“I Will Never Forget”: What We Learned from Medical Student Reflections on a Palliative Care Experience

Abstract

Purpose:

To use reflective writing to evaluate a new required palliative care experience for third year medical students.

Method:

The authors used a constant comparison method based on grounded theory to conduct a thematic analysis of reflective writings produced by third-year medical students completing a mandatory week-long clinical rotation in palliative care during academic year 2010 at the University of Louisville.

Results:

Two broad thematic categories were identified: what the students learned and what the students experienced. Student writings revealed learning about palliative care (pain management, family meetings, goals of care, patient-family centered care, timing of palliative care, and delivering bad news); being a doctor (knowledge, communication, presence, empathy, not giving false hope, and person-focused care); the patient (importance of family, the experience of dying, and the uniqueness of each patient); and themselves (need to be non-judgmental, ability to do palliative care, self-limitations, becoming a better physician, and dealing with death). Student reflections centered on encounters with patients and families, internal emotional responses, and self-transformation.

Conclusions:

Systematic analysis of reflective writing provides educators with valuable data about students' learning experiences. These results may inform the design and modification of the curriculum.

Our patients aren't just objects that we are supposed to fix, but instead they are people with values and ideals that we must respect. This is a lesson that I learned while on that rotation that I will never forget …

I will never forget her facial expression or her verbalization of pain and how scared she was. I will also never forget how much I wanted to do something for her to alleviate her suffering.

–reflections of third-year medical students

Introduction

Clinical experiences with seriously ill and dying patients are vital to physician education in palliative medicine. Too often, preparation to care for such patients consists entirely of preclinical didactic lectures. Students themselves believe that care of the dying requires learning from direct clinical experience,¹ but meaningful contact with seriously ill and dying patients is often absent from the medical school experience.²

Experiential learning involves interpreting and integrating experience into existing knowledge structures to produce new knowledge.³ D.A. Kolb refers to this as the experiential learning cycle.⁴ According to Kolb, the learner emotionally transforms the experience into something meaningful through either (a) gaining new information by thinking, analyzing, or planning (abstract conceptualization or thinking) or (b) experiencing the concrete, tangible, felt qualities of the world (concrete experience or feeling).

Reflecting on experience is essential for self-discovery, self-regulation, and the therapeutic use of self in clinical situations and is important for professional development.⁵ The aim of reflection is to inform future actions so they can be more purposeful and deliberate.³ Reflection cultivates the self-awareness crucial to those providing compassionate care for seriously ill and dying patients.¹ Reflective writing, one tool for reflection, is an established method for teaching empathetic patient interactions⁶ and has been linked to effective use of feedback and improved diagnostic accuracy.⁷

Reflective activities have also been shown to provide a rich source of information about the “informal and hidden curriculum,” those things that are learned during the everyday experiences of students outside of the formal curriculum.^8,9 Experiences in the clinical setting may well determine perceptions of acceptable behaviors and values as students enter the medical profession.^10,11 Evaluations of student reflections can be an important tool for end-of-life curriculum planning, evaluation, and reform.^1,9,12

In 2007, the University of Louisville School of Medicine redesigned the curriculum to integrate palliative care into all 4 years of medical school. With the assistance of mentors from the Medical College of Wisconsin, the project team evaluated the components of the existing curriculum, reworked the preclinical curriculum, developed novel educational materials, and developed a one-week required palliative care clinical rotation during the third-year Medicine clerkship. During this rotation, students were assigned to a palliative care program in a hospital setting where they rounded with the physician, provided medical care for palliative patients, completed learning modules on topics such as pain, symptom management, and communication, and responded to a structured clinical vignette designed to teach palliative care principles.

