By Dr Noreen Chan,

Head & Senior Consultant, Division of Palliative Care,

National University Cancer Institute, Singapore (NCIS)

World Hospice and Palliative Care Day falls in October each year, which would explain the increased number of newspaper articles, radio segments and public activities from late September to early November. All of which is important and necessary of course. But if the positive publicity was so compelling that everyone started asking for Palliative care, our specialist services would not be able to cope with the demand. There are, after all, so very few of us. And to quote Dr Chong Poh Heng of HCA Hospice Care, "This little group of us cannot look after all the people who are dying in Singapore, and we need to engage the society at large."


That engagement includes not only awareness building, but also education. Of the public, patients and their families, and healthcare professionals. About what palliative care is, and is not, who could benefit, and what we can do, individually and as a community, to support people living and dying with chronic progressive illness. My colleagues from Taiwan and Hong Kong have commented about the dearth of “death education” in Singapore, and the paucity of national conversations about the one thing that all of us will face one day.


But we can all start somewhere, and undergraduate medical education is as good a place as any. It may surprise readers to know that Palliative Medicine has been part of the undergraduate medical curriculum of the NUS medical school since 2002, when it started as a modest one-day posting. It reached its present 4-day form in 2010, as part of the Family Medicine posting. More information about its evolution can be found in a special issue of the Singapore Medical Association (SMA) News Dying Well.

When and what

When and how to teach Palliative care to medical undergraduates, depends on when in their five-year training we receive them, and what we would expect them to learn. That in turn is related to what is expected of graduating doctors, and their role in the Singapore healthcare system.


As the Palliative Medicine posting occurs in the third year in NUS, when students are having their first intensive exposure to patients and to clinical care, the approach is to build awareness and foundational knowledge. It is expected that they will continue to acquire skills and understanding during their postgraduate years, as part of lifelong learning.


In contrast, I learned from a colleague at a medical school in Malaysia that a short time after graduation many doctors will be working independently in district hospitals or clinics, so the training at university emphasises practical aspects such as the use of opioids.


There is a lot about Palliative care education in cyberspace, including excellent websites like PCC4U (Palliative Care Curriculum for Undergraduates), so the problem is not a shortage of information. Rather, it is the quality and quantity of information, and how to apply that knowledge to practice. So the teacher’s role is to “curate” the information sources, stimulate students to think about what matters to patients, guide them to apply the palliative approach, and encourage self-reflection.

Exposure to “daily practice” and interacting with patients and healthcare teams, is essential for students to appreciate the realities of Palliative care. This is a bit of a doubled-edged sword, because exposure to suffering in all its harsh aspects, witnessing pain, loss and all the emotions that come with it, can bring up uncomfortable emotions. But that is part of the learning too; understanding ourselves and our responses, helps us in our personal growth, and enables us to better support patients and families going through difficult times.


The hidden curriculum

There is a significant amount of learning that takes place outside formal teaching activities, and this is sometimes called the “hidden curriculum”. Education, in many respects, is a form of socialisation, and it is said the hidden or informal curriculum is where beliefs, values and certain behaviours are transmitted, which learners absorb as they become part of the profession culture.


Students will observe what their teachers and seniors say and do, so we are all role models for everyone around us. Not only modelling positive or desirable behaviour e.g. good hand hygiene, but also pointing out the behavior – “let’s all stop and use the hand-rub before we approach the patient” – can be a powerful teaching tool. By the same token, there can be negative role models, such that the students might think “my goodness I should avoid being like that”.


The teachers

Students will encounter many teachers during their undergraduate and postgraduate training, and some of the most important teachers in this respect will be the patients. Medical students have more time to spend with patients and get to know them as people, so it is not surprising that their stories may have a lasting impression.


What about doctors as teachers, why do we do it? Some are passionate about it, others are naturally gifted teachers, yet others see it a way of paying forward the guidance they received from their seniors. There is something about teaching that also forces the teacher to learn as well, to reflect on what is to be taught, on how to connect with the learners and to light the spark within them.>/p>


For myself, it is also a way to see my field of practice through fresh eyes, and to understand my students’ aspirations, hopes and worldview. Palliative care is ultimately about caring for people (not merely their diseases or organ systems), and as long as students appreciate our shared humanity and the ethical duty to respond to suffering in all its forms, and recognise that everyone has the power to make a difference… then I would have done my job as a teacher.




 Love, Teach and Be Gentle

A person will not attain Knowledge
Unless he seeks refuge with God
From the crudeness of distraction
And from an ignorance so blind
That he makes much of the little that he sees in himself
And belittles the much and great which is in others,
And admires himself for that self-conceit,
Which God would never approve.

But it is good for one who has knowledge
And is seeking
That he should learn whatever he does not know,
And teach others what he knows already,
And deal gently with those of weak intelligence,
And neither be made conceited by the stupidity of the stupid

Not harshly rebuke one who is dull of understanding.
Such were you were before, but God has been gracious to you.