Digital Palliative Care Curriculum Improves Knowledge, Skills, and Opioid Prescribing Behavior

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A new electronic curriculum delivered via e-mail with push technology may provide an efficient, cost-effective solution to the shortage of palliative care faculty serving the nation’s oncology fellowship programs. According to data presented at the 2017 Palliative and Supportive Care in Oncology Symposium,1 the online learning training program improved oncology fellows’ primary palliative care knowledge, regardless of the timing of the training. More importantly, the 5-year project, funded by the National Cancer Institute, demonstrated a positive change in prescribing behavior once fellows entered practice. 

In my view, this is the leading edge of education research.
— Charles F. von Gunten, MD, PhD

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“We’ve shown that this curriculum, disseminated electronically to any fellowship program, can give oncologists the knowledge they need,” said Charles F. von Gunten, MD, PhD, a hospice and palliative medicine specialist, in Columbus, Ohio. “This study also represents an example of measuring behavior in practice in the year after fellowship as an educational outcome. In my view, this is the leading edge of education research.”

Although ASCO has stated that palliative care should be a standard part of all oncologists’ practice, as Dr. von Gunten reported, Program Directors of Oncology Fellowships cite lack of adequate faculty as a barrier to teaching these skills to oncology fellows.

“The directors agree that palliative care needs to be taught, but they just don’t have the faculty to teach it,” he explained. “In order to provide oncologists with basic skills in palliative care, we partnered with ASCO and its Quality Training Program directors to develop, evaluate, and disseminate a palliative care curriculum using an innovative format.”

Spaced Education Curriculum

For this study, investigators randomized all of the fellows in a program as a single group to one of three cohorts. In the first cohort, all fellows received two multiple-choice questions (on their phones or other devices) focused on a particular teaching point, every other day over the course of 12 months. In the second cohort, fellows also participated in a clinical rotation with a palliative care program. In the third cohort, fellows received the same training as the first cohort but delayed by 1 year (beginning in fellowship year 2). Palliative care knowledge was assessed during the in-training exam pre- and postintervention, and opioid prescribing behavior was tracked during the year after graduation and compared with a control group.

Dr. von Gunten elaborated on the spaced education curriculum, which delivers “teaching bites” of information over intervals of time to increase long-term retention.

“We developed a series of clinical vignettes, videos, and multiple-choice questions based on a comprehensive grid of what oncologists need to know,” he explained. “Fellows could answer questions on their smart phones as they were waiting for the elevator or on their computers between patient visits. If the question was answered incorrectly, focused educational material was forwarded to the learner, and the testing point was retested at a later date.”

Test-Based Knowledge and Prescribing Behavior Improved

As Dr. von Gunten reported, a total of 283 fellows from 71 programs were randomized for the study, and the average score on posttest examination was between 73% and 75% correct across all groups and all years. Furthermore, the addition of a 4-week palliative care rotation did not improve outcomes beyond the online training.

“These scores were better than the average of a national sample of internal medicine faculty, so clearly, this intervention worked in delivering test-based knowledge to oncology fellows,” said Dr. von Gunten. 

More important, however, investigators also looked at opioid prescribing behavior in the year after training to analyze the long-term impact of the digital curriculum. 

“Most of us have experienced testing at the knowledge level, but an educational curriculum generally doesn’t look at what we do when no one else is watching,” said Dr. von Gunten.


  • In a study of oncology fellows, spaced education via a handheld device improved knowledge of primary palliative care.
  • Opioid prescribing behavior also improved as a result of the education intervention. 
  • The addition of a 4-week palliative care rotation did not improve outcomes beyond the online training.

According to prescribing data obtained from National Provider Identifier numbers, 72% of fellows who had just completed the online training program prescribed opioids correctly (ie, always prescribed a long-acting opioid with a short-acting agent). For fellows randomized to the delayed curriculum, prescribing behaviors were the same, at 72%. The historical control of oncology fellows now in practice who had never been exposed to this curriculum, however, showed that less than half (46%) were prescribing opioids correctly.

“This was basically a 50% improvement, and the results were highly statistically significant,” said Dr. von Gunten, who underscored the importance of behavioral analysis in education research. “We’re no longer ‘teaching to the test,’ as many of us remember. Rather, it’s about changing people’s practice in a routine way, and I think these exciting results will pave the way for other measures of behavior in practice after an educational intervention.”

Importance of Primary Palliative Care

Joseph Greer, PhD, Program Director of the Center for Psychiatric Oncology & Behavioral Sciences at the Massachusetts General Hospital Cancer Center, underscored the critical role that training will play in bringing palliative care to a greater number of patients in need.2 

Given staffing limitations, training in primary palliative care is essential to ensure that patients who have serious illnesses like cancer do receive the comprehensive supportive care that they need.
— Joseph Greer, PhD

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“Given staffing limitations, training in primary palliative care is essential to ensure that patients who have serious illnesses like cancer do receive the comprehensive supportive care that they need, and the fellowship training time is an ideal moment for developing those skills and delivering palliative care in a supervised environment,” said Dr. Greer. “This study had a number of innovative aspects with respect to push online learning and the method of spaced testing, as well as the fact that they didn’t just test knowledge or skills but also looked at behavioral practices.”

“We need innovative and scalable models for delivering concurrent palliative and oncology care,” Dr. Greer concluded. “This is a promising approach for improving clinician knowledge, skills, and behavior.”

Fellowship programs will be able to access this palliative care curriculum for training in ASCO University (, the authors noted. ■

DISCLOSURE: Dr. von Gunten is a consultant for AstraZeneca and is on the speakers bureau for Salix. Dr. Greer has received research funding from Pfizer.


1. von Gunten CF, Periyakoil V, Brown A, et al: Integration of palliative care into oncology: A curriculum development project. 2017 Palliative and Supportive Care in Oncology Symposium. Abstract 202. Presented October 27, 2017.

2. Greer J: Discussion. 2017 Palliative and Supportive Care in Oncology Symposium. Presented October 27, 2017.