The new curriculum included a writing assignment in which students reflected on a patient interaction or experience related to palliative care. The assignment had two purposes: (1) to provide an opportunity for student reflection and (2) to provide evidence of the impact of the revised curriculum. The aim of this study was to use students' reflective writings to explore the value of this new mandatory palliative care experience for third-year medical students. Approval to conduct the research was granted by the University of Louisville's Human Subject Protection Program. The study was determined to be exempt as it was research conducted in an established educational setting for the purpose of evaluating instructional effectiveness and the identity of the students was not revealed to the research team.

Method

Data source

The assignment

For the reflective writing assignment, students were instructed to: (1) summarize a specific doctor-patient experience/encounter involving palliative care (a telling of the story without interpretation); (2) explore/interpret the possible meanings of the event; and (3) describe/predict how the knowledge gained from the encounter could be used professionally in the future. This assignment structure reflected the four phases of the experiential learning cycle as conceptualized by D.A. Kolb: (1) the learner has an experience; (2) the learner reflects on the experience; (3) the learner makes an attempt to understand his or her actions or reactions to the experience; and (4) the learner applies the new knowledge.⁴ Papers were to be approximately one page in length and were submitted online.

All third-year medical students (academic year 2009–2010, n=155) completed the palliative care rotation during their medicine clerkship and submitted the required assignment at any chosen point before the end of the clerkship.

Sample selection

Student names were removed from the essays and the essays were copied to a computer disk. A member of the research team (BH) who had no previous contact with the students or their essays selected 40 essays randomly from the group of 155. It was believed that 40 essays would be manageable for in-depth analysis. The research team agreed that if data saturation was not evident after analyzing these essays, more would be selected and analyzed. The essays were assigned numbers, copied, and distributed to the six members of the research team.

Ensuring trustworthiness

The six members of the research team represented diverse backgrounds and included four Department of Medicine faculty members (three M.D.s and one Ph.D./social worker), the Associate Dean for Medical Education, and a Medicine resident. Each team member read the essays several times. Dialogue and peer debriefing ensured reliability of the overall findings. Random selection of the essays contributed to the data being representative of the whole. The process of conceptualizing categories, agreeing on domains and themes, and developing an overall scheme was documented at each meeting using flip charts, thereby providing a clear audit trail.

Analysis

Analysis proceeded using a constant comparison approach based on grounded theory.¹³ Steps in the analysis follow:

(1) A “naïve” first reading of all essays. Researchers read all essays while “bracketing” or putting aside any preexisting ideas or thoughts about what should or might be revealed. Researchers noted themes that they observed separate from the data.

(2) A second reading of essays and identification of quotes related to themes by coding in the margins. Both the first and second readings were done by each member of the team in isolation.

(3) Development of an exhaustive list of themes. The team reached consensus regarding the dominant themes. The team concluded that data saturation had been achieved (no new themes emerged; repetition of those identified was evident).

(4) Identification of two core domains encompassing the themes: what the students experienced and what the students learned.

(5) Division of the team into two smaller groups, each assigned to one of the two domains.

(6) Small-group “deconstruction” of the data by selecting quotes representative of the themes within each domain.

(7) Small-group presentation of findings to the research team.

(8) Development of consensus about the themes and quotes to include as representative of each domain.

Results

Initial coding of the data into themes delineated two broad domains: what the students learned and what the students experienced. These two domains reflect Kolb's two methods of transforming experience into meaning: (1) thinking, analyzing or planning (our domain of what the student learned) and (2) experiencing the felt qualities of the world (our domain of what the students experienced). Within each domain, further themes emerged during the constant comparison process.

What students learned

This domain encompassed the development of knowledge or skill and the modification of a behavioral tendency by experience. Student learning was further categorized into four topical areas or subdomains: learning about palliative care (Table 1); learning about being a doctor (Table 2); learning about the patient (Table 3); and learning about oneself (Table 4). Key points for each area evolved as the data were further analyzed. For most subdomains, there were five or more related quotes by students. The Tables include only key quotes selected to be representative of the students' thinking in each topical area. Students' writing was not edited.

Table 1.

