Preclinical Medical Students’ Diverse Educational and Emotional Responses to a Required Hospice Experience

Abstract

Background:

Physicians’ lack of comfort and skill in communicating about hospice care results in deficits and delays in hospice referrals. Preclinical exposure to hospice may lay a foundation to improve medical students’ knowledge and comfort with hospice care.

Objective:

To understand how preclinical medical student (MS)-2s respond both educationally and emotionally to a required hospice care experience (HCE).

Design:

Accompanied by hospice clinicians, MS-2s spent 3 hours seeing inpatient or home hospice patients followed by a 1-hour debriefing. Students submitted written reflections to e-mailed educational and emotional prompts.

Setting/patients:

Two hundred and two MS-2s from 2 academic cohorts completed the HCE at 1 of 2 hospice sites.

Measurements:

Written reflective responses were analyzed qualitatively, where salient themes extracted and responