A 40-Year History of End-of-Life Offerings in US Medical Schools: 1975-2015

Abstract

The purpose of this longitudinal study of US medical schools over a 40-year period was to ascertain their offerings on end-of-life (EOL) issues. At 5-year intervals, beginning in 1975, US medical schools were surveyed via a questionnaire to determine their EOL offerings. Data were reported with frequency distributions. The Institute of Medicine has encouraged more emphasis on EOL issues over the past 2 decades. Findings revealed that undergraduate medical students in the United States are now exposed to death and dying, palliative care, and geriatric medicine. The inclusion of EOL topics has definitely expanded over the 40-year period as findings reveal that US undergraduate medical students are currently exposed in over 90% of programs to death and dying, palliative care, and geriatric medicine, with the emphasis on these topics varying with the medical programs. Such inclusion should produce future favorable outcomes for undergraduate medical students, patients, and their families.

Keywords

death and dying palliative care geriatric medicine medical school curricula

When I first surveyed the then 113 US medical schools in 1975 regarding their end-of-life (EOL) offerings, such an emphasis was so rare that the American Association of Medical Colleges actually contacted me to inquire about death and dying exposure in their medical schools. Major medical textbooks have traditionally said little about what to expect or how to care for people near death.¹ Palliative medicine was not even on the horizon for medical school offerings in 1975, and a modular course or rotation devoted exclusively to palliative care was still the exception rather than the norm even as recently as 2000.² Geriatric medicine was more or less lost in medical school curricula at the time, with the first geriatric residencies developed only in the early 1970s.³ It is still likely that most medical students have had minimal experience with death and that for many entering students the cadaver is their first sight of a dead person.⁴

Introduction

It has been nearly 20 years since the Institute of Medicine published its landmark report calling for major improvements in professional training on care for the dying patient on the part of medical educators.⁵ The quality of patient care can be significantly improved if medical doctors learn to effectively manage patients’ EOL symptoms, therefore addressing EOL care training in medical school has become an extremely salient topic in medical education today (see Melissa Mott and colleagues⁶). Following EOL training, Mott found that medical students desired even more training, a need to learn empathetic communication skills, ways to help both patients and caregivers, and additional knowledge of ways to support hospice patients beyond meditation.

With a traditional emphasis on “cure” rather than “care” in US medicine, medical students tend to become competent in curative treatments, often at the expense of care. It is, therefore, not surprising that many physicians have difficulty communicating in a personal way with patients, particularly those with terminal illnesses. With an aging population and an increasing prevalence of chronic illness, it is of importance that future physicians be able to address palliative medical care, from managing pain and other symptoms of illness to communicating with patients and families about EOL care.⁷ My 1975 initial survey of US medical schools regarding EOL offerings has continued at 5-year intervals in order to ascertain the evolution of emphasis on such offerings. Thus, the objective of this research endeavor is to chronicle over a 40-year period the attention given to EOL issues in US medical schools.

Methods

Data Collection

I obtained data via a brief questionnaire mailed to the deans of all accredited medical schools in the United States at 5-year intervals from 1975 to 2015. The mailing addresses were obtained from the AAMC (American Association of Medical Colleges) Medical School Admissions Requirements for US and Canadian Medical Schools Directory.⁸ In each of the surveys, the first mailing was followed up with at least 2 mailings to enhance the response rate. The mailings included a cover letter and a self-addressed, stamped return envelope. In the latter surveys, some respondents requested an electronic survey and were so obliged.

Publications resulted from each of the previous 8 surveys and were solely authored by me, except for the 1990 and 1995 surveys when Alan Mermann at the medical school at Yale University co-authored a paper from each with me. The first 3 publications were published in the Journal of Medical Education (JME), the next 2 in Academic Medicine (the new name for JME), the sixth was in Death Studies, and the last 2 were in the American Journal of Hospice and Palliative Medicine.