What Students Learned about Palliative Care

Pain management	The most important thing I learned…was what a huge impact proper pain control can have on a patient with end-stage disease.
The importance and power of the family meeting	I felt as if I became a part of this family and had a much greater sense of who this person was. I witnessed this family arrive at that epiphany and it prepared them for what was ahead.
Setting goals of care	In the future, I plan to take a few moments to establish overall goals before I jump into acquiring a thorough medical history. This will enable more meaningful conversation between patients and myself.
The importance of having both the patient and family involved in care, and caring for both the patient and the family	Dr. ____ was very supportive and spoke to members of the family individually and as a group to accommodate everyone to the best of her ability. She allowed the family an opportunity to take the patient off support when they were ready…I believe that was very helpful for the patient's family's emotional well-being. Caring for a family who has come to terms with the death of their loved one and are very sharing with this difficult time is an enriching and honorable experience.
The importance of knowing when to switch to a comfort care focus	We must learn when we should discontinue unnecessary tests and accept a counseling role for our patients and their families. In my opinion, knowing when to switch from treatment to comfort is a key component to being a good physician. I have always felt like cerebrally I would know to contact palliative medicine, and now I know when I have that feeling to act on it. More harm can be done in waiting too long to contact the palliative team than by going too early.
Skill in giving bad news	I have never heard bad news broken to a family better than that and probably never will. I learned the importance in communication when dealing with sensitive issues like DNRs and advance directives. It's very important to make sure that the patient and family are fully informed, understand the situation, and are generally on the same page.

Table 2.

What Students Learned about Being a Doctor

The critical importance of communication	In my belief, a good doctor is not just one that makes and treats diagnoses, but is also a good communicator and listener for their patient. It is an invaluable skill.
The importance of “presence”	What the patient needed most at that time, and what I failed to provide, was my presence…not me checking to see if I could appreciate his JVD or listen for his absent breath sounds, what he needed was me. This encounter has helped me realize that sometimes when there is nothing to do to medically treat a patient, sometimes the greatest treatment you can give is your time.
Not giving false hope	Lastly, and most importantly, I never want to give a patient false hope. I have learned the importance of examining my own thoughts and emotions towards the patient and ensuring that I'm honest and clear…not providing false hope, but also providing care in a manner that is caring and concerned.
Treating the patient, not the disease	Although it is easy to forget, I think it is of the utmost importance that we always remember that we do not treat medical problems or diagnoses, we do not even treat patients, in our jobs as physicians, we are trusted with the care of our fellow human beings and we should never take that lightly. I can only hope that I am not fully motivated by objective data and literature and never lose sight of my duty to treat the whole patient and treat them like a person and not a lab experiment.
The importance of empathy	Knowledge is the backbone to medicine, but I have learned there is a triad that goes along with it, that is caring and compassion which can take on more of a role of medicinal healing than any other therapeutic treatment. I think that empathy for your patients is what gives you the extra energy to stay around at the end of the day to get things done for them when you could be on your way home. Medicine without empathy is not medicine at all.
The privilege of being a doctor	What I take from this experience is an understanding that not everyone has that knowledge (of palliative medicine). It is a privilege, and we have to use it to help families like this one through palliative care and end-of-life decisions. It is easy to wander in and out of patient's rooms without really ever stopping to think about how I'm wandering in and out of another human being's life. When I stop to think about that, I feel completely undeserving.
Responsibility to be knowledgeable and share that knowledge	Even though I am not attempting to cure the disease, in palliative medicine I must always be prepared to answer any questions dealing with the patient's condition. Knowledge is powerful, and as physician, we possess a lot of knowledge. To me, one of the most important parts of our job is helping patients understand their health care.

Table 3.

