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# Career Trajectories After Palliative Care Training:
A National E-Survey of Medical Interns in France

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

CHU de Nantes (G.L., A.E.), Service de soins palliatifs et de support, Nantes Université, 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; UFR Lyon SUD-Charles MERIEUX (E.P.), Hospices Civils de Lyon, Université Claude Bernard Lyon 1, France; Palliative Care Unit; CHU Louise Michel (V.G.), Palliative Care Center of the Clermont-Ferrand University Hospital, 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; Centre pour l'Innovation en Cancérologie de Lyon (G.E.), Université Claude Bernard Lyon 1, Oullins-Pierre-Benite, France; CHU Nantes (A.E.), CHU Tours, INSERM, Methods in patients-centered outcomes and Health Research, SPHERE, Nantes Université, Tours Université, Nantes, France

## Abstract

**Background.** Palliative care has become a crucial component of healthcare, with an increasing need for specialized training. In France, a new one-year palliative care diploma was introduced in 2019 to disseminate palliative care knowledge across various medical specialties. Offered in the final year of medical residency, the program includes 2 six-month internships in palliative care settings and four national seminars covering topics such as symptom management, ethics, and communication. However, the impact of this training on physicians' career paths remains underexplored.

**Aim.** This study aimed to assess the current practices of physicians trained in palliative care, and how the training influenced their career choices.

**Methods.** A national e-survey was conducted, aimed at all physicians who completed the palliative care training course between 2019 and 2023. Data were collected through a 36-question survey covering training completion and current practices.

**Results.** We contacted 179 physicians. After excluding 40 responses from those who had not completed their diploma, the eligible sample consisted of 139 respondents. Of these, 81 complete responses were obtained, yielding a 58% response rate (81/139). Of those, 52 were currently practicing in specialized palliative care settings. Interestingly, 88.5% of those not practicing directly in palliative care still integrated a palliative dimension into their daily work. The proportion of physicians intending to work exclusively in palliative care tripled after the training course compared to before.

**Conclusion.** This study highlights the significant role of the palliative care training in shaping physicians' career paths and disseminating palliative care practices across medical specialties. J Pain Symptom Manage 2025;70:523–531. © 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, medical training, career path, healthcare professionals, disseminating, France

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, cedex 1, Nantes 44093, France. E-mail: adrien.evin@chu-nantes.fr

Accepted for publication: 1 August 2025.
## Key Message

This national study evaluates the effects of a new medical training program in palliative care in France. The findings show greater integration of palliative care into medical practice and increased specialization among recent graduates, suggesting that structured, targeted training can influence early career choices and promote broader adoption of palliative care within healthcare systems.

## Introduction

### Developing Training in Palliative Care: A Priority

Palliative care is now acknowledged as a fundamental component within the continuum of care.¹ It is now recognized as a medical specialty, characterized by constant evolution and a need for adaptation. Worldwide, there is a rapid increase in the number of patients currently receiving palliative care, with forecasts of exponential growth.²,³ The World Health Organization recognizes an increase in the need for palliative care associated with a glaring lack of training, recognition, and access.⁴ Two commissions published in the Lancet,⁵,⁶ demonstrate this increase with a strong impact on patients, structures, careers, and even the economy. Studies have shown that new physicians in general practice are not sufficiently trained in palliative medicine⁷ and given the development of pathologies, the complexity of treatments and, new support options, it is impossible to properly practice palliative care without appropriate training.⁸

### Existing Training Efforts and Their Limitations

Internationally, a variety of training formats exist for palliative care, ranging from single seminars to multi-year programs, with varying degrees of theoretical and clinical exposure.⁹ A systematic review shows that regardless of the type of palliative care training received, residents reported feeling more comfortable with end-of-life care after the training.¹⁰ Given this need, in 2014 the World Health Assembly issued clear guidelines calling for the integration of basic and continuing palliative care education into the training of all healthcare workers.¹¹

### Evolution of Palliative Medicine Training in France

In France, palliative care is not a recognized medical specialty.¹² Despite this, there are diplomas that enhance the skills and knowledge of physicians undergoing initial training in addition to their specialty. Until 2019, physicians could complete a two-year university diploma designed to train them for specialized palliative care roles.¹³ In 2019, this was replaced by a one-year program known as Specialized Transversal Training in Palliative Medicine. Unlike the previous

program, which targeted specialization, the new training aims to introduce a palliative care approach across all medical disciplines.¹⁴ This decision was linked to a nationwide overhaul of the medical curriculum, driven by political choices and implemented without prior evaluation of the previous curriculum.

The curriculum includes both theoretical and practical components: four national seminars (the same each year) covering key aspects of palliative and end-of-life care (symptom management, communication, ethical issues, interdisciplinary collaboration), and two six-month clinical internships, typically in a palliative care unit and a mobile palliative care consultation team. This training is undertaken during the final year of residency, just before physicians begin independent practice.

Since the implementation of this new palliative medicine training program, four annual cohorts (promotions) have completed the full curriculum across France, with a growing number of participants each year. It is estimated that approximately 180 physicians have completed both the theoretical and practical components of the training. However, no formal evaluation has been conducted, and little is known about the professional trajectories of these physicians or whether the program met their expectations regarding palliative care practice. This lack of data underscores the need to assess the perceived impact of the training on future clinical practice.

The aims of this study were to describe the current practice of physicians who completed the new program in palliative medicine (position and type of healthcare setting) and the place of palliative care in this practice. The secondary objectives were to establish whether the completion of this training course had altered their initial practice intentions, and to gather the participants' opinions on the program.

## Methods

### Study Design

We conducted a national online survey targeting graduates of the new program in palliative care (Specialized Transversal Training in palliative medicine).

### Population

The target population consists of all students in France who have completed the three components of the new palliative medicine training program since its implementation in 2019. These components include two medical internships in specialized palliative care settings, four theoretical seminars, and the writing and defense of a dissertation. The dissertation is an additional requirement, distinct from the medical thesis,
and is necessary for completing the palliative care training.

