries.<sup>10-12,31</sup>
Some studies have indicated that France is among the
countries with the most effective teaching of palliative
medicine.<sup>32</sup> This does not prevent the need for
improvement, in fact, in comparison to previous stud-
ies, there appears to have been an enhancement in the
quality of training (unpublished data from CNEFUSP).
This heterogeneity persists even if the number of hours
has increased in recent years, as suggested by various
earlier studies. Noguera et al.<sup>26</sup> in 2018 demonstrated
that the training program in Lyon consisted of only 20
hours of lectures. And, unpublished work by the CNE-
FUSP in 2013 and 2017 indicated an increase in train-
ing time for medical students. In 2017, the mean
duration of instruction was 10.5 hours, with a range of
2 hours–21 hours (only 6 hours in 2013). Our survey
does not permit a comparison of instructional time per
student, as our focus was on time per student per
instructional format. However, we have observed the
emergence of novel instructional methods, including
the use of simulations, flipped classrooms, and video
modules.

In our study, theoretical teaching is primarily con-
ducted through lectures or case studies in groups of
varying sizes. It is noteworthy that several universities
employ a combination of teaching methods, tailored to
the specific objective of the course. Nine institutions
offer both group teaching and lectures, while three
institutions offer both large and small group teaching.
This seems to be in line with what is observed abroad. ³³
Although some studies³⁴ show that all teaching meth-
ods have a beneficial effect on learning about palliative
care, but in general education, teaching in small
groups has been shown to be more beneficial for skill
acquisition. ³⁵,³⁶

Several institutions informed us of their use of objec-
tive structured clinical examinations (OSCE) as a
teaching method. However, we chose not to specifically
study this approach due to its recent adoption (gener-
alized in France in 2022) and the challenge universities

face in distinguishing between OSCEs used for forma-
tive versus evaluative purposes. Consequently, the use
of OSCEs may currently be underestimated. It would
be valuable to conduct more specific studies on this
method in the coming years, once all faculties have
become more accustomed to it.

A number of studies³⁷⁻³⁹ have explored interprofes-
sional training, showing improvements in communica-
tion and collaboration. However, limitations include
small sample sizes, self-selection bias, self-reported out-
comes, low response rates, and limited longitudinal
measures. This theoretical aspect was not addressed in
the present study and could be the subject of a broader
research project, extending beyond the scope of medi-
cal education.

International Palliative Care Learning

Few studies have been conducted on clerkships in
particular. Clerkships are available on an international
level in countries such as Switzerland and Australia,⁴⁰
or the UK⁹; however, these are optional and involve a
limited number of students, as is the case in France. It
should be noted that hospice visits are incorporated
into the training curriculum in multiple countries. In
contrast, the French medical training system does not
typically include hospice visits, and practical training in
palliative medicine is more commonly achieved
through clerkships.

In terms of theoretical teaching, the EAPC's objec-
tive is to provide 40 hours of instruction in palliative
medicine.¹⁷ However, France appears to be falling
short of this target. It is important to note that the pres-
ent study was not conducted with this criterion in
mind. The hourly volume varies across studies and
between countries. Fitzpatrick et al.²⁶ report training
that ranges from 90 minutes to one week in duration.
In European countries, the mean is 20 hours in the
UK,⁹ 10.2 hours in Switzerland,⁴⁰ and 17.6 houre
in Germany.¹² Fitzpatrick's³³ and Dickinson's⁸ studies
show a predominance of lectures and small group
teaching, which seems consistent with the French data.
On the other hand, since theoretical courses are not
compulsory in France, the participation rate appears to
be lower than in other countries.⁸,⁹

Strength and Limitation

This study's strength lies in its comprehensive exam-
ination of palliative medicine education in the second
cycle at all French medical schools. It addresses both
theoretical and practical aspects of teaching, and the
individuals interviewed were the most knowledgeable
about their institution's palliative medicine teaching.
However, this point is also a limitation, as there may
sometimes be a lack of awareness of what can be done
by certain lecturers or in the field. Additionally, some
universities have only recently initiated their second
cycle, resulting in their exclusion from this survey due
to the lack of a complete cycle. The survey focused
exclusively on educator perspectives and did not
include user perspectives or assessments of knowledge
and skills, which will be the assessment model of the
future.⁴¹ As the survey was an e-survey, some questions
may have been misunderstood. The data examined
could have included the number of hours of instruc-
tion per student in autonomy and total instruction,
which would have provided more data for comparison
with the international literature. Moreover, the curric-
ula of some universities are designed over a six-year
period, which precludes the inclusion of certain
courses in the survey, particularly those offered during
the first cycle (three first years). However, unlike the
first cycle of medical studies, the second cycle benefits
from an educational framework with clear objectives.¹⁶

Conclusion

Training in palliative medicine in the deepened
cycle of medical school varies widely across France. A
comparison of the practical training offered in France
with that of other institutions around the world reveals
that it is offered quite widely, but to a limited number
of students. By contrast, the theoretical training
appears to be aligned with international standards;
however, it does not fully align with the objectives of
the EAPC. We advocate developing access for all to
clerkships and theoretical training, preferably in small
groups, in all universities. Inter-professionality, whether
in theoretical or practical training, needs to be initiated
systematically. Many avenues will enable these improve-
ments to be implemented: the appointment of full pro-
fessors in palliative medicine, the development of the
care offer and therefore of palliative care clerkships,
the facilitation of interdisciplinary teaching with the
universitarization of paramedical professions.

Author Contributions

AE and DK are responsible for study design and
manuscript preparation. LC, EPC, VG and GE partici-
pated in study design and manuscript preparation. DK
is responsible for data analysis. AE and DK act as guar-
antor and accept full responsibility for the work and/
or conduct of the study, had access to the data and con-
trolled the decision to publish.

Research Ethics and Patient Consent

This study has been validated by ethics committee
of professional conduct and scientific integrity from
Nantes University on 01/22/2024 (reference no.
22012024-2).

Data Sharing

Data are available on reasonablerequest.

Disclosures and Acknowledgments

The authors declare that they have no known com-
peting financial interests or personal relationships that
could have appeared to influence the work reported in
this paper. The authors have not declared a specific
grant for this research from any funding agency in
the public, commercial or not-for-profit sectors. The
authors would like to thank all French universities.

Supplementary materials

Supplementary material associated with this article
can be found in the online version at doi:10.1016/j.
jpainsymman.2025.03.027.

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