Nordic Specialist Course in Palliative Medicine: Evaluation and Impact on the Development of Palliative Medicine in the Nordic Countries: A Survey among Participants from Seven Courses 2003–2017

Background: The ﬁve Nordic Associations for palliative medicine (PM) have since 2003 organized a common specialist course for six weeks in two years. Aim: To describe the course: participants, evaluations, impact on participants’ careers, and on the development of PM in the Nordic countries. Methods: Information on participants taken from the course archive and national registries. A web survey sent to graduates from the courses 2003–2013 ( n = 150) and 2013–2017 ( n = 72). Results: Mean age at course start was 46.9 years; 66% were women. Mean overall evaluation score 5.7 (range 5.4–6.0, max 7.0). Survey response rate 84% ( n = 186); 80% of respondents were working in PM, the majority as leaders, > 90% engaged in teaching PM. About 40% were active in PM associations, lobbying, and guideline development. Conclusion: The Nordic Specialist Course in PM has had a profound impact on the participants’ postcourse careers, inﬂuencing the development of PM in the Nordic countries.


Introduction
T he Nordic countries are one of the world's most in- tegrated regions, comprising Denmark, Finland, Iceland, Norway, and Sweden. 1 These countries, with a total population of *27 million people, 2 have a mutual cultural heritage and language origin (except Finland), and a long tradition of co-operation around diverse issues. 3ound the millennium, recommendations published in official reports led to an increasing number of palliative care (PC) programs being established in the Nordic countries. 4,5However, no specialist education in palliative medicine (PM) was available in any of the countries, nor was there any interest for such an education within the medical community.In 2003, PM pioneers from the five countries together launched the Nordic Specialist Course in Palliative Medicine (NSCPM) to meet the increasing need for education in this new medical field. 6,7uring the period 2007-2015, PM was recognized as a formal competence field or add-on specialty in each of the five Nordic countries. 8Even so, the number of physicians with education and experience in the field was still limited, and the NSCPM still needed.The aim of this article is to describe the course, participation and evaluation over time, and to assess the impact of this educational program on the participants' professional career and on the development of PM in the Nordic countries.

The NSCPM
The first course 2003-2005 has previously been described. 6The course is still organized in six week-long modules for two years.Participants must be approved in a relevant medical specialty and work in PC.Language throughout the course is English.To obtain the course diploma, the participants must attend all modules, complete and present a limited research project, pass an assignment after each module, and pass the final written examination. 7ach course is planned for 38 participants; allocated places per country are based on population size.The budget is covered by students' course fees.A Steering Group with representatives from the Associations for PM in the five countries is responsible for organizing and administering the course pro bono.The course has a website: www.nscpm.org

Course contents and changes made over the years
0][11] The content has largely remained unchanged, but with increasing emphasis on decision making and PC in nonmalignant diseases, in line with the international development in PM.Pediatric PC was added for the seventh course. 7The educational approach is based on adult learning theory, 12 with ample time for group work and plenary discussions.Learning methods range from self-study to role plays and creative activities.

Course participants
Information on participants was obtained from the course archive.National registries were searched to find the number of participants who had obtained formal approval in PM.

Course evaluation
In addition to oral group evaluations, the participants hand in anonymous written evaluations of all teachers/facilitators and complete SETh Long Course Rating Scale at the end of each module. 13The SETh scale covers precourse material, course content, ambiance, course style, and presentation, and the end of the course, and is scored on a 1-7 numerical rating scale, with 7 as the highest score.

Web-based surveys
During the first five courses (2003-2013), 153 participants completed all modules and passed the examination.A webbased survey by use of SurveyMonkey 14 was sent in 2014 to this group except three participants from course 4, who had not completed their course projects (n = 150).The same questionnaire was in 2017 sent to participants of the two courses 2013-2017 (n = 72) (Table 1).The questionnaire was composed by the authors (Supplementary Appendix SA1).Informed consent was implied when answering.No ethical committee or institutional review board approval was needed.Survey data were analyzed with descriptive statistics using SPSS version 22. 15

Course participants
Altogether, 225 physicians from the first seven NSCPM completed all modules and passed the examination.There were 16 dropouts (7%).Three students did not complete their projects and, therefore, did not receive the course diploma.Only participants who completed the course (completed all modules and passed the examination) are included.M = male; F = female.Participants from Faroe Islands and Greenland were included in the Danish group.Participants of five other nationalities were placed with their country of residence.
a Six respondents in survey 1 did not answer which course they had attended.b Three participants did not complete their course projects and were not included in the survey.

NORDIC SPECIALIST COURSE IN PALLIATIVE MEDICINE
The number of participants per country, gender, and mean age at course start are shown in Table 1.Table 2 shows the proportion of NSCPM graduates among the physicians formally approved in PM in the Nordic countries.