To be included in the study, participants had to have completed both the full training program and their original medical degree.

The exclusion criteria were as follows:

1. Students who had not yet completed their original medical degree or the palliative care training program.

2. Incomplete responses to the questionnaire.

## Data Collection

Data collection was conducted via an online questionnaire 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. The initial distribution of the questionnaire occurred on April 22, 2024. If no response was received, up to three separate reminder emails were sent and a text message was sent by telephone when the number was available. Only fully complete questionnaires were considered.

## Questionnaire Design

The questionnaire contained 36 questions, including both open-ended and closed-ended questions, with some using sliding answers. It was developed by the two main authors (GL and AE). GL was a recent graduate of the training program, and AE is an assistant professor in palliative medicine. The questionnaire was pretested by five university-based palliative care faculty members from different regions of France (LC, VG, EPC and GE), who are co-authors of this work. This pre-testing led to several adjustments to the questionnaire, including the addition, removal, or rephrasing of certain questions and response options. We chose not to test the questionnaire with other students to avoid reducing the final sample size.

The questionnaire was divided into three parts:

1. Part 1 Characteristics of the study population: collected data about the participant's training pathway during residency, including the year of the start of hospital internship, medical specialty, city of internship, training cohort (promotion), and validation of their medical thesis.

2. Part 2 Information on medical practice since internship: Focused on their professional practice after completing the training, including current position and location, previous positions in palliative care, and the integration of palliative care into their current practice.

3. Part 3 Choice of exercise, opinions on the training course and other palliative care training courses: assessed participants' views on the

training and its influence on career development. It included questions on whether they intended to work in palliative care before and after the program, how the training influenced their choices, their evaluations of the theoretical and practical components, and whether they had completed additional palliative care training.

## Ethical and Legal Aspects

All the data were anonymized. Participants received written information explaining the purpose of the study and the ethical regulations applicable to this type of research. Completion of the questionnaire was considered as implied consent to participate.

The study was approved by the Nantes University Ethics, Deontology and Scientific Integrity Committee (CEDIS) (IRB No. IORG0011023, approval No. 13032024) on March 21, 2024.

## Statistical Analysis

We used descriptive statistics to summarize the data. Categorical data were reported as number (n) and percentage (%). Given the exploratory nature of the study, no inferential analyses were conducted. Open-ended responses were reviewed and grouped to identify recurring themes, although no formal qualitative analysis was performed. Microsoft Excel (Version 2412) was used for data processing.

## Results

### Characteristics of the Study Population

As shown in Fig. 1, we contacted 179 students and received 160 responses in total. Of these, 40 were excluded because the respondents had not yet completed their diploma. This left us with 139 eligible responses. Among these, 81 were complete, corresponding to a response rate of 58% (81/139).

Of the 81 respondents who answered the questionnaire, 49.4% (n = 40) completed their second cycle (the French equivalent of medical school) in 2018. The remaining respondents were 28.4% (n = 23) in 2017, 19.8% (n = 16) in 2019 and 2.5% (n = 2) in 2016 (Table 1).

The most commonly represented specialties were general medicine at 63% (n = 51), geriatrics at 18.5% (n = 15) and oncology at 9.9% (n = 8).

The four main cities of internship were Paris 17.3% (n = 14) and Lyon, Strasbourg, Tours, each with 7.4% (n = 6). Five cities had no students represented.

A total of 11.1% (n = 9) of respondents completed the training over several years: eight over two consecutive years and one over three years, with the dissertation completed two years after the theoretical and practical training.
<figure><img src="image_2.png" /><figcaption>Fig. 1. Flow chart of data collection and sample.</figcaption></figure>

Almost all respondents (92.6% (n = 75)) had completed their medical thesis (a mandatory requirement for completing medical studies in France). Of these, 60% (n = 40) were related to palliative care. Among the 45 thesis topics provided, 40% (n = 18) addressed general issues in palliative practice, 33.3% (n = 15) focused on end-of-life or death-related issues, 15.6% (n = 7) addressed quality of life and patient outcomes in palliative situations, and 11.1% (n = 5) explored the experiences of healthcare staff in palliative care. The theses were completed at different times during the students' internship, but most were completed either

during the training year (44%, n = 33) or in the following year (42.7%, n = 32).

## Information on Medical Practice Since Internship

Regarding their medical practice since completing their internship, 42% (n = 34) had completed a fellowship in palliative care. They worked in various types of units (Table 2), sometimes with assignments shared between several departments (which is why the percentages add up to more than 100). Overall, 91.2% (n = 31) of them worked in a mobile palliative care
<table><caption>Table 1
Information on the Internship</caption><thead><tr><th></th><th>Number of Students (n=81)</th><th>Percentage % (Out of 81)</th></tr></thead><tbody><tr><td colspan="3"><strong>Medical specialty</strong></td></tr><tr><td>Geriatrics</td><td>15</td><td>18.5</td></tr><tr><td>General medicine</td><td>51</td><td>63.0</td></tr><tr><td>Internal medicine</td><td>1</td><td>1.2</td></tr><tr><td>Neurology</td><td>1</td><td>1.2</td></tr><tr><td>Oncology</td><td>8</td><td>9.9</td></tr><tr><td>Pediatric</td><td>2</td><td>2.5</td></tr><tr><td>Pneumology</td><td>2</td><td>2.5</td></tr><tr><td>Psychiatry</td><td>1</td><td>1.2</td></tr><tr><td colspan="3"><strong>City of medical internship</strong></td></tr><tr><td>Antilles-Guyane</td><td>0</td><td>0</td></tr><tr><td>Amiens</td><td>2</td><td>2.5</td></tr><tr><td>Angers</td><td>1</td><td>1.2</td></tr><tr><td>Besançon</td><td>3</td><td>3.7</td></tr><tr><td>Bordeaux</td><td>2</td><td>2.5</td></tr><tr><td>Brest</td><td>0</td><td>0</td></tr><tr><td>Caen</td><td>2</td><td>2.5</td></tr><tr><td>Clermont-Ferrand</td><td>2</td><td>2.5</td></tr><tr><td>Dijon</td><td>0</td><td>0</td></tr><tr><td>Grenoble</td><td>3</td><td>3.7</td></tr><tr><td>Lille</td><td>2</td><td>2.5</td></tr><tr><td>Limoges</td><td>2</td><td>2.5</td></tr><tr><td>Lyon</td><td>6</td><td>7.4</td></tr><tr><td>Marseille</td><td>4</td><td>4.9</td></tr><tr><td>Montpellier-Nimes</td><td>2</td><td>2.5</td></tr><tr><td>Nancy</td><td>3</td><td>3.7</td></tr><tr><td>Nantes</td><td>5</td><td>6.2</td></tr><tr><td>Nice</td><td>2</td><td>2.5</td></tr><tr><td>Océan-Indien</td><td>3</td><td>3.7</td></tr><tr><td>Paris</td><td>14</td><td>17.3</td></tr><tr><td>Poitiers</td><td>0</td><td>0</td></tr><tr><td>Reims</td><td>2</td><td>2.5</td></tr><tr><td>Rennes</td><td>3</td><td>3.7</td></tr><tr><td>Rouen</td><td>1</td><td>1.2</td></tr><tr><td>Saint-Etienne</td><td>0</td><td>0</td></tr><tr><td>Strasbourg</td><td>6</td><td>7.4</td></tr><tr><td>Toulouse</td><td>5</td><td>6.2</td></tr><tr><td>Tours</td><td>6</td><td>7.4</td></tr><tr><td colspan="3"><strong>Promotion of the training course</strong></td></tr><tr><td>2019–2020</td><td>11</td><td>13.6</td></tr><tr><td>2020–2021</td><td>23</td><td>28.4</td></tr><tr><td>2021–2022</td><td>20</td><td>24.7</td></tr><tr><td>2022–2023</td><td>18</td><td>22.2</td></tr><tr><td>Realization over several years</td><td>9</td><td>11.1</td></tr><tr><td colspan="3"><strong>Validation of a medical thesis</strong></td></tr><tr><td>No</td><td>6</td><td>7.4</td></tr><tr><td>Yes</td><td>75</td><td>92.6</td></tr><tr><td>Thesis in connection with palliative care</td><td>45</td><td>60<sup>a</sup></td></tr><tr><td colspan="3"><strong>Year of validation of thesis (n total 75)</strong></td></tr><tr><td></td><td>N total 75</td><td>% (Out of 75)</td></tr><tr><td>Thesis before starting this training course</td><td>1</td><td>1.3</td></tr><tr><td>Thesis during the training course</td><td>33</td><td>44</td></tr><tr><td>Thesis the year after this training course</td><td>32</td><td>42.7</td></tr><tr><td>Thesis two years after this training course</td><td>7</td><td>9.3</td></tr><tr><td>Thesis three years after this training course</td><td>2</td><td>2.7</td></tr></tbody></table>

consultation service, and 64.7% (n = 22) in a palliative care unit.

After the internship, 24.7% (n = 20) reported having secured a palliative care position other than the

fellowship (a position other than Clinical Assistant or Assistant clinical professor).

Concerning the current distribution of medical activities of respondents, 43.2% (n = 35) were currently on fellowship, 18.5% (n = 15) were private practitioners and 16% (n = 13) were employees on fixed-term contracts. Three respondents indicated that they were not currently practicing medicine. Among those who were practicing, 66.7% (n = 52) worked in palliative care.

By cross-referencing the responses, if we exclude those who had worked in palliative care or were currently doing so, it appears that 35.8% (n = 29) of those who completed the training course did not subsequently practice in palliative care. Notably, among the 11 respondents who, before the training, had already planned to work exclusively in palliative care, all of them (100%) went on to do so.

Of the 26 respondents who reported working outside a specialized palliative care setting, 88.5% (n = 23) indicated that their daily medical practice included a palliative dimension. Specifically, 52.2% (n = 12) reported integrating palliative care into the overall management of their patients, 26.1% (n = 6) into the development of care plans, 13% (n = 3) into their approach to patients and end-of-life issues, and 8.7% (n = 2) into pain management.

## Choice of Exercise, Opinions on the Training Course and Other Palliative Care Training Courses

Before starting the training course, 58% (n = 47) of respondents planned to have a mixed practice between their original specialty and palliative care, while 13.6% (n = 11) planned to work exclusively in palliative care and 11.1% (n = 9) only in their original specialty (Table 3).

After completing the training course, 42% (n = 34) wanted to have a mixed practice, while 39.5% (n = 32) were thinking of working exclusively in palliative care and 9.9% (n = 8) only in their original specialty.

In total, 61.7% (n = 50) of respondents reported that the training course had influenced their choice of practice. When asked to explain, 34% (n = 17) stated that it had increased their interest in palliative care, and 8% (n = 4) indicated a desire to integrate a palliative dimension into their original specialty.

Former students were also asked whether the training course offered to their graduating class met the needs they have in their current practice. Of the 32.1% (n = 26) of respondents who felt that the theoretical part of the training did not meet the needs of their current practice, 30.8% (n = 8) reported a lack of courses on specific topics, while 26.9% (n = 7) described the content as too general or insufficiently in-depth overall.

<footnote>aPercentage out of 75.</footnote>
<table><caption>Table 2
Past and Current Medical Practice Since Internship</caption><thead><tr><th></th><th></th><th>Number of Students<br>(n = 81)</th><th>Percentage % (Out of 81)</th></tr></thead><tbody><tr><td colspan="4">Carrying out a fellowship in palliative care (Clinical Assistant or Assistant clinical professor)</td></tr><tr><td rowspan="7">If Yes, Where ? n = 34</td><td>No</td><td>47</td><td>58.0</td></tr><tr><td>Yes</td><td>34</td><td>42.0</td></tr><tr><td>Palliative care unit</td><td>22</td><td>64.7<sup>a,b</sup></td></tr><tr><td>Mobile palliative care consultation service</td><td>31</td><td>91.2<sup>a,b</sup></td></tr><tr><td>Unit with identified palliative care beds</td><td>0</td><td>0<sup>a,b</sup></td></tr><tr><td>Palliative care day hospital unit</td><td>6</td><td>17.6<sup>a,b</sup></td></tr><tr><td>Palliative care consultation service</td><td>7</td><td>20.6<sup>a,b</sup></td></tr><tr><td rowspan="2">Other post (than Clinical Assistant or Assistant clinical professor) in palliative care following internship</td><td>Palliative care day hospital unit</td><td>1</td><td>2.9<sup>a,b</sup></td></tr><tr><td>Home hospital for palliative care or with palliative care network</td><td>0</td><td>0<sup>a,b</sup></td></tr><tr><td rowspan="7">If Yes, Where ? n = 20</td><td>No</td><td>61</td><td>75.3</td></tr><tr><td>Yes</td><td>20</td><td>24.7</td></tr><tr><td>Palliative care unit</td><td>13</td><td>65.0<sup>a,c</sup></td></tr><tr><td>Mobile palliative care consultation service</td><td>14</td><td>70.0<sup>a,c</sup></td></tr><tr><td>Unit with identified palliative care beds</td><td>1</td><td>5.0<sup>a,c</sup></td></tr><tr><td>Palliative care day hospital unit</td><td>2</td><td>10.0<sup>a,c</sup></td></tr><tr><td>Palliative care consultation service</td><td>2</td><td>10.0<sup>a,c</sup></td></tr><tr><td rowspan="2">Their current position</td><td>Palliative care coordination unit</td><td>0</td><td>0<sup>a,c</sup></td></tr><tr><td>Home hospital for palliative care or with palliative care network</td><td>1</td><td>5.0<sup>a,c</sup></td></tr><tr><td rowspan="7">For those practicing medicine: is it palliative care ? n = 78</td><td>Clinical Assistant</td><td>23</td><td>28.4</td></tr><tr><td>Assistant clinical professor</td><td>12</td><td>14.8</td></tr><tr><td>Private practitioner</td><td>15</td><td>18.5</td></tr><tr><td>Mixed practice (salaried and private practitioner)</td><td>6</td><td>7.4</td></tr><tr><td>Salaried practitioner</td><td>9</td><td>11.1</td></tr><tr><td>Employee on fixed-term contract</td><td>13</td><td>16.0</td></tr><tr><td>Not practicing medicine</td><td>3</td><td>3.7</td></tr><tr><td rowspan="7">If Yes, Where ? n = 52</td><td>No</td><td>26</td><td>33.3<sup>d</sup></td></tr><tr><td>Yes</td><td>52</td><td>66.7<sup>d</sup></td></tr><tr><td>Palliative care unit</td><td>29</td><td>55.8<sup>a,e</sup></td></tr><tr><td>Mobile palliative care consultation service</td><td>34</td><td>65.4<sup>a,e</sup></td></tr><tr><td>Unit with identified palliative care beds</td><td>4</td><td>7.7<sup>a,e</sup></td></tr><tr><td>Palliative care day hospital unit</td><td>6</td><td>11.5<sup>a,e</sup></td></tr><tr><td>Palliative care consultation service</td><td>6</td><td>11.5<sup>a,e</sup></td></tr><tr><td rowspan="2">Regional palliative care coordination unit</td><td>Home hospital for palliative care or with palliative care network</td><td>1</td><td>1.9<sup>a,e</sup></td></tr><tr><td></td><td>4</td><td>7.7<sup>a,e</sup></td></tr></tbody></table>

In the open-ended responses to this question, several recurring themes emerged:

1. Many cited insufficient coverages of complex therapeutic situations (e.g., use of methadone, ketamine, intrathecal pumps, or palliative sedation), as well as a general lack of technical and pharmacological content.

2. Some reported a lack of structured teaching on key areas such as pain management, pediatrics, interdisciplinarity, and ethics.

There are two respondents who consider that the practical training provided over two semesters is not

sufficient. They both mentioned the need for more semesters to improve their practice.

Of the respondents, 28.4% (n = 23) reported having undertaken additional palliative care training since completing the course. Of these, 65.2% (n = 15) had completed a clinical Master in palliative care, 26.1% (n = 6) had attended training days or conferences on the subject, and 8.7% (n = 2) had obtained a university diploma in palliative care (one or two years of multi-professional training). Of the 52 respondents currently working in palliative care, 14 had completed a master's degree, compared to only one out of 26 not working in this field. Among those who found theoretical training

<footnote><sup>a</sup>The sum of the percentages in the sub-category is greater than 100% because a physician may work in several departments at the same time, at different rates.</footnote>

<footnote><sup>b</sup>Percentage out of 34.</footnote>

<footnote><sup>c</sup>Percentage out of 20.</footnote>

<footnote><sup>d</sup>Percentage out of 78.</footnote>

<footnote><sup>e</sup>Percentage out of 52.</footnote>
<table><caption>Table 3
The Impact of the Training Course on the Choice of Exercise</caption><thead><tr><th></th><th>Number of Students (n = 81)</th><th>Percentage % (Out of 81)</th></tr></thead><tbody><tr><td colspan="3"><strong>The type of exercise envisaged before the training was carried out</strong></td></tr><tr><td>Practice only in the initial specialty</td><td>9</td><td>11.1</td></tr><tr><td>Practicing in the initial specialty before practicing in palliative care</td><td>3</td><td>3.7</td></tr><tr><td>Mixed practice (initial specialty and palliative care)</td><td>47</td><td>58</td></tr><tr><td>Practice only in palliative care</td><td>11</td><td>13.6</td></tr><tr><td>Don't know</td><td>11</td><td>13.6</td></tr><tr><td colspan="3"><strong>The type of exercise envisaged after the training was carried out</strong></td></tr><tr><td>Practice only in the initial specialty</td><td>8</td><td>9.9</td></tr><tr><td>Practicing in my initial specialty before practicing in palliative care</td><td>6</td><td>7.4</td></tr><tr><td>Have a mixed practice (initial specialty/palliative care)</td><td>34</td><td>42.0</td></tr><tr><td>Practice only in palliative care</td><td>32</td><td>39.5</td></tr><tr><td>Don't know</td><td>1</td><td>1.2</td></tr><tr><td colspan="3"><strong>Do they think that the training has changed their choice of practice?</strong></td></tr><tr><td>No</td><td>31</td><td>38.3</td></tr><tr><td>Yes</td><td>50</td><td>61.7</td></tr></tbody></table>

insufficient (n = 26), 7 had a master's degree, while 8 out of the 55 who found it satisfactory had also completed one.

