Training in end-of-life care through interaction with dying patients

Facing Death in Medical Training

This study explores how medical students feel about caring for terminally ill patients as well as how their medical courses prepare them for addressing end-of-life (EOL) issues with patients. Four hundred and five Mexican medical students were surveyed through the Student Views on Death questionnaire. The vast majority of students (94%) felt that physicians should inform patients of their impending death. Most students said they felt comfortable talking with (61%) or examining (76%) terminally ill patients. However, only half the students actually talked with patients about death. Participants in our study were interested in learning about EOL medical attention, yet most considered themselves poorly prepared to offer this type of care to terminally ill patients. The study provides objective data on a topic that has scarcely been explored in Mexico, data that will be useful in designing educational activities to improve EOL medical training.

Development and Testing of a New Instrument for Measuring Concerns about Dying in Health Care Providers

A new measure of concerns about dying was investigated in this psychometric study. The Concerns About Dying instrument (CAD) was administered to medical students, nursing students, hospice nurses, and life sciences graduate students ( N = 207) on two occasions; on one occasion they also completed three related measures. Analyses included descriptive statistics, factor analysis, Cronbach’s alpha, test-retest correlations, t tests, and correlations with other measures. Results suggest the CADmeasures three distinct but related areas: general concern about death, spirituality, and patient-related concern about death. Reliabilityestimates were good, and correlations with related measures were strong. Between-group differences suggest scores are related to actual differences in level of concern and beliefs about death and dying. The CAD has the advantage of being very brief, and of explicitly assessing concerns about working with patients who are dying.

Show what you know and deal with stress yourself: a qualitative interview study of medical interns' perceptions of stress and gender

BACKGROUND

Medical students report high stress levels and in particular, the clinical phase is a demanding one. The field of medicine is still described as having a patriarchal culture which favors aspects like a physicians' perceived certainty and rationalism. Also, the Effort-Recovery Model explains stress as coming from a discrepancy between job demands, job control, and perceived work potential. Gendered differences in stress are reported, but not much is known about medical interns' perceptions of how gender plays in relation to stress. The aim of this study is to explore how medical interns experience and cope with stress, as well as how they reflect on the gendered aspects of stress.

METHODS

In order to do this, we have performed a qualitative study. In 2010-2011, semi-structured qualitative interviews were conducted with seventeen medical interns across all three years of the Masters programme (6 male, 11 female) at a Dutch medical school. The interview guide is based on gender theory, the Effort-Recovery Model, and empirical literature. Transcribed interviews have been analyzed thematically.

RESULTS

First, stress mainly evolves from having to prove one's self and show off competencies and motivation ("Show What You Know…"). Second, interns seek own solutions for handling stress because it is not open for discussion (… "And Deal With Stress Yourself"). Patient encounters are a source of pride and satisfaction rather than a source of stress. But interns report having to present themselves as 'professional and self-confident', remaining silent about experiencing stress. Female students are perceived to have more stress and to study harder in order to live up to expectations.

CONCLUSIONS

The implicit message interns hear is to remain silent about insecurities and stress, and, in particular, female students might face disadvantages. Students who feel less able to manifest the 'masculine protest' may benefit from a culture that embraces more collaborative styles, such as having open conversation about stress.

Should we involve terminally ill patients in teaching medical students? A systematic review of patient's views

OBJECTIVE

To review available published research that has explored how terminally ill patients feel about being involved in undergraduate medical teaching.

METHODS

A systematic review using narrative synthesis. Qualitative or quantitative publications were included if they directly explored the views of adult patients, with a terminal diagnosis, about their involvement in undergraduate clinical teaching.

RESULTS

Seven publications met the inclusion criteria: one case report, one qualitative study and five questionnaire-based studies. A total of 269 patients were included across all studies. Patients were predominantly studied in a hospice or hospice day care setting. Both patients who had, and who had not, previously been involved in student teaching were captured by the included publications. In general, the views of patients were highly positive: overall 85%-100% were in favour of involvement in teaching. There were also some negative aspects, such as: concerns about being physically examined by a student; finding involvement in teaching tiring; feeling unable to decline consent to participate.

CONCLUSIONS

An assumption that clinical undergraduate medical teaching involving terminally ill patients may be too burdensome is not reflected overall in studies that have sought the views of the patients themselves. Understanding the patient's perspective provides a number of practical points in relation to how clinical teaching should be adapted in this patient group; for example, using smaller student group sizes; direct supervision if physical examination performed; short encounters with multiple patients rather than a longer encounter with one patient; adequate informed consent beforehand and without the students automatically being present.

The Effects of an Early Observational Experience on Medical Students’ Attitudes Toward End-of-Life Care

End-of-life care is paramount in maintaining the quality of life of the terminally ill, protecting them from unnecessary treatment, and controlling costs incurred in their care. Training doctors to be effective end-of-life caregivers begins in medical school. A survey design was used to collect data from 166 first-year medical students before and after exposure to hospice or palliative care through an early clinical exposure program. Data demonstrated that students had a significant change in attitude scores after the observational experience ( P < .05). Providing students with the opportunity to observe and participate in end-of-life care has a positive effect on attitudes toward the care of dying persons. We recommend that direct exposure to end-of-life care practices be incorporated early in the medical school curriculum.

Exposure to death is associated with positive attitudes and higher knowledge about end-of-life care in graduating medical students

OBJECTIVE

To examine the relationship between exposure to death and attitudes and knowledge about end-of-life care in graduating medical students.

PARTICIPANTS AND METHODS

Survey of students graduating from the University of Pittsburgh School of Medicine between 2001 and 2006. Students reported their personal experience with death and their exposure to death and dying patients during medical school. They rated their agreement, on a 4-point Likert scale, with 8 attitude items that were previously used in a national survey. Knowledge about end-of-life care was assessed with a 15-item test about pain and symptom management, ethics, treatment appropriateness, and hospice.

RESULTS

Three hundred and eighty students completed the survey; the response rate was 47%. Seventy-six percent of students reported personal experience with death, and 73% reported caring for dying patients or witnessing a patient's death during their third-year clerkships. Students had positive attitudes about physicians' responsibility and ability to help dying patients and their families, but reported negative emotional reactions to end-of-life care. Students who reported personal or professional experience with death had more positive attitudes and higher knowledge scores than those who did not, p = 0.05.

CONCLUSIONS

Educational initiatives should maximize the time medical students spend caring for dying patients. Teaching students end-of-life care during the course of their clinical clerkships is an effective way to improve attitudes about end-of-life care. Schools should focus on developing emotionally supportive settings in which to teach students about death and dying.

End-of-Life Care Curricula in Undergraduate Medical Education: A Comparison of Allopathic and Osteopathic Medical Schools

End-of-life care curricula in osteopathic medical schools were compared with allopathic school offerings. An 8-question online survey of undergraduate medical education administrators at all United States osteopathic medical schools (n = 26) and 26 allopathic schools geographically closest to them was conducted in 2007. Responses from 80% (n = 21) of osteopathic schools and 77% (n = 20) of allopathic schools revealed that both osteopathic and allopathic medical schools offered end-of-life care education. Of note is that 71% of the osteopathic medical school respondents had a course that concentrates on end-of-life care compared with 37% of allopathic school respondents ( P = .03). This disparity in percentages may be due to a number of reasons, 2 of which may include course identification methods and the primary care orientation and philosophy inherent in osteopathic medical schools.

Medical student distress: causes, consequences, and proposed solutions

The goal of medical education is to graduate knowledgeable, skillful, and professional physicians. The medical school curriculum has been developed to accomplish these ambitions; however, some aspects of training may have unintended negative effects on medical students' mental and emotional health that can undermine these values. Studies suggest that mental health worsens after students begin medical school and remains poor throughout training. On a personal level, this distress can contribute to substance abuse, broken relationships, suicide, and attrition from the profession. On a professional level, studies suggest that student distress contributes to cynicism and subsequently may affect students' care of patients, relationship with faculty, and ultimately the culture of the medical profession. In this article, we review the manifestations and causes of student distress, its potential adverse personal and professional consequences, and proposed institutional approaches to decrease student distress.

Pilot of a Hospice-Based Elective to Learn Comfort with Dying Patients in Undergraduate Medical Education

BACKGROUND

A majority of medical students feel uncomfortable with dying patients.

OBJECTIVE

We designed a pilot program to train medical students to be hospice volunteers to determine (1) the value of contact with dying patients in changing medical students' comfort level and (2) the mechanics of starting such a course in cooperation with a nonacademic agency.

DESIGN

Students were required to undergo hospice training provided by the local hospice. Students were eligible for Hospice volunteer placement after the training was completed. This provided students with an opportunity to interact with dying patients in a nonclinical capacity. Quantitative data and qualitative data were collected about the students' experiences with patients as well as about the effectiveness of the rotation.

SETTING/SUBJECTS

First- through fourth-year medical students were recruited to participate in this semester long project via a medical school-wide e-mail.

MEASUREMENTS

(1) A self-rating questionnaire on emotions and attitudes about death and dying at three points in time: before training, after training, and after placement; (2) A Likert-type questionnaire on barriers to participation and the usefulness of the components of an end-of-life course; (3) The "Attitudes About End-of-Life Scale"; (4) An in-depth structured interview with students after completion of the course.

RESULTS

Fourteen students participated in the evaluation phase of the program and reported increased comfort in interacting with dying patients after participating in the program. Students had less anxiety and fear of being around a dying person after placement as compared to before training. In-depth student interviews provided valuable qualitative data on the impact of the pilot, and insight into the strengths and areas for improvement in this type of elective.

CONCLUSIONS

A Hospice based elective can be an effective model for facilitating learning about how to approach the patient with a terminal illness.