Course evaluation
Based on the SETh Long Course Rating Scale, the mean overall score for the seven courses was 5.7, range 5.4-6.0,slightly improving over time.
Web-based surveys Demographic information.The questionnaire was sent to 222 students in two rounds; total response rate 84% (n = 186; 126 + 60, Table 1).Respondents were 64% women.The most common medical specialties are shown in Table 3.
Workplace before attending the NSCPM.The majority of the respondents in both survey rounds were already working in PC when starting the course, 80% and 87%, respectively.In the first survey, 45% of the respondents had worked in a local or a regional hospital, 35% in a university hospital, and 20% in primary care (n = 114).In the second survey, 27% came from regional and local hospitals, 38% from university hospitals, and 28% from primary care (n = 59).
PC activity after attending the NSCPM.Postcourse PC activities are presented in Table 4. Working within a hospital PC in-patient unit, a hospital-based specialist PC consult team, or a specialist PC home care team was most common (114/186).

Discussion
This article describes the successful experience of establishing and running a common PM specialist training course between the five Nordic countries.The survey results and registry data demonstrate a profound impact of the course on the participants' career within PM, as well as implications for the development of PM in the Nordic countries.
Almost all of the 225 participants on the first seven NSCPM fulfilled the requirements for the course diploma (98%).The mean age at course start was *47 years, and almost all participants were approved in a medical specialty.In other words, course participants were experienced doctors when choosing a new career path.As seen elsewhere within PM, the majority of the course participants were female. 16he participants' evaluation of the course has been good.Moreover, besides the formal evaluation, participants have stressed the social and networking aspects of the education.Exchanging knowledge and experiences and building a network are seen as additional professional gains in their new medical field.These aspects weighed heavily when the Steering Group recently decided to return from digital teaching to the former structure of face-to-face modules  Have presented an abstract from their NSCPM course project at a conference 28 14 Have published an article from their NSCPM course project in a peer-reviewed journal placed in different Nordic locations once the Covid-19 pandemic allows it. 17The networking aspects, the international faculty, and the reputation for high quality have made the course stay attractive, also when Sweden 18 and Finland 19 in later years have organized national courses to obtain formal approval in PM.
To gain better insight into the impact of the course on participants' working situation, two web surveys were conducted.The excellent response rate (84%) probably reflects the participants' recognition of the importance of the course for their professional development.At the time of the survey, a large majority of the alumni were working within PC, around half as leaders, and >90% were engaged in PM teaching activities.Even if most of the participants were already holding a consultant position in PM when starting the course, we believe the NSCPM has been instrumental in their establishing or strengthening a new professional identity.
The NSCPM or an equivalent course is required as the theoretical part of the training to obtain formal approval in PM in the Nordic countries (Finland and Sweden also accept their national courses, which are less comprehensive). 8The NSCPM has played an important role in establishing these approval systems, and consequently influenced considerably the development of PM in this European region.The establishment of the formal approval systems has led to structured training programs (2-2.5 years of clinical training; less in Finland) as well as positions for doctors in training and requirements for consultant positions, in turn leading to improved quality in the PC service provision.Table 2 shows that former NSCPM participants form the backbone of the physicians approved in PM in several of the Nordic countries.
1][22] Consequently, the NSCPM is still both needed and attractive.A total of 40 participants completed the 8th course in 2019, a 9th course finishes in September 2021, and applicants have been admitted to the 10th course 2021-2023.Before the ongoing course, the Steering Group revised the course program as to be based on learning outcomes, in line with current academic recommendations. 7,23

Conclusion
The NSCPM has had a profound impact on participants' postcourse careers.Most former participants are now working within PM as leaders and teachers and are actively promoting the development of PC in their respective countries.The course has been instrumental in getting PM approved as a formal competence field in Finland, Norway, and Denmark, and an add-on specialty in Sweden and Iceland.

Table 1 .
Characteristics of the Participants on the Nordic Specialist Course in Palliative Medicine 2003-2017, and Number of Survey Respondents

Table 2 .
Year of Palliative Medicine Special Competence Authorization in the Nordic Countries, Number of Approved Physicians by January 2021, and Number of Those Approved Who Have Completed the Nordic Specialist Course in Palliative Medicine

Table 3 .
Precourse Medical Specialty of Survey Respondents (n = 186; Survey 1, 126; Survey 2, 60) X 11 respondents to survey 1, and 3 to survey 2, had double specialty, so numbers add up to >100%.aIncluding various subspecialties.b Not all Finnish participants were approved in a medical specialty.

Table 4 .
Participation in Postcourse Palliative Care Activities by Survey Respondents