## Discussion

This study is the first in France to assess the impact of this new training course on physician practices. This national survey of graduates of the new palliative care training course (Specialized transversal training in palliative medicine) provides key information about their career paths after completing the program. Of the 81 respondents, 52 are currently working in palliative care, with a predominance of possibly shared activities in mobile palliative care consultation service (65.4%) and palliative care units (55.8%). For the remainder, 88.5% incorporate a palliative dimension into their daily practice through overall patient care or, more specifically, the development of care plans or end-of-life support. In total, 42% of respondents completed a fellowship in palliative care and 28.4% (n = 23) reported having taken other palliative care training since completing the program.

The study also highlights the program's influence on professional orientation. Before the training, only 13.6% of respondents were planning to practice exclusively in palliative care, whereas after the training, the proportion increased to 39.5%. Almost all the respondents (97.5%) considered that the practical training was sufficient for their current practice. On the other hand, 32.1% said that the theoretical training did not meet their expectations.

These findings suggest that the training course influenced professional intentions and encouraged greater interest in palliative care, even if not all respondents ultimately pursued exclusive careers in this field. While

it is not possible to directly attribute all career outcomes to the training itself, the program appears to have played an important role in shaping professional perspectives and integrating palliative care into clinical practice.

## Impact on the Career Path

This study shows that palliative care training has significantly impacted their career paths. A retrospective study conducted in 2021 showed that clinical rotations within a specialty positively influenced medical career choices.¹⁵ This has been particularly demonstrated in psychiatry.¹⁶ The fact that the number of graduates wishing to devote themselves exclusively to palliative care almost tripled after the training underlines the major impact of this program in raising the profile and recognition of this medical specialty. However, as the training has only been available for less than six years, it remains unclear whether these physicians will continue to work in this field in the long term. Longitudinal studies conducted in 10–20 years will be necessary to better understand the factors that contribute to retaining professionals in palliative care over time.

In addition, the diversity of the participants' specialties (general medicine, geriatrics, oncology, etc.) makes it possible to understand how palliative care training can be integrated into a variety of career paths. Previous studies have shown that integrating palliative care into the various hospital departments and structures can be difficult. The training of interns from different specialties enables palliative care to be integrated more effectively.¹⁷

## Impact on Disseminating a Palliative Culture

In addition, this study shows that even among those who do not work directly in palliative care, a large
majority integrate palliative principles into their daily practice, illustrating the cross-disciplinary impact of the training. This suggests that the program not only contributes to the development of future specialists, but also plays a key role in disseminating a palliative care culture across the broader medical field. Such diffusion is particularly valuable given the increasing demand for palliative care in all care settings. This finding echoes previous research in pediatrics, where education in palliative and end-of-life care has been shown to improve clinical practice and promote the transmission of acquired knowledge to peers.¹⁸

These results suggest that trainees not only benefit from acquiring core palliative care competencies but also perceive the structure and content of such targeted programs as motivating. This underscores the potential role of well-designed, dedicated training in fostering interest and retention in the field, even in systems without a formal specialty track.

## Opinion on the Training Course

Although the overall perception of the training was positive, a significant proportion of participants felt that the theoretical training could have been better adapted to their current needs. The difficulty is that the desired level of competence varies considerably between students who intend to practice only palliative care and those who will continue in their specialty. This underscores the need to adapt and enhance the educational content to better align with the diverse expectations and clinical needs of future palliative care professionals. Another consideration is the pedagogical approach that could improve skills acquisition. The relevance of simulation in palliative care seems interesting,¹⁹ and a more systematic implementation for students should be envisaged in this training.

## Strengths and Limitations

One of the main strengths of this study is its national scope, which makes it possible to collect representative data on the impact of training across different regions and specialties. The large number of respondents, representing several graduating classes over a four-year period, considerably enhances the reliability and robustness of the results. This temporal perspective is particularly valuable, as it enables us to monitor changes in physicians' professional practices after their initial training. This provides insight into the stability of the professional choices made by graduates, particularly those who have moved into palliative care, and makes it possible to assess the impact of training on the integration of palliative practices in different medical contexts.

However, several limitations need to be considered. First, although the response rate is satisfactory, it does not include all graduates, which may introduce a

selection bias. While this is expected for certain fields such as radiology or medical biology, the absence of surgeons is more surprising, especially given that the relevance of palliative care training for surgeons has been well established in recent years.²⁰ The participants who responded to the survey are perhaps those who feel most concerned or involved in palliative care, which may overestimate the impact of the training. We did not ask about the duration of the training or the number and length of internships, as these elements are determined by the national framework established by the Ministry and are therefore standardized. This represents a limitation of our data, as such information could have provided insights into potential areas for improvement within this framework. The absence of any questions on interdisciplinarity is noteworthy, as this is a core component of palliative care work. Yet, previous studies have shown that the interdisciplinary nature of palliative care training is highly valued by students.²¹ Finally, the lack of in-depth qualitative data limits our understanding of the reasons why some graduates chose not to practice directly in palliative care.

## Conclusion

This study highlights the importance of specialized training in palliative care in the development of physicians' career paths. It shows that training course has not only enabled a significant number of graduates to join palliative care structures, but that it has also encouraged the integration of a palliative dimension into the daily practice of many physicians, including those not working in specialist units.