What Students Learned about the Patient

The importance of family	I saw the impact of having people who love you around in times of need. This man physically did better when his wife was around. The nurses had less calls to his room. The man's vitals stabilized. He simply looked and was more comfortable with his wife there. Families are just worried about their loved one. These are not simply patients, but rather someone's trust blanket.
The experience of dying	Even as their bodies fail them and they appear apathetic to the world around them, these patients retain a great deal of their personality, and they are just as susceptible to fear and anxiety as anyone else.
The uniqueness of each patient	This patient encounter made me realize that different patients have different needs. The experience made me realize that every one deals with the dying process differently. To Mr. Smith, living a life in bed all the time wasn't really a life worth living, so I think that played a large part in his decision to be DNR.

Table 4.

What Students Learned about Themselves

The need for a nonjudgmental approach	Overall, I think I need to remind myself not to assume what a patient or his/her family will want, and I should try to approach every patient with a clean slate so I don't let prior experiences cloud my judgment.
“I can do” palliative care	I felt natural talking with a patient quietly and for a long time as they meandered their way across their points with only gentle guidance and comments from me…With this patient's encouragement, I was able to practice this gentle medicine that feels so natural to me. Through all of this I learned that I can handle myself in tough situations, that I can be proud of the way I handled things, even if others might disagree. Taking the time to sit down with the patient, making sure the family was present, answering all of her questions, and really talking to her was a completely different and refreshing experience. It made me remember why I had initially wanted to pursue medicine.
Self-limitations	We will never beat death, but we can cheat it. We fight death, yet it is a part of everything living, and sometimes it is the best way. We cheat when we can, but sometimes we shouldn't. I realize that I cannot fix a patient's personality or alter the way they react to stress but I can help with direct medical and/or palliative issues.
On being a better physician	I will try to keep this person and experience with me with every person I see, and try to remember the person in front of me has a mother or brother or daughter who loves them, sees them for who they are, as a person, not the disease they presented with. This experience made an impact on me and I think it will make me a better physician…it taught me to learn to listen to my patients and make sure they are comfortable and feel that they are aware of what is going on and why. Witnessing this type of end-of-life amends making process will no doubt benefit me in my future practice. I will be able to talk about such issues with dying patients and can hopefully facilitate, at least in some small way, their preparations for death.
Dealing with death as part of doctoring	No matter what we, as medical professionals, do, we will always lose, and a patient will always die.…a physician merely plays an infinitesimal intermediary between life and eternity, trying when we can to stave the course of fate. I know how fleeting life is, but that is one lesson no one is ever truly prepared for.…I'm not sure I will ever be completely equipped for that situation, but I have learned it is a part of life, and part of being a doctor.

What students experienced

Analysis revealed that the required palliative care experience was also an emotional experience for the students. This domain addressing what they experienced included three subdomains: intimate encounters with patients and families, internal emotional responses, and transformation and journey in patient experiences. Representative quotes from the data are displayed in Table 5.

Table 5.

What Students Experienced

Intimate encounters with patients and families	I realized that the way he turned his hand when I approached was his signal that he wanted to hold my hand while I talked and examined him. At that moment I sat down on his bed like he was my brother. I really got to know him. I knew his whole story, right down to the fact that he liked to watch cartoons in the morning. He asked me to hold his hand and to pray with him. I did. Maybe some physicians will tell me that I was wrong to, that it was inappropriate or too personal of a gesture. I'd do it again.…I'm not the most religious person, but I am aware of the significance it has on someone who believes. How could I have turned him down? I developed a genuine fondness for his family and many times I would feel a lump in my throat after speaking with them.
Internal emotional responses	I found it easy to dehumanize him. It sounds awful, but at first he seemed to me to be a cadaver in waiting. I was nervous. In my mind, this was going to be tough. I was afraid to see people so weak and hopeless. I was scared to see an actively dying patient…This was a very powerful experience. Some lessons you learn aren't great or profound. They're ugly, nasty, and painfully real. The encounter was terribly upsetting for me. It had been quite some time since I had been so shaken by a patient encounter. I teared up in the car on my drive home.…He was the first patient that I had really been taking care of myself who had died.…This was the first time that it felt really personal to me. Why me? Why do I get to be part of a very intimate event in their lives? To watch on rounds as the doctors basically evaluated her like cattle angered me as few things in life do. I can't interpret accurately in my young career what exactly I understand about our visit that day. I do know that I felt good in many ways. I was happy about my place in medicine, and glad about my role. I questioned whether medical school had made me jaded or calloused to my gut feelings. I sympathized with how foreign this place must be and how scared it must be to not understand what everyone was saying. I sat and held his hand through these painful moments, and attempted to hold back tears.…I sensed his loneliness and wanted to cry with him. In fact, I did cry as soon as I hit the door.
Transformation and journey in patient experiences	I came to understand Mr. Smith more. To me, he became a person and not just a patient to try and fix. As I started to work with him I found there was a very real person beneath it. A patient that I never actually talked to had taught me about trust, loyalty, and family. These are all things that I have not learned much about during my training. I wondered how I could confront my own mortality. Witnessing this type of end-of-life amends making process will no doubt benefit me in my future practice. I will be able to talk about such issues with dying patients and can hopefully facilitate, at least in some small way, their preparations for death.

