Knowledge in PC is essential for the doctor, because the general practitioner will take care of patients facing terminality in the daily practice. Several recommendations have already been made with the intention of standardizing PC teaching in undergraduate courses [8,9,18-23]. In general, all of them recommend an approach to pain management and other uncomfortable symptoms, a psychosocial and spiritual approach, bioethics, communication and teamwork. It is known that teaching activities should present theoretical and practical content in an integrated manner throughout the entire undergraduate course, with a focus on basic actions [3]. EAPC was innovative and proposed teaching through competencies [8,9].
It is necessary to assess the learning of PC in medical graduation. One way of doing this would be to assess the acquisition of competencies throughout the training, so that learning could be measured and qualified. The authors found that there was no instrument to measure the acquisition of PC competencies among medical students. In this way, an effort was devoted to building and validating the Palliative Competency Tool in this version 1, which has the characteristic of being self-applicable and requiring less than 30 minutes to be completed.
Building and validating the research instrument was a challenging experience. The inserted content should be based on consistent scientific literature and demanded research time from the authors. However, the competencies required for basic palliative care are broad and numerous, and the degree of depth of the approach in medical training has rarely been described in the literature [24,25].
It was decided to approach the competencies in the most direct way possible, avoiding hindering students' understanding. As the student answered the degree of agreement with each item, allowing a neutral response, the authors believe that the items that may have generated doubts had a response tending to neutral. It is known that the competencies used in this research have been described for several professions, including medicine [8,9], and in this way, some competencies had greater depth than others [26]. The researchers were careful to take these characteristics into the development, as well as the experts in the content validation were oriented to this fact.
The process of constructing the tool was a quite challenging, since the intention was that a set of statements would represent a competence, without interfering with the others and, at the same time, have the discriminative power, that is, the ability to assess whether the student showed whether or not knowledge, avoiding random success (because it is very easy) or error (very difficult) and, even, that it had appropriate language for the student. The content validation step with the specialists was essential to make the instrument suitable for what was proposed and the Delphi methodology, which is one technique that consists of the evaluation of a material by specialists, proved to be adequate for the proposed objective [10-13].
In order to Delphi methodology allow better results, the experts' choice was judicious, as their opinion guided the instrument. The experts' experience was defined by their degree and working time, as both knowledge in PC, clinical experience and teaching were fundamental. It was interesting to note that in the second stage, most items were already approved. As there was a need to follow the rules previously established, another step occurred, with the incorporation of corrections, which curiously reduced the score of isolated items, without compromising the final approval in the third step. The inclusion of the experts' suggestions, which had proven scientific suitability, is subject to personal perception.
The sample of students was chosen due to the feasibility and the need for a heterogeneous sample for validation. At the time of data collection, students were at the end of the academic semester and less than 25% studied PC, resulting in four competencies with insufficient performance, demonstrating that the acquisition of competencies could still improve. The purpose of this description was to build and validate the instrument and, therefore, this discussion is not part of the material and may not reflect the course as a whole.
The study of the instrument's internal reliability and consistency was assessed using Cronbach's alpha index, and it was considered adequate between 0.6 and 0.95.14- 16 The correlation found in this study (= 0.7) may be better with the application in a larger population, as in the entire medical course. However, massive application would only be justified if we had confirmation of the validation of the questionnaire. The statistical validation of the research tool was satisfactory.
The competencies described by the EAPC [8,9] are broad and sometimes overlaping. Such overlap may have hindered the validation, since the competencies are mixed in the writing of the questionnaire items. A review will be valid; however, it is assumed that it is almost impossible to isolate each competence in just one item and would be inconsistent with the assistance reality.
It should be remembered that competency education was defined by the process of acquiring knowledge, skills and attitudes that belong to a specific professional area.2 In this context, teachers are concerned with how to teach competencies, correct and evaluate this acquisition. Measuring the acquisition of competencies is challenging, but a necessary effort to improve medical education. From this instrument, the process of acquiring competencies can be evaluated and better targeted.
The PC education in Brazil are still insufficient. Out of 300 registered courses, only 14 offer them regularly [27]. In Europe, of the 53 countries recognized, 65% teach PC in medical school, and 30% in all schools as a compulsory subject [28]. However, Centeno and Rodrigues Núñez [29] reported the weakness of studies in medical education and affirmed the need to better structure education to promote medical but favourable attitudes towards end-of-life care. In the United States, PC education has been taking place for over fourth years, with variation among medical schools and it is estimated that over 90% of students were affected by the content [24,30].
This study has limitations. In order to study the process of acquiring competencies, it is necessary to expand the sample and include all students of the course and also apply the instrument prospectively. The authors have already started the prospective study in two years and we will have more answers. The study was entirely carried out in Brazil and the choice was due to the feasibility of the research, but it can bring cultural limitations. In the future, it will be interesting to validate and adapt culturally in other contexts. The intention was to create a toll that would allow to qualify PC teaching and compare it over time. Therefore, it can be said that the data obtained can be treated as a “diagnosis” of PC teaching [5] and should not be interpreted individually or for the purpose of classificatory assessment.