In view of the growing need for palliative care, this study highlights the importance of improving training for healthcare professionals in this field. The results also call for reflection on how to adjust the theoretical and practical content of training to better meet the expectations and needs of future practitioners, while considering the diversity of the specialties participating in this training course. Respondents identified gaps in the theoretical curriculum, particularly concerning complex therapeutic situations (e.g., methadone, keta mine, and palliative sedation), pharmacological knowl edge, pain management, pediatrics, interdisciplinary work, and ethics. We recommend incorporating more advanced modules and case-based learning to enhance practical relevance. In addition, the curriculum should evolve to include innovative approaches, such as simu lation-based education.

Although this study is grounded in the French context, its findings may be of broader relevance to other countries seeking to expand palliative care education beyond formal specialty tracks.
## Authorship

AE and GL are responsible for study design and manuscript preparation. LC, EPC, VG and GE participated in study design and manuscript preparation. GL is responsible for data analysis. AE and GL act as guarantor and accepts full responsibility for the work and/or conduct of the study, had access to the data and controlled 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 03/21/2024 (reference no. 13032024).

## Data Management and Sharing

Data are available on reasonable request.

## Disclosures and Acknowledgments

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

## References

1. World Health Organization. Framework for countries to achieve an integrated continuum of long-term care. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO https://www.who.int/publications/i/item/9789240038844.

2. Etkind SN, Bone AE, Gomes B, et al. How many people will need palliative care in 2040? Past trends, future projections and implications for services. BMC Med déc 2017;15(1):102.

3. World Health Organization. Palliative care fact sheet. Available at: https://www.who.int/news-room/fact-sheets/detail/palliative-care; Accessed June 5, 2025.

4. Connor S. Global atlas of palliative care. 2nd Edition London, UK; 2020.

5. Kaasa S, Loge JH, Aapro M, et al. Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018;19(11):e588–e653.

6. Knaul FM, Farmer PE, Krakauer EL, et al. Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commissions report. The Lancet 2018;391(10128):1391–1454.

7. Bowden J, Dempsey K, Boyd K, Fallon M, Murray S. Are newly qualified doctors prepared to provide supportive and end-of-life care? A survey of foundation year 1 doctors and consultants. J R Coll Physicians Edinb. 2013;43(1):24-8.

8. Elsner F, Centeno C, Ellershaw J. Early integration needs early education. Palliat Med. 2016;30(9):805-6.

9. Paal P, Brandstötter C, Lorenzl S, Larkin P, Elsner F. Postgraduate palliative care education for all healthcare providers in Europe: results from an EAPC survey. Pall Supp Care 2019;17(5):495-506.

10. Shaw EA, Marshall D, Howard M, et al. A systematic review of postgraduate palliative care curricula. J Palliative Med 2010;13(9):1091-108.

11. World Health Assembly. Strengthening of palliative care as a component of comprehensive care throughout the life course resolution WHA67.19. Available at https://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R19-en.pdf; Accessed June 5, 2025.

12. Natalia Arias-Casais, Eduardo Garralda. Atlas of palliative care in europe 2019. EAPC; 2019. Available at: https://www.hospiz.at/wordpress/wp-content/uploads/2019/07/EAPC-Atlas-2019-final-web.pdf.

13. Ministère de l'éducation nationale. de l'enseignement supérieur et de la recherche. Bulletin officiel 2007. liste et réglementation des DESC Available at https://www.education.gouv.fr/bo/2007/9/MENS0700129A.htm Accessed June 5, 2025.

14. Ministère de l'éducation nationale, de l'enseignement supérieur et de la recherche. Arrêté du 21 avril 2017 relatif aux connaissances, aux compétences et aux maquettes de formation des diplômes d'études spécialisées et fixant la liste de ces diplômes et des options et formations spécialisées transversales du troisième cycle des études de médecine. 2017. Available at: https://www.legifrance.gouv.fr/loda/id/LEGISCTA000036524397. Accessed June 5, 2025.

15. Collins H, Eley C, Kohler G, Morgan H. Foundation rotations in medical training: is it love at first sight? Postgraduate Medical Journal 2022;98(1163):689-693.

16. Appleton A, Singh S, Eady N, Buszewicz M. Why did you choose psychiatry? A qualitative study of psychiatry trainees investigating the impact of psychiatry teaching at medical school on career choice. BMC Psychiatry 2017;17(1):276.

17. Qureshi M, Robinson MC, Sinnarajah A, et al. Reflecting on palliative care integration in Canada: a qualitative report. Curr Oncol 2021;28(4):2753-2762.

18. Postier AC, Wolfe J, Hauser J, et al. Education in palliative and end-of-life care-pediatrics: curriculum use and dissemination. J Pain Sympt Manage 2022;63(3):349-358.

19. Dewhurst F, Howorth K, Billett H, et al. Palliative care simulation for internal medicine trainees: development and pilot study. BMJ Support Palliat Care 2024;14(3):358-364.

20. Bonanno AM, Kiraly LN, Siegel TR, Brasel KJ, Cook MR. Surgical palliative care training in general surgery residency: an educational needs assessment. Am J Surg 2019;217(5):928-931.

21. Gierach M, Brechtelsbauer D, Serfling J, et al. Students practicing interprofessional collaboration in the context of hospice and palliative care. Am J Hosp Palliat Care 2020;37(12):1062-1067.
# Supplementary material 1: Questionnaire: What happens to interns who have completed the FST in palliative medicine (Specialized Transversal Training in palliative medicine)?

## Introduction

Hello everyone,

Since 2019, medical interns from all specialties in France have been offered the opportunity to complete a transversal specialized training course in palliative medicine.

You are one of the four graduating classes.

We are interested in your future as part of a thesis for your FST in palliative medicine.

Thank you in advance for answering this questionnaire.

There are 36 questions in this questionnaire.

### Part 1: Your identity

Question 1: Name: *

Please enter your answer here:

Question 2: First name: *

Please enter your answer here:

Question 3: What is your e-mail address? *

Please enter your answer here:

Question 4: Have you completed your internship (including Junior Doctor semesters)?

