Assessing Third Year Medical Students' Understanding of Code Status

Abstract

Purpose:

To assess third-year medical students' understanding of code status and its impact on patient care.

Methods:

Nonrandomized, cross-sectional survey completed at the end of inpatient internal medicine clerkship rotation. The survey assessed third-year medical students' understanding, knowledge, experiences, and attitudes pertaining to code status.

Results:

Sixty-three of 94 third-year medical students completed the survey at the end of their medicine rotation in academic year 2009. More than 90% of the respondents stated that “on the job training” was their primary means of knowledge of code status and that they would like to have code status discussion as part of their medical school's curriculum. Although 100% of students knew what “code status” means, only 17% reported an “excellent” understanding. Only about 5% of students were “extremely comfortable” in facilitating a code status conversation with their patients and more than 95% felt it should be supervised. Themes emerged included the importance of role modeling and accountability for good patient care.

Conclusions:

Third-year medical students' understanding of code status was limited to informal training during clinical care. Students perceive a lack of preparedness, which indicates an inadequacy in educating medical trainees about medical decision for resuscitation. The training for code status is greatly influenced by both resident and attending physicians, which accounts for variability in students' experiences. Further development in clinical teaching and learning about medical decision for resuscitation is needed.

Introduction

The culture of medicine places tremendous emphasis on intellectual and clinical skill development and often leaves little room for improvement in clinical teaching and learning about end-of-life care. The Liaison Committee for Medical Education (LCME) requires end-of-life education,¹ and despite the momentum gained over the past several decades with an increase in both formal and informal curricula in many U.S. medical schools, training has remained inadequate as graduating seniors still report being unprepared for end-of-life issues.^2–3

In 1976, the first do not resuscitate (DNR) policies were established in the U.S. hospitals,⁴ noting a patient's code status in which no attempt is made at cardiopulmonary resuscitation (CPR) after cardiopulmonary arrest. Code status discussions between physicians and patients, therefore, should be not only an informed process, but also a planned decision-making initiative that requires attention in a sensitive and timely manner. In the era of evolving advances in medical and technological therapies and procedures, the understanding of code status becomes increasingly important and more relevant to end-of-life care than ever before,⁵ especially to our physicians in training.

We surmised that medical students' understanding of code status was limited to “on the job learning,” influenced by variability from resident and attending physicians. The purpose of this study was to assess third-year medical students' understanding of code status and to understand their personal experiences and attitudes toward code status training.

Methods

The internal medicine clerkship at Dartmouth Medical School is a 7-week inpatient rotation in which students rotate through three university-affiliated hospitals. After orientation, students join clinical teams at either Dartmouth-Hitchcock Medical Center (DHMC) and the White River Junction Veterans Affairs Medical Center (WRJVA) sites (for two 3-week alternating blocks) or California Pacific Medical Center (CPMC) in San Francisco (6.5 weeks). Through a lottery system, students are assigned to their respective locations in which they join medicine teams consisting of an attending, a resident, and an intern.

This study was a nonrandomized, cross-sectional survey. Participation in the survey was voluntary and had no influence on the students' grade in clerkship, and no personally identifiable information was collected. The questionnaire was approved by the Dartmouth College Committee for the Protection of Human Subjects and the Dartmouth Medical School Medical Education Institutional Review Committee. The survey was designed to assess several domains: 1) knowledge questions regarding students' understanding of code status; 2) students' experience with code status and end-of-life issues; and 3) open-ended questions addressing students' attitude about education regarding patient code status. Descriptive data were summarized using standard analytic statistics and qualitative data were evaluated for presence of overarching themes.

Results

Sixty-seven percent (63 of 94) of third-year medical students completed the survey at the end of their internal medicine clerkship inpatient rotation from August 2009 through June 2010 at the Dartmouth School of Medicine (51% of the respondents were female and 49% were male). The respondents did not differ significantly from nonrespondents in their gender or their hospital locations, with the following distributions by race: 37 (59%) Caucasian, 19 (30%) Asian, 3 (5%) Hispanic, 1 (1.6%) African-American, and 3 (5%) other.

Students' knowledge and understanding of code status

Although 100% of students knew what “code status” means, only 17% reported an “excellent” understanding (Table 1). Ninety-percent of students learned about code status through informal “on the job training,” and 71% stated that a member of their inpatient team had introduced them to code status discussion. Sixty-five percent thought it would be beneficial to have a formal workshop before entering the wards, with strong interest in a brief overview with their attending physicians at the beginning of their internal medicine clerkship rotation (47%).