Research Instrument

Most of the survey questions were multiple-select formats with a few closed-end questions. On several questions, the respondent could check more than one answer. The entire survey covered the front and back of a single page. Information in the questionnaires going back to 1975 included the types of courses on death and dying offered, teaching methods used, the percentage of students participating, and the background of the instructors. Whether a patient with a terminal illness addresses the students goes back to the 1995 mailings. Beginning with the 2000 survey, additional questions were included: the number of teaching hours on dying, death and bereavement, the extent of offerings on palliative care, hospice involvement, and the EOL topics covered in the curriculum. With the 2015 survey, the inclusion of geriatric offerings was added. Thus, the original 1975 survey questions remained the same, though additional questions were added with subsequent surveys. As a result of some of these changes, findings for some years are not available.

Results

Return Rates

The number of US medical schools within the 50 states has increased from 113 in 1975 to 130 in 2015. Total responses for the 9 surveys diminished over time from 90 or more percent with the first 6 mailings down to 58% in 2015 (see Table 1). With each mailing, the survey was addressed to the dean of the medical school, requesting him or her to complete it or pass it on to the appropriate individual. The position of the individual actually filling out the survey, however, likely varies from school to school, perhaps a shortcoming of the study.

Table 1.

Responses of US Medical Schools to End-of-Life Surveys From 1975-2015 (in Percentages).^a

Year of Survey	Responses
1975	95
1980	96
1985	90
1990	90
1995	93
2000	92
2005	81
2010	79
2015	58

^aNumber of medical schools increased from 113 in 1975 to 130 in 2015.

Format of the Survey

The format of teaching dying, death, and bereavement utilized in US medical schools tends to be lecture and seminar/small group discussions with these methods increasing in popularity over time (see Table 2). Role-playing has consistently been included in the curriculum since 2000 in about one-third of medical schools. The use of audiovisual materials is about the same in 2015 as in 2000. A patient with a terminal illness has addressed a class in about one-fourth of the schools since 1995, though their participation increased to one-third in 2015.The use of simulated patients has gradually increased from 2000 in 2015, with nearly half of the medical schools using such a teaching method in 2015. Clinical case studies have become popular since 2000, with some 70% of schools now using them. Hospice visits have increased from 43% to 75% of programs between 2000 and 2015, with contact lasting from “a few hours” to a period over “several weeks” with a range of participation from 51% of students in 2000 to 90% in 2015.

Table 2.

Format of Teaching Methods Used in Dying, Death, and Bereavement Offerings in US Medical Schools, 1995-2015 (in Percentages).

Teaching format	1995	2000	2005	2010	2015
Teaching format	N = 111	N = 112	N = 99	N = 99	N = 76
Lecture	73	84	87	92	85
Seminar/small group discussions	67	81	86	87	85
Role-play	NA	31	33	35	31
Hospice visit	NA	43	45	60	75
Video/film/DVD	NA	46	39	49	41
Simulated patients	NA	33	39	38	47
Clinical case discussions	NA	43	70	72	69
Terminally ill patient addresses class	26	28	27	28	35

Abbreviation: NA, not applicable.

Dying, Death, and Bereavement Offerings

When asked about the “greatest extent to which the topic of dying, death, and bereavement is represented in your curriculum,” the most frequent answers over the 40-year period (see Table 3) were “occasional lectures” and “forms a module of another course(s).” The number of medical schools offering a “separate death and dying course” has steadily increased over the years from a low of 6% in 1975 to a high of 27% in 2015. Various offerings were often integrated into other courses, with a multidisciplinary team approach increasing over the 40-year period. Some medical schools checked more than one option on some questions. Students participating in the various offerings increased from 71% in 1975 to near 100% in the 21st Century.

Table 3.

US Medical School Offerings on Dying, Death, and Bereavement (DDB), 1975-2015 (in Percentages).

Student exposure to DDB	Year^a
Student exposure to DDB	1975	1980	1985	1990	1995	2000	2005	2010	2015
Separate DDB course	6	13	12	18	8	18	16	21	27
Occasional lectures/module of another course(s)	80	80	82	73	70	82	87	90	99
At least some DDB offering	80	80	82	89	90	100	100	100	99
Students in DDB offerings	71	74	75	NA	77	96	96	100	96
Schools with multidisciplinary team approach	59	64	62	NA	76	78	82	77	79

Abbreviation: NA, not applicable.