Please select only one of the following:

YES

NO

*You can complete all of the following questions only if: The answer was 'YES' to question '4 (Have you completed your internship (including Junior Doctor semesters))?*

### Part 2: Your internship

These questions aim to define your internship experience

Question 5: Year of ECN: *

Please select only one of the following:

<table><tr><td>2012</td><td>2013</td><td>2014</td><td>2015</td><td>2016</td><td>2017</td><td>2018</td></tr><tr><td>2019</td><td>2020</td><td>2021</td><td>2022</td><td>2023</td><td></td><td></td></tr></table>

### Question 6: Specialty DES *

Please select an answer below

<table><tr><td>Allergology</td><td>Pathological anatomy and cytology</td><td>Anesthesia and Intensive Care</td></tr><tr><td>Medical biology</td><td>Maxillofacial Surgery</td><td>Oral Surgery</td></tr><tr><td>Orthopedic Surgery</td><td>Pediatric Surgery</td><td>Plastic Surgery</td></tr><tr><td>Thoracic Surgery</td><td>Vascular Surgery</td><td>Visceral Surgery</td></tr><tr><td>Dermatology</td><td>Endocrinology</td><td>Medical genetics</td></tr><tr><td>Geriatrics</td><td>Gynaecology-Medical</td><td>Gynaecology-Obstetrics</td></tr><tr><td>Hematology</td><td>Hepato-gastro-enterology</td><td>Cardio-vascular medicine</td></tr><tr><td>Emergency Medicine</td><td>General Medicine</td><td>Intensive care medicine</td></tr><tr><td>Internal Medicine</td><td>Forensic medicine</td><td>Nuclear Medicine</td></tr><tr><td>Physical medicine and rehabilitation</td><td></td><td>Occupational medicine</td></tr><tr><td>Vascular medicine</td><td>Nephrology</td><td>Neurosurgery</td></tr><tr><td>Neurology</td><td>Oncology</td><td>Ophthalmology</td></tr><tr><td>Ophthalmology</td><td>Pediatrics</td><td>Pneumology</td></tr><tr><td>Psychiatry</td><td>Radiology</td><td>Rheumatology</td></tr><tr><td>Urology</td><td></td><td></td></tr></table>

### Question 7: Subdivision (town) in which the DES is produced: *

Please select only one of the following:

<table><tr><td>Amiens – Angers</td><td>Antilles-Guyane” Besançon</td><td>Bordeaux</td></tr><tr><td>Brest</td><td>Caen</td><td>Clermont-Ferrand</td></tr><tr><td>Dijon</td><td>Grenoble</td><td>Lille</td></tr><tr><td>Limoges</td><td>Lyon</td><td>Marseille</td></tr><tr><td>Montpellier-Nimes</td><td>Nancy</td><td>Nantes</td></tr><tr><td>Nice</td><td>Indian Ocean</td><td>Paris</td></tr><tr><td>Poitiers</td><td>Reims</td><td>Rennes</td></tr><tr><td>Rouen</td><td>Saint-Etienne</td><td>Strasbourg</td></tr><tr><td>Toulouse</td><td>Tours</td><td></td></tr></table>
Question 8: Promotion of FST palliative medicine: (Year of dissertation completion) *

Please select only one of the following:

<table><tr><td>I did my FST over several years</td><td>2019-2020</td><td>2020-2021</td></tr><tr><td>2021-2022</td><td>2022-2023</td><td></td></tr></table>

Question 9: If validation of the FST over several years: *

Add a comment only if you select the answer.

Please select all that apply and leave a comment:

<table><tr><td>Year of dissertation</td><td>Year of theoretical courses</td><td>Year of internship</td></tr></table>

Question 10: Are you a graduate? *

Please select only one of the following:

YES

NO

Answer the next question only if the following conditions are met: The answer was 'YES' to question '10 [Q8]' (Are you a PhD student?)

Question 11: In which year did you complete your thesis? *

Please select only one of the following:

<table><tr><td>2016</td><td>2017</td><td>2018</td><td>2019</td><td>2020</td></tr><tr><td>2021</td><td>2022</td><td>2023</td><td>2024</td><td></td></tr></table>

Answer the next question only if the following conditions are met:

The answer was 'YES' to question '10 [Q8]' (Are you a PhD student?)

Question 12: Was your thesis related to palliative care? *

Please select only one of the following:

YES

NO

Answer the next question only if the following conditions are met: The answer was 'YES' to question '12 [Q10]' (Was your thesis topic related to palliative care?)

Question 13: If YES, what was your thesis subject? *

Please enter your answer here:

Part 3: Your ideals when you enrolled at FST

Question 14: What type of practice did you hope to achieve when you enrolled at FST? *

Please select all that apply:

Practice only in my original DES

Practice in my original DES for a few years before considering palliative medicine

Mixed practice in my original DES + palliative medicine

Practice only in palliative medicine

Did not know

Other

Question 15: Please write your answer here if you selected Other:

Part 4: Where are you today?

Question 16: Have you completed a post-internship specialized in palliative care? Specialized assistant or head of a university-assisted hospital clinic (CCA)? *

Please select only one of the following:

YES

NO

Answer the next question only if the following conditions are met: The answer was 'YES' to question '16 [Q14]' (Have you completed a post-internship specialized in palliative care: Specialized assistant or chief of clinic of the universities-assistants des hopitaux (CCA)?)

Question 17: If YES, in what type of structure and at what percentage of time? *

Add a comment only if you select the answer.

Please select all that apply and leave a comment:

USP (Palliative Care Unit)

EMSP (Mobile Palliative Care Consultation Service)

LISP (Palliative Care Identified Beds)

HDJ (Day Hospital) Palliative Care

Palliative care consultations

Cellule d'animation régionale de Soins Palliatifs (Palliative care regional coordination unit)

HAD (Hospitalisation à Domicile) for palliative care or with a palliative care network
Question 18: Have you worked in a palliative care facility in any capacity other than assistant clinical supervisor (CCA) or assistant? *

Please select only one of the following:

YES \NO

Answer the next question only if the following conditions are met: The answer was 'YES' to question '18 [Q16]' (Have you worked in a palliative care facility in a capacity other than assistant clinical director (CCA) or assistant?)