Discussion

What we learned

What we learned about the students

Analysis revealed that the students' experiences with dying patients and their exposure to palliative care left them with positive attitudes related to the practice of palliative care. Specifically, they learned that the physician-patient encounter can provide healing and help prepare patients and families for life-changing experiences.

Similar to other studies,⁸,¹⁴ we found that both positive and negative observations shape student perceptions of the profession and its values. These observations also contribute to development of their professional identities and shape their views about the physicians they want to become. Their writings conveyed realization of the privilege of being a physician and the immense responsibility that accompanies this role.

The writings provide evidence that the clinical experience in palliative care made them more prepared. They learned first-hand about pain management, the power of the family meeting, and giving bad news. They experienced empathy as they identified with patient situations (“he is a young man around my age which wasn't something I was prepared for …”, “I sat down on his bed like he was my brother.”), and reflected on mortality (“I know how fleeting life is,” “we will never beat death.”).

Many students reflected upon medicine's tendency to evaluate patients based upon objective measures (patient's outward physical appearance, vital signs, physical exam, or lab results) and “lump” them into disease categories. After this clinical exposure, students realized they often lost sight of the uniqueness of the individual. The palliative care experience served as a reminder of how physicians should actually relate to and treat “our fellow human beings.”

Students also realized the importance of being “present” for the patients. We were struck by how descriptive their writings were. They were truly in the moment with their patients, and evidence of the depth of their presence manifested itself in the richness of their descriptions. Many students indicated that being able to spend time with patients, learning their stories, and relating to them as fellow human beings were the reasons why they became physicians. They rediscovered their initial motivation and interest in medicine during their palliative care experience.

What we learned about the curriculum

Previous authors have suggested that didactic training in palliative medicine is not adequate preparation to enable students to provide such care.^1,8 Students also need role models and experiences with both positive and negative behaviors. In our analysis, we found this to be true. Students were extremely impressed by their observations of palliative care physicians in action, and their eyes were opened to improper treatment of seriously ill patients, be it poor pain management, inadequate education, discrimination, or an unwillingness to be present to the patient's suffering. In many of their reflective writings, the students clearly state they had learned both what to do and not do on the basis of their observations of medical practitioners. According to Karniele-Miller and colleagues, these experiences compose the “informal curriculum” that shapes students' perceptions of professionalism.⁸

Students reported observing essential skills (i.e., giving bad news, conducting a family conference, or setting goals of care) that will provide guidance to them in future practice. Most would agree that students should not be expected to use a skill they haven't observed,¹ but without a palliative care rotation, most students' medical education would be void of such exposure. Pain management was frequently cited as an area of new learning, whereas management of other symptoms was not viewed as noteworthy by these students. Perhaps this reflects an area of medical practice (pain management) that is severely neglected during the course of medical education unless it is taught during exposure to palliative care.