Table 1.

Students' Knowledge and Understanding of Code Status

Do you know what a “code status” means?
yes	63/63=100%
no
How would you rate your understanding?
excellent	11/63=17.4%
good	40/63=63.5%
satisfactory	11/63=17.5%
poor	1/63=1.6%
How did you learn about code status? (Your primary source of information)
on the job training	57/63=90.5%
television	2/63=3.2%
movies	2/63=3.2%
in a classroom (through a workshop)	3/63=4.8%
others (please specify)	3/63=4.8%
During your internal medicine clerkship rotation, did any member of your inpatient team discuss with you what a “code status” entails?
yes	45/63=71.4%
no	17/63=27%
no response	1/63=1.6%
If the above response is no, through which of the following means would it be helpful to have this introduction? (Please mark all that apply)
a formal classroom workshop before entering the wards	11/17=65%
a brief overview with your resident at the beginning of your rotation	5/17=29.5%
a brief overview with your attending at the beginning of your rotation	8/17=47%
others (please specify)	2/17=12%
don't really care, as on the fly learning opportunity	1/17=6%

Students' experiences with code status and end-of-life issues

The numbers of code status discussions initiated by students with patients varied considerably, ranging from 0 to 25, with an average of 4.5, a median of 3, and a mode of 2. Eighty-four percent of students related that having formal documentation of patients' code status would enhance patient care, and all of them agreed that a code status ought to be reviewed upon admission. However, only about 5% of students were “extremely comfortable” in facilitating a code status conversation with their patients, and more than 95% felt it should be supervised by either a resident or an attending physician, especially with their very first code discussion on the wards (Table 2). Responses regarding the students' own perception of their inexperience with medical decision for resuscitation included the following:

Table 2.

Students' Experiences with Code Status and End-of-life Issues

How many code status conversations have you initiated on your own during third-year clerkship? 0 – 25; median of 5
How comfortable were you with facilitating your first code status conversation with a patient?
extremely	3/63=4.8%
quite comfortable	20/63=31.8%
somewhat	30/63=47.6%
not really	9/63=14.2%
not at all
no facilitation of code discussion at all	1/63=1.6%
What additional factors, if any, would help with the above process?
Was your first code status discussion supervised by a member of your inpatient team? (resident, attending, etc.)
yes	42/63=66.6%
no	20/63=31.8%
no response	1/63=1.6%
Do you think a code status conversation should be supervised? If so, why?
yes	60/63=95.2%
no	3/63=4.8%
Do you think having a formal documentation of patients' code status enhances patient care? If so, why?
yes	53/63=84%
no	3/63=4.8%
don't know	5/63=8%
no response	2/63=3.2%
When do you think a code status ought to be reviewed? (Please mark all that apply)
upon each admission	63/63=100%
based on age and medical comorbidities	20/63=31.8%
when there is a transfer of care	34/63=54%
when a patient's clinical status changes	40/63=63.5%
when a patient undergoes a major procedure	39/63=62%
when a terminal disease is identified, such as cancer	43/63=68.2%
when new staff assume care	18/63=28.5%
Do you feel a patient's level of education influences the outcome of code status discussion? If so, please specify.
yes	36/63=57.2%
no	21/63=33.3%
don't know	2/63=3.2%
no response	4/63=6.3%
In general, what else would you have liked to learn about “code status”?

• “Watching a few beforehand, debriefing them and then being coached a bit on what works and what doesn't.”

• “Need for better teaching about how to approach the subject.”

• “Especially during the learning process as a medical student…it would be helpful to have a supervising physician in the room.”

• “So our resident or attending can help us out or clarify as needed…it's too important of a conversation for the patient to misunderstand.”

• “So you have the benefit of feedback from someone more experienced.”

• “Because it is too important to leave to a new student.”

Fifty-seven percent of respondents believed that a patient's level of education would influence the outcome of code status discussion. A few commented that end-of-life issues pertained more to a patient's own personal and cultural beliefs and comfort with dying rather than education.