^aSample sizes per survey period are as follows: 107 for 1975, 123 for 1980, 113 for 1985, 111 for 1990, 113 for 1995, 112 for 2000, 99 for 2005, 99 for 2010, and 76 for 2015.

Duration of Offerings and Professional Background of Instructors

The average “number of teaching hours” on dying, death, and bereavement has not changed significantly in the 21st Century (14 hours in 2000, 13 in 2015). Earlier surveys did not include this question, thus no data to report. The professional background of instructors varied over time (see Table 4), with nurses and social workers more often being a part of the team in the 21st Century. As would be expected, physicians are the more frequent players, especially since 2000, and the medical specialty of psychiatry plays a pivotal role, though less so since the 1980s. Teachers with theology and psychology backgrounds have consistently been team members, though waning somewhat in recent years. Sociologists have faded significantly in their participation over the 40 years. Philosophers and attorneys have been up and down since 1975, though much more down for attorneys in 2015.

Table 4.

US Medical Schools With Death Education Instructors From Various Professional Backgrounds, 1975-2015 (in Percentages).

Background^a	1975	1980	1985	2000	2005	2010	2015
Background^a	N = 107	N = 123	N = 113	N = 122	N = 99	N = 99	N = 76
Physician^b	85	71	71	94	96	99	99
Theologian	46	40	31	37	39	38	27
Psychologist	37	33	25	26	24	23	19
Sociologist	26	18	14	8	5	8	8
Psychiatrist	13	55	59	30	31	38	27
Nurse	8	17	19	36	43	37	44
Philosopher	5	19	29	15	14	12	23
Social Worker	4	14	23	31	35	31	33
Attorney	2	10	10	15	20	18	8

^aOther professional areas mentioned less than 1% were bioethics, medical humanities, anthropology, medical examiner, art, health education, literature, pharmacy, nutrition, and communication.

^bIncludes all medical specialties except psychiatry.

Palliative Care

Data gathered since 2000 on palliative care offerings revealed 87%, 94%, 99%, and 99% of medical schools, respectively, in 2000, 2005, 2010, and 2015, with approximately 90% of students in each time period participating in the palliative care offerings. The number of separate courses on palliative care has increased from 10% in 2000 to 20% in 2015. Average number of teaching hours in palliative care has stayed rather steady, ranging from 12 hours in 2000 to 15 hours in 2015. If not offered as a separate course, palliative care is offered as a module of a larger course, covered in “1 or 2 lectures,” or “scattered throughout the curriculum and in clerkships.”

End-of-Life Topics

In the surveys completed in the 21st Century, respondents were asked to note whether or not 18 specific topics were addressed (see Table 5). Overall, 16 of the topics were presented slightly less in 2015 than in 2010, reversing the trend from 2000. Eleven topics were presented in over 70% of the schools. Although the extent of coverage of each of the topics is not available from these data, more of an absolute response (coverage or no coverage) reveals a reduced involvement in most of the topics in 2015.

Table 5.

Topics Covered in the Curricula of US Medical Schools on End-of-Life Issues, 2000-2010 (in Percentages).

Topics covered in the curricula	2000 (N = 112)	2005 (N = 99)	2010 (N = 99)	2015 (N = 76)
Attitudes toward dying and death	80	90	95	85
Communication with dying patients	87	92	99	91
Communication with dying patients’ family	76	87	95	92
Grief and bereavement	72	87	90	77
Social contexts of dying (eg, family care)	63	68	79	71
Psychological aspects of dying (depression)	71	79	91	76
Religious and cultural aspects of dying	66	70	82	76
The experience of dying (eg, pain)	61	70	80	65
Analgesics for chronic pain	78	87	91	81
Analgesics for cancer pain	74	80	88	80
Symptom relief, advanced terminal illness	66	79	71	71
End-of-life hydration	49	59	63	56
End-of-life nutrition	51	60	67	59
Neonatal issues	26	37	29	21
Relating to patients with AIDS	52	50	44	36
Euthanasia	46	51	48	36
Advance directive (living will and durable power of attorney)	81	94	93	89
Death certificates	26	37	36	36

