This questionnaire-based study provides further evidence of both medical students' limited confidence in dealing with palliative care issues, and in general, their limited knowledge in the field of palliative care at universities that do not provide a comprehensive mandatory curriculum. This study innovatively combines self-assessment, a knowledge-based examination, and the students' perspective on curricular developments at the advent of legislative changes in Germany that will include mandatory undergraduate palliative care teaching.
Medical students self-reflected on their own incapacities in all relevant fields of palliative care (first part of the questionnaire), and immediately provided a proof of concept with their low scores in the second part of the questionnaire, where knowledge on palliative care issues was required. Only the self-assessment on pain therapy was more positive than on other subjects. However, the scores achieved on the pain - related MCQs did not accordingly correspond with the students' assessments. Interestingly, pharmacology of pain therapy was an integral part of the curriculum at both study sites shortly before the final year began.
The degree of confidence with respect to psychosocial issues was shown to be extraordinarily low; 80% of the medical students stated that they were "rather non confident" or "non confident" with respect to the accompaniment of severely ill or dying patients, and 57% with respect to communication in the palliative care setting. Seventy - three percent were "rather non confident" or "non confident" regarding all questions addressing psychosocial issues.
The weighing of ethical problems also proved to be deficient (MCQ # 15); this also referred to the understanding of common and basic treatment modalities, such as refraining from IV volume substitution or terminating artificial ventilation, that have been commonly misunderstood as illegal euthanasia. It remains speculative whether the mandatory courses in medical ethics shortly before the final year begins contributed to a relatively better score at the Göttingen study site. In a previous study six years earlier which explored medical students' attitudes towards ethical decision making, the problem of misunderstanding the term euthanasia proved to be even more prominent (32% with respect to terminating IV hydration; 46% with respect to discontinuing artificial ventilation) . This misunderstanding appears to be even more problematic in the light of current discussions about legalizing end-of-life practices like physician - assisted suicide or even euthanasia in Germany.
Spiritual care proved to be a major obstacle, as only a sixth of the study participants felt confident in this area.
A lack of confidence and knowledge in palliative care is not limited to German medical students. The "Palliative Care Examination", a test that served as a draft for the second part of our questionnaire, was performed on 32 first year interns in US hospitals (44% correct answers), and residents and attending doctors (58% correct answers). The questions concerning pain assessment and management were scored correctly in 46% and 57%, respectively . In another study, 39% of medical students denied being well prepared to talk with patients about their anxious thoughts and death . Fraser et al. questioned senior medical students of six medical schools concerning their education in palliative care, only 50% felt sufficiently prepared to treat common end - of - life symptoms or to communicate adequately in this setting (34%) .
The vast majority of our study participants (> 90%) would welcome the implementation of mandatory courses in palliative care. This finding is quite remarkable, as in June 2010, the Medizinische Fakultätentag der Bundesrepublik Deutschland declined to take a stand in favor of a mandatory implementation of palliative care into the undergraduate curriculum, as such a regulation would be superfluous; palliative care would be already covered by curricular legislation, and medical schools were already authorized to implement courses "on demand" [press release 4.6.2009, http://idw-online.de/pages/de/news318654; accessed 14.6.2010].
A recently published study of United States medical schools suggests a similar situation. A minority of US medical schools, from which information was obtained, required formal training in palliative care and evaluated students in their care of patients with advanced, incurable conditions. The majority chose to include palliative care topics within existing courses . While the British General Medical Council has clearly recommended that all medical students should receive core teaching on relieving pain and distress, and in caring for the terminally ill, surveys have shown that the palliative care curriculum provided by British medical schools varies widely, ranging from 6 to 100 hours . In a comparative study published in 2007, 85% of final - year British students, but only 25% of US students, reported having taken a course or clinical rotation in end-of-life care . Whereas the optimal structure and content of formal palliative care teaching is still a matter of debate [20, 21], several studies have described the positive effects of such mandatory teaching [22, 23]. Due to the new legislation, undergraduate palliative care education in Germany will undergo significant changes during the next three years. This process provides a unique opportunity to evaluate the impact of a new mandatory curriculum for all German medical schools. Our study gives a snap-shot of the current situation and provides a convenient instrument which can be repeated during and after the implementation process.
The response rate of 31% (Mainz 49%, Göttingen 14%) was rather low, especially at the Göttingen study site, despite several efforts to improve recruitment. Therefore, scoring differences between the two study sites cannot easily lead back to differences between the two existing curricula, and results cannot be considered to be representative of all medical students in Germany. Considering the possibility that rather motivated students responded, it is possible that scores would have been even more disappointing if the overall response rate had been higher. Furthermore, a biased response behavior towards desired answers in the third part of the questionnaire cannot be excluded.