Question 19: If YES, in what type of structure and at what percentage of time? *

Add a comment only if you select the answer.

Please select all that apply and leave a comment:

USP (Palliative Care Unit)

EMSP (Mobile Palliative Care Consultation Service)

LISP (Palliative Care Identified Beds)

HDJ (Day Hospital) Palliative Care

Palliative Care Consultations

Cellule d'animation régionale de Soins Palliatifs (Palliative care regional coordination unit)

HAD (Hospitalisation à Domicile) for palliative care or with a palliative care network

Question 20: What is your current professional status? *

Please select only one of the following:

CCA

Assistant Specialist

CHP / Temporary employee

PH / Center practitioner / Permanent employee

Self-employed (replacement or established)

Mixed (salaried and self-employed)

No practice

Other

Answer the next question only if the following conditions are met: The answer was 'CCA' or 'Assistant Specialist' or 'PHC / Salaried on fixed-term contract' or 'PH / Center practitioner / Salaried on permanent contract' or 'Liberal (Replacement or installed)' or 'Mixed (salaried and liberal)' or 'Other' to question '20 [Q18]' (What is your current professional status?)

Question 21: If you are currently practising, what percentage of your time do you work? *

Please select only one of the following:

<table><tr><td>100%</td><td>90%</td><td>80%</td><td>70%</td><td>60%</td><td>50%</td></tr><tr><td>40%</td><td>30%</td><td>20%</td><td>10%</td><td>Other</td><td></td></tr></table>

NB: For CCAs, enter 100%.

Example: I work as a private practitioner 3 days a week, with half a day corresponding to 10%, giving me a practice quota of 60%.

Answer the next question only if the following conditions are met: The answer was 'CCA' or 'Assistant Specialist' or 'PHC / Salaried on fixed-term contract' or 'PH / Centre Practitioner / Salaried on permanent contract' or 'Liberal (Replacement or Installed)' or 'Mixed (salaried and liberal)' or 'Other' to question '20 [Q18]' (What is your current professional status?)

Question 22: If you are currently practising, do you work in a palliative care facility? *

Please select only one of the following:

YES \NO

Answer the next question only if the following conditions are met: The answer was 'YES' to question '22 [Q20]' (If you are currently practising, are you practising in a palliative care facility?) Add a comment only if you select the answer.

Question 23: If YES, in which type of facility, and at what percentage of time? *

Please select all that apply and leave a comment:

USP (Palliative Care Unit)

EMSP (Mobile Palliative Care Consultation Service)

LISP (Lits Identifié Soins Palliatifs)

HDJ (Day Hospital) Palliative Care

Palliative care consultations

Cellule d'animation régionale de Soins Palliatifs (Palliative care regional coordination unit)

HAD (Hospitalisation à Domicile) for palliative care or with a palliative care network

Other:

Answer the next question only if the following conditions are met: The answer was 'NO' to question '22 [Q20]' (If you are currently practising, do you practice in a palliative care facility?)
Question 24: If NO, do you have a palliative care perspective/acculturation in your medical practice? *

Please select only one of the following:

YES NO

Answer the next question only if the following conditions are met: The answer was 'YES' to question '24 [Q22]' (If NO, do you have a palliative care outlook / acculturation in your medical practice?)

Question 25: If YES, in a few words, describe your practice: *

Please write your answer here:

Answer this question only if the following conditions are met: The answer was 'NO' to question '24 [Q22]' (If NO, do you have a palliative care outlook / acculturation in your medical practice?)

Question 26: If NO, would you like to work in such a facility on a full-time or part-time basis within the next 5 years? *

Please select only one of the following:

YES NO

Part 5: What impact did the FST have on your career?

Question 27: Has the completion of the FST modified the direction of your project and your future professional practice? *

Please select only one of the following:

YES NO

Answer the next question only if the following conditions are met: The answer was 'YES' to question '27 [Q25]' (Did the completion of the TSP change the direction of your project and your future professional practice?).

Question 28: If YES, how? *

Please write your answer here:

Question 29: What type of practice would you like to have, now that you have completed the FST in palliative medicine? *

Please select all that apply:

Practice only in my original DES

Practice in my original DES for a few years before considering palliative medicine

Mixed practice in my original DES + palliative medicine

Practice only in palliative medicine

Don't know

Other

Answer this question only if the following conditions are met: The answer was 'Other' to question '29 [Q26bis]' (What type of practice would you like to have, now that you have completed the palliative medicine FST?).

Question 30: Question Other: (Please specify) *

Please write your answer here:

Part 6: Your opinion on the theoretical and practical training:

Question 31: Did the four seminars of theoretical training meet your needs for your current practice? *

Please select only one of the following:

YES NO

Answer the next question only if the following conditions are met: The answer was 'NO' to question '31 [Q27]' (Did the theoretical training of four seminars meet your needs for your current practice?).

Question 32: If NO, why not?

Please enter your answer here:

Question 33: Did the two-semester practical training in a specialized palliative care facility meet your expectations for your current practice? *

Please select only one of the following:

YES NO

Answer the next question only if the following conditions are met: The answer was 'NO' to question '33 [Q29]' (Did the two-semester practical training in a specialized palliative care facility meet your expectations for your current practice?).
Question 34: If NO, why not? *

Please write your answer here:

Question 35: Since the FST, have you received any other training in palliative care? *

Please select only one of the following:

YES

NO

Answer the next question only if the following conditions are met: The answer was 'YES' to question '35 [Q31]' (Since the FST, have you received any other training in palliative care?)

Question 36: If YES, which one(s)? *

Please write your answer here:

Thank you for taking the time to answer this questionnaire, which was aimed at people who had completed their internship.