Geriatric Medicine

Yet not addressed in the previous surveys, the extent of geriatric medicine offerings was sought in the 2015 mailings. Twenty-two percent of those responding in 2015 said that they offer a “separate course” in geriatric medicine, 45% present such material in a “module of a larger course,” and 31% “cover the topic in one or two lectures.” Only 3% of the responding medical schools said that geriatric medicine is “not formally taught.” Average number of teaching hours offered is 24, with 88% of the students participating in the geriatric medicine offerings.

Discussion

Diminished Return Rates Over Time

Over the 40-year period, return rates have gradually diminished. Why the diminished return rates from a high of 96% to a low of 58% with the latest mailing? The mailing procedures did not change each time, though the questionnaire became slightly longer, gradually from a single page to 2 pages. My own previous experiences with other mailed surveys yielded better results with surveys through the post office, thus consistency with the medical school mailings over time with similar mailings, unless an electronic mailing was requested. A slightly longer questionnaire might deter a response, and then maybe medical schools are “surveyed to death” (no pun intended). Perhaps the AAMC has a better handle on curricula offerings in their medical schools today than in 1975 when they asked me about death and dying offerings, therefore a better compilation of medical school offerings, thus not the felt need of medical schools to respond to surveys such as mine. Whatever the reasoning, my results dropped significantly over the 40-year period.

As suggested earlier regarding who actually completes the survey, though addressed to the dean of the school, I asked that question in the 2010 survey. Not too surprising, the deans typically do not fill out the questionnaire, as was only the case with 2 schools. The others were assistant/associate deans, directors of various programs, professors, department chairs, committee chairs, and clerkship directors.

End-of-Life Offerings Over Time

Certainly US medical schools have improved their EOL offerings on the topics of dying, death, and bereavement and palliative care and as of 2015 seem to be addressing geriatric medicine within their curricula. Thus, previous encouragement of medical educators and policymakers in the 1990s to enhance training in EOL issues is being addressed. Yet, this study does not delve into the entire spectra of such exposure, as the primary focus is on classroom offerings, not so much on clerkships and beyond in the students’ medical training. More separate courses on dying, death, and bereavement are being offered today than in 1975, thus likely more concentrated depth in the exposure.

Why more emphasis on dying and death in medical school curricula today than some 40 years ago? Perhaps the publication of popular books in the 1960s and 1970s contributed to the start-up of this topic. Books such as Jessica Mitford’s The American Way of Death (1963), Elizabeth Kubler-Ross’ On Death and Dying (1969), and Ernest Becker’s The Denial of Death (1973) likely were an influence on such. Medical breakthroughs, for example, organ and tissue transplants, attracted the attention of the media, thus highlighted the topic of death in the news and brought it to the attention of medical personnel. Professional journals on the topic emerged in the 1970s and early 1980s (eg, Omega: Journal of Death and Dying, Death Studies, and The American Journal of Hospice and Palliative Care). Ralph Nader’s emphasis on the rights of consumers might have sparked interest in consumers desiring more information about their illnesses and whether or not death was imminent. Today, versus the 1970s, there is more open talk about death, many more books written on the topic, movies with such a theme, television addressing the topic of dying and death, and many more medical discoveries. Additionally, we are dying of chronic illnesses today more so than in the past, thus “lingering illnesses” versus acute. The changing times probably have forced medical schools to go along with these changes. For example, physicians “tell” the patient of his or her impending death much more today than in the 1970s. With these changes, medical schools see the need to better prepare young doctors to deal with EOL issues more so than previously. It is the patient’s right to know his or her medical situation, somewhat contrary to some 40 years ago. As noted earlier, the Institute of Medicine 20 years ago called for major improvements in professional training on care for dying patients, coupled with medical students desiring more such training. With medical schools addressing EOL care, the quality of patient care can be significantly improved. As noted earlier, there is more of an emphasis on care rather than cure today. Therefore, an increase in medical school offerings on dying and death is not surprising.

The number of teaching hours, however, has not changed significantly in the 21st Century (average number in 2015 was 13; United Kingdom averaged 27 hours).⁹ An interdisciplinary team effort has increased, as the trend in offerings and the professional background of the “team” has varied over time, with physicians continuing as the key players. A meta-analysis of EOL studies¹⁰ presented evidence of the training experience of residents revealing that a multidisciplinary approach improved confidence and overall EOL care and also helped students to cope with death experiences.

Didactic Versus Clinical Orientation

The lecture and seminar approaches are both intertwined into the medical school curricula. Such a format integrated with hands-on learning via hospice involvement or relating to a patient with a terminal illness in a hospital setting should complement each other and help to make didactic classroom activities more meaningful for these future medical doctors. Patients can teach the experiences of illness, the devastations of suffering, and the qualities essential for the caring physician.⁴ The University of Massachusetts Medical School in the early part of the 21st Century in a study of first-year and third-year medical students concluded that students exposed to curricula on EOL issues via group exercises integrated with encounters with terminally ill patients reported less concern about working with dying patients at the end of the course, showed less general concern about dying, and increased their valuation of clinical criteria in thinking about a “good death.”¹¹

Findings from a ward-based EOL care experience for third-year medical students at Yale University School of Medicine¹² suggested that a hands-on EOL exercise was well received in the acute inpatient setting and also improved students’ comfort and skills in communicating with and assessing patients facing the end of life. Beyond the didactic teaching sessions, many curricula include a clinical component.⁶ Another study of over 1400 medical students found that they believed didactic curricula had less of an impact than mentored experiences on their EOL care learning, thus the best format is not always easily determined.¹³

Simulated Patients

Simulated patients are now used in nearly half of the medical schools responding to the survey. Simulation may involve the use of actors as simulated patients or computer-enhanced mannequin simulators.¹⁴ In a study evaluating simulation in teaching medical students,¹⁵ student knowledge improved significantly after the simulation session, and students who received the simulation-based training outperformed those who received usual teaching. With regard to computer use in learning, using electronic media (e-learning) is increasingly popular as a way of taking core information subjects out of a lecture format and allowing students to learn in their own time and at their own pace.¹⁶

Hospice Involvement

Hospice visits by medical students have increased over time, from 43% of medical schools offering such in 2000 to 75% in 2015, approaching the percentage of involvement in British medical schools where 85% of schools have such visits.⁹ The majority of US medical schools now offer this option for which 90% of students are involved. Studies have shown^17,18 that introducing medical personnel to palliative care, particularly hospice, helps to protect the patient from ineffective interventions near the end of life and assists the patient and family in making educated decisions regarding treatment options.

Why the increased emphasis on hospice in US medical schools today versus 1975? The US population is certainly living longer, thus more medical issues as we prolong life. Gone are the days when pneumonia was the “old person’s friend,” as acute illnesses contributed much more to death than today. Our lingering in old-old age and not always so healthy, though “alive,” has stimulated a need for programs like hospice. Hospice began in the US in 1971, having originated in England in 1967 with Saint Christopher’s Hospice. As physicians are involved when death is approaching, the need to be knowledgeable about such programs as hospice is imperative for orientation in medical schools. Hospice presents an alternative in dying and gives palliative care to patients.

Palliative Care

The Institute of Medicine¹⁹ noted in 2015 a shortage of palliative medicine physicians and recommended that all physicians be trained in palliative care techniques, including communication skills and symptom management. A good place to have such training would be with medical students. Indeed, palliative care in US medical school curricula tends to be forging its way into such training of undergraduate students, with respondents in this study noting that 99% offer something in palliative care in the 21st Century. Average number of teaching hours in palliative care was 15 in the US, compared to 27 hours in the United Kingdom,⁹ thus the British are much more involved in this area than US medical schools. Many of the schools scatter their palliative care offerings throughout the curricula, though 20% of respondents offer a separate course.

An earlier survey of US medical schools regarding palliative care offerings²⁰ found that most schools favor integrative subject material rather than creating new courses devoted to palliative care. Due to already overstrained curricula, Horowitz and colleagues²¹ advocate integrating developmentally appropriate, basic palliative care competencies into each year of the medical school curriculum to avoid both neglect of the topic and educational overload. An evaluation of palliative care offerings in a medical school of over 300 medical students in Germany²² concluded that they appreciated both the interdisciplinary team and lecturers’ engagement.

Geriatric Medicine

Geriatric medicine is definitely integrated into US medical schools today, as only 3% of responding schools in 2015 said that such is “not formally taught.” Median number of teaching hours offered is 10, lower than the 14 hours reported in a 2005 survey of US medical schools.²³ On the other hand, the average number of hours offered in 2015 is 24. Oakley and colleagues¹⁶ showed amazement that teaching involving older patients is not more widespread. Even with the aging of the US population, few medical schools have a dedicated department of geriatrics.²⁴

Geriatric medicine as a specialty is not popular. For example, of the nearly 75 000 family physicians in the United States, just over 2000 (<3%) were certified in geriatrics, as of 2009,²⁴ yet geriatrics will be a significant part of their practice. Interestingly, the majority of those going into geriatric medicine fellowship programs within the past 10 years have attended medical school outside the United States.²⁵

Why are limited numbers of medical students going into the specialty of geriatric medicine? Monetary compensation for this specialty is not nearly as appealing as many other specialty areas in medicine. Also, to work with the elderly with their likely numerous problems of physical and mental deterioration may not be as “uplifting” as working in pediatrics where life is just beginning and the joy of “new life” exists. The end of the life cycle may not, therefore, be as appealing. Additionally, Medicare coverage begins at 65, thus more red tape with which physicians must cope.

End-of-Life Topics Presented

Studies⁶ note that in most EOL programs, didactic sessions are integrated into preexisting coursework which includes topics such as psychological and spiritual aspects, pain and symptom management, advance care planning, grief, and bereavement. Such a finding is confirmed with these data, yet why is the coverage found less in most of the 18 topics covered in the curricula of US medical schools in 2015? Perhaps this is a reflection of the smaller return from respondents in 2015, thus giving less of a full picture of all medical schools than previously. No matter the change, the topics least covered continue to be neonatal issues, relating to patients with AIDS, euthanasia, and death certificates, all around one-third or less in coverage. Neonatal issues likely are not covered so often as this would probably involve a neonatal specialist, thus not something to which the average physician would relate. Additionally, infant mortality rates have dropped significantly in the United States in recent years. Also, while not eradicated, breakthroughs in medicine have helped to “control” the AIDS epidemic in the United States. Euthanasia is not legal in the United States, other than physician-assisted suicide currently in 5 states, thus likely not a high priority topic for most medical schools. Finally, death certificates are one of the more “overlooked” topics in medical schools which might need further attention. With few medical schools covering death certificates in the curricula, this hit-and-miss completion of such relies on on-the-job training, often resulting in incomplete reports.²⁶

Conclusion

Studies cited earlier suggest that more direct contact through hospice or with patients with terminal illnesses would enhance medical students’ skills in relating to these patients and their families. Progress in this arena is noted from the data presented. The phenomenology approach to studies suggests that to study “the thing itself” enhances that for which one is seeking knowledge. How better to learn about dying and death than from those actually experiencing it (“the thing itself)? That information learned from interaction with hospice patients or having an individual diagnosed with a terminal illness speak to a medical school class might be retained better by the medical students than reading about something in a book. Is not what we actually experience often better remembered than that about which we read? A didactic approach coupled with hands-on learning should complement each other.

Assisting medical students in facing their own anxieties about dying and death at the time they are first faced with patients with terminal illnesses would seem appropriate for medical schools. By including dying, death and bereavement, palliative care, and geriatric issues in the medical curricula, a more humanist outcome could help both the patients and the students. Overall, the changes regarding EOL issues noted here are in a direction that should be favorable to all concerned—a win-win situation.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Carron

Lynn

Keaney

. End-of-life care in medical textbooks. Ann Intern Med. 1999;130(1):82–86.

Meekin

Klein

Fleishman

Fins

. Development of a palliative education assessment tool for medical student education. Acad Med. 2000;75(10):986–992.

Liebow

. A geriatric medical residency program. Ann Intern Med. 1976;85(5):641–647.

Merman

Gunn

Dickinson

. Learning to care for the dying: a survey of medical schools and a model course. Acad Med. 1991;66(1):35–38.

Field

Cassel

. Approaching Death: Improving Care at the End of Life. Committee on Care at the End of Life. Washington, DC: The National Academics Press; 1997.

Mott

Gorawara-Bhat

Marschke

Levine

. Medical students as hospice volunteers: reflections on an early experiential training program in end-of-life care education. J Palliat Med. 2014;17(6):696–700.

Wood

Meekin

Fins

Fleischman

. Enhancing palliative care education in medical school curricula: implementation of the palliative education assessment tool. Acad Med. 2002;77(4):285–291.

AAMC. Medical School Admissions Requirements for U.S. and Canadian Medical Schools. Washington, DC: AAMC; 2015.

Dickinson

Paul

. End-of-life issues in UK medical schools. Am J Hosp Palliat Care. 2015;32(6):634–640.

10.

Kottewar

Bearelly

Johnson

Fleming

. Residents’ end-of-life training experience: a literature review of interventions. J Palliat Med. 2014;17(6):725–732.

11.

Schwartz

Clive

Mazor

Reed

Clay

. Detecting attitudinal changes about death and dying as a result of end-of-life care curricula for medical undergraduates. J Palliat Med. 2005;8(5):975–986.

12.

Ellman

Rosenbaum

Bia

. Development and implementation of an innovative ward-based program to help medical students acquire end-of-life care experiences. Acad Med. 2007;82(7):723–727.

13.

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(3):319–326.

14.

Khan

Pattison

Sherwood

. Simulation in medical education. Med Teach. 2011;33(1):1–3.

15.

Fisher

Walker

RW.

A new age approach to an age old problem: Using simulation to teach geriatrics medicine to medical students. Age Ageing. 2014;43(3):424–428.

16.

Oakley

Pattinson

Goldbert . Equipping tomorrow’s doctors for the patients of today. Age Ageing. 2014;43(4):442–447.

17.

Temel

Greer

Muzikansky

. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–742.

18.

Lin

Levine

Scanlon

. Evolution of end-of-life care at United States hospitals in the New Millennium. J Palliat Med. 2012;15(5):592–601.

19.

IOM (Institute of Medicine). Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: The National Academics Press; 2015.

20.

Aalst-Chen

Riggs

Byock

. Palliative care in medical school curricula: a survey of United States medical schools. J Palliat Med. 2008;11(9):1200–1202.

21.

Horowitz

Gramling

Quill

. Palliative care education in U.S. medical schools. Med Educ. 2014;48(1):59–66.

22.

Gerlach

Mai

Schmidtmann

. Does interdisciplinary and multiprofessional undergraduate education increase students’ self-confidence and knowledge toward palliative care? Evaluation of an undergraduate curriculum design for palliative care at a German academic hospital. J Palliat Med. 2015;18(6):513–519.

23.

Eleazer

Doshi

Wieland

Boland

Hirth

. Geriatric content in medical school curricula: results of a national survey. J Am Geriatr Soc. 2005;53(1):136–140.

24.

Weiss

Fain

. Geriatric education for the physicians of tomorrow. Arch Gerontol Geriatr. 2009;49(suppl 2):s17–s20.

25.

AGS: American Geriatrics Society; 2014. Web site. http://www.americangeriatrics.org/advocacy. Accessed December 10, 2015.

26.

Eberstein

Nam

Heyman

. Underlying and multiple causes of death among the elderly: United States, 1986–1997. Paper presented at the Southern Sociological Society Annual Meeting, April 13–16, 2005; Charlotte, NC.