Students' attitude about education and training with regard to patient code status

Ninety percent of students preferred that code status discussion be a part of the core curriculum, and 84% felt that their interns would benefit from this mandatory workshop also (Table 3). In regard to recent statistics suggesting in-hospital cardiopulmonary resuscitation for cardiac arrest was associated with ∼40% success inrestoring spontaneous circulation with only about 15% of resuscitated patients having the likelihood of surviving hospital discharge,^6–8 more than 87% of students wished they had received information about resuscitation before entering the wards and 65% believed that their knowledge of CPR statistics would influence their patients' code status decisions. Examples of their comments on CPR statistics included:

Table 3.

Students' Attitude about Education and Training with Regard to Patient Code Status

Please rate the importance of having a code status education/workshop before your clerkship years?
extremely	31/63=49.2%
somewhat	22/63=35%
not really	9/63=14.2%
don't care for it	1/63=1.6%
Should code status discussion be a part of your curriculum in medical school?
yes	57/63=90.5%
no	6/63=9.5%
Do you think a formal education/workshop on code status discussion should be mandatory for the following? (Please mark all that apply)
resident	34/63=54%
intern	53/63=84%
medical students	50/63=79%
for none	3/63=4.8%
How important is it to you to know statistics on survival rate of cardiopulmonary resuscitation?
extremely	35/63=55.5%
somewhat	27/63=42.9%
not at all	1/63=1.6%
Recent studies cited in-hospital cardiopulmonary resuscitation for cardiac arrest was associated with ∼40% success in restoring spontaneous circulation while only about 15% with the likelihood of surviving hospital discharge. Do these CPR statistics help your code status conversation with your patients?
yes, definitely	26/63=41.2%
yes, somewhat	31/63=49.2%
no, not really	5/63=8%
not at all	1/63=1.6%
Did you wish you had received information about resuscitation before entering the wards?
yes	55/63=87.3%
no	8/63=12.7%
Do you think your own knowledge of CPR statistics would influence your patients' decisions? If so, how?
yes	41/63=65%
no	12/63=19%
no response	10/63=16%
Do you think your resident or attending should know CPR statistics off hand?
yes	59/63=93.7%
no	4/63=6.3%

CPR, cardiopulmonary resuscitation.

• “Being able to offer statistics provides a more objective view.”

• “Because if you have a feeling for what interventions could be life-saving versus futile, you can guide a patient to make better-informed decisions.”

• “More confident in answering patient's questions and thus their decisions would be better informed.”

• “It allows a more honest discussion to occur since patients often seem to change their decisions based on knowledge.”

• “So patients can have concrete data of survival benefits of CPR versus the aggression of the procedure itself.”

Approximately 94% expected that either their resident or attending physician would know these CPR statistics.

Discussion

Our study suggests that medical students' understanding of code status was limited to “on the job learning.” This is similar to recent work that reported that 80% of interns at one hospital gave a poor rating for their communication skills with regard to discussing advance directives with their patients despite having had some formal teaching.⁹ This is also consistent with the concept of the “hidden curriculum,” a well-known phenomenon from Hafferty¹⁰ whereby students learn a great deal through experiential learning that is not part of the “official” curriculum. The students' free-text responses emphasized the strength and value of learning through both example and experiences that shaped their informal interactions. Over 90% of students stated that they would like to have code status discussion as part of their medical school's curriculum, but fewer than 50% recognized value in having this workshop before their clerkship years. Hence, this implies that formal teaching for code status discussion may not be the right approach. The significance of this is twofold: 1) the educational importance of role modeling for medical students; and 2) the development of a formal curriculum for teaching code status.

Although hospital census and patient volume, number of new admissions, and complexities of medical care are factors that might attribute to medical students' varied clinical exposure during their clerkship rotation, their overall understanding of code status was also influenced by variability from resident and attending physicians. Students learn from what they see or experience. They recognize the influence of positive and negative role models on their education. Our study also finds that students look to their more experienced colleagues for standards and guidance. Role modeling is known to be a key factor in the “hidden curriculum.”¹⁰

The need for code status curriculum is apparent because students perceived a lack of preparedness not only in themselves, but also in residents and interns. Additionally, they perceived that an attending physician's medical opinion weighs more heavily than others, and this may be related to students placing a greater value on more years of clinical experience. Educational interventions to teach communication skills differ from those applied to basic science or bedside teaching. Existing literature suggests that improved action of skills usually stems from practice, not necessarily from increased knowledge.^11–12 Moreover, recent literature review cites that despite an improvement in end-of-life teachings made through curricular reforms in U.S. medical schools, there is still a need for standardization in medical education related to various end-of-life issues.¹³

So then, how can we design an intervention and standardization for teaching code status discussion? Perhaps, a reasonable starting point would be for a clerkship student to have a one-on-one, sit-down session with an attending physician to go over the basics of a code status discussion (approach and communication tips to effective discussion are available from Loertscher and colleagues⁵), followed by multiple live observations with designated debriefing time for self-assessment and self-reflection. This proposed educational intervention would help promote students' professional and personal growth by integrating their own identity with clinical experience. It would also, in turn, acknowledge their awareness and subsequent transformation on the wards.