During analysis, themes emerged that reflect student exposure to all six core competency domains defined by the American Academy of Hospice and Palliative Medicine work group¹⁵ and adopted by the Accreditation Council of Graduate Medical Education (ACGME) as standards for palliative medicine education¹⁶ (see Table 6). Learning objectives guiding the revised curriculum were structured to address all of these domains. The reflective writing analysis validated progress toward student mastery of the objectives.

Table 6.

Qualitative Responses Related to ACGME Competency Domains

Competency Domain	Related Qualitative Responses in Student's Reflective Writing
Patient and Family Care	I came away from the family meeting with such gratitude for the work of the palliative service. Listening to the family's questions and arguments…made me realize how important family meetings are. Caring for a family who has come to terms with the death of their loved one and are very sharing with this difficult time is an enriching and honorable experience. I witnessed this family arrive at that epiphany and it prepared them for what was ahead.
Medical Knowledge	I learned the proper way to dose and escalate opioids for pain and delirium. Even though I am not attempting to cure the disease, in palliative medicine I must always be prepared to answer any questions dealing with the patient's condition. The most important thing I learned was what a huge impact proper pain control can have on a patient with end stage disease. Knowledge is powerful, and as physician, we possess a lot of knowledge. One of our most important jobs is getting patients to understand their healthcare.
Practice-based Learning and Improvement	I have a greater appreciation for what palliative medicine does after being on that rotation Not everyone has that knowledge of palliative medicine.
Interpersonal and Communication Skills	In my belief, a good doctor is a good communicator and listener for their patient. I learned the importance in communication when dealing with sensitive issues such as DNRs and advance directives. This experience confirmed once again how important communication is when taking care of people. Effective communication is the only way to customize a patient's care when so many…are involved. Empathy for your patients is what gives you the extra energy to stay around at the end of the day to get things done.
Professionalism	I think it is of the utmost importance that we always remember that we do not treat medical problems or diagnoses, we do not even treat patients; in our jobs as physicians, we are trusted with the care of our fellow human beings and we should never take that lightly. I can only hope that I am not fully motivated by objective data and literature and never lose sight of my duty to treat the whole patient and treat them like a person.
Systems-Based Practice	More harm can be done in waiting to contact the palliative team than by going too early. Knowing when to switch from treatment to comfort is a key component to a good physician

Student exposure to interdisciplinary teams was an initial goal of the curricular redesign. Although some students did refer to the “team,” this did not evolve as a significant theme in the coding process. Realizing the need for interdisciplinary learning, our research team has since received funding for the development and testing of an interdisciplinary palliative care curriculum involving students from medicine, nursing, social work, and chaplaincy in interdisciplinary learning opportunities.

Limitations

One significant limitation of our study is that the data are drawn from a single academic center. In addition, the reflections were written at different times during the medical clerkship as students rotated through palliative medicine at various points during the 12-week experience. Experiences either before or after the week in palliative medicine could have had an impact on their essays, which is unaccounted for in the analysis.

Conclusion

Our in-depth qualitative analysis of the reflective writings of third-year medical students completing a mandatory week-long rotation in palliative care supports the call for “hands on” teaching and role modeling via a clinical experience¹ and “reflective time”¹⁷ as essential components of palliative medical education. If physicians are to effectively care for the dying, they must participate in the clinical care of the dying as part of their educational experience.¹⁸ Such exposure teaches not only the skills and knowledge required in palliative care but also compassionate, person-centered care crucial to all medical practice. The reflections of these students provided insight into learning not easily measured by traditional evaluation techniques (i.e., pre-test, post-test, knowledge-based questions)—learning that, in their own words, they will never forget.

Footnotes

Acknowledgments

The Robert Wood Johnson Foundation funded the revision of the curriculum discussed in this article. Ethical approval was granted by the University of Louisville's Human Subject Protection Program.

Author Disclaimer Statement

No competing financial interests exist.

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