The strengths of our study were a reasonable sample size for a descriptive and qualitative study, a good response rate, and multiple measures of students' understanding of code status. However, this is a single-institution study. Also, it many have been helpful to know students' age, cultural background, religion, personal experience with death and life/career before medical school, which could certainly influence their communication skills, confidence, and perception of code status. Recall bias is also a concern in any survey such as this and may have influenced our data.

This study begins to elucidate third-year medical students' understanding of code status and highlights their various personal experiences and attitudes toward code status training. Similar to the pilot test of experience-based intervention to teach communication skills by Han and colleagues,¹⁴ this study provides a starting point for further work to refine our teaching about code status at Dartmouth Medical School and to test more specific interventions. It also offers a direction for development and clinical teaching about medical decision for resuscitation.

Footnotes

Acknowledgments

The authors express sincere gratitude to Roshini Pinto-Powell, M.D., for her belief and support in the death debriefing curriculum, to Trevor Law for his support, to Jennifer Schiffman for additional research data, and to the medical students at the Dartmouth School of Medicine for their survey responses and insightful feedback. This material is based on support, resources, and the use of facilities at Dartmouth Hitchcock Medical Center and the White River Junction VA in White River Junction, Vermont.

Author Disclosure Statement

No competing financial interests exist.

References

Liaison Committee on Medical Education: Functions, Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. June 2010 www.lcme.org/standard.htm. 2010 October.

Fraser

, Kutner

, Pfeiffer

. Senior medical students' perceptions of the adequacy of education on end-of-life issues. J Palliat Med, 2001; 4:337–343.

Billings

, Engelberg

, Curtis

, Block

, Sullivan

. Determinants of medical students' perceived preparation to perform end-of-life care, quality of end-of-life care education, and attitudes toward end-of-life care. J Palliat Med, 2010; 13:319–326.

Optimum care for hopelessly ill patients. A Report of the Clinical Care Committee of the Massachusetts General Hospital. N Engl J Med, 1976; 295:362–364.

Loertscher

, Reed

, Bannon

, Mueller

. Cardiopulmonary resuscitation and do-not-resuscitate orders: A guide for clinicians. Am J Med, 2010; 123:4–9.

Ebell

, Becker

, Barry

, Hagen

. Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis. J Gen Intern Med, 1998; 13:805–816.

Saghafinia

, Motamedi

MHK

, Piryaie

, Rafati

, Saghafi

, Jalali

, Madani

, Kolahdehi

. Survival after in-hospital cardiopulmonary resuscitation in a major referral center. Saudi J Anaesth, 2010; 4:68–71.

Peberdy

, Ornato

, Larkin

, Braithwaite

, Kashner

, Carey

, Meaney

, Cen

, Nadkarni

, Praestgaard

, Berg

. National Registry of Cardiopulmonary Resuscitation Investigators: Survival from in-hospital cardiac arrest during nights and weekends. JAMA, 2008; 299:785–792.

Ury

, Berkman

, Weber

, Pignotti

, Leipzig

. Assessing medical students' training in end-of-life communication: A Survey of interns at one urban teaching hospital. Acad Med, 2003; 78:530–537.

10.

Hafferty

. Beyond curriculum reform: Confronting medicine's hidden curriculum. acad med, 1998; 73:403–407.

11.

Allard

, Maunsell

, Labbe

, Dorval

. Educational interventions to improve cancer pain control: A systemic review. J Palliat Med, 2001; 4:191–203.

12.

Ferris

, von Gunten

, Emanuel

. Knowledge: Insufficient for change. J Palliat Med, 2001; 4:145–47.

13.

Bickel-Swenson

. End-of-life training in U.S. medical schools: A systematic literature review. J Palliat Med, 2007; 10:229–235.

14.

Han

, Keranen

, Lescisin

, Arnold

. The palliative care Clinical Evaluation Exercise (CEX): An experience-based intervention for teaching end-of-life communication skills. Acad Med, 2005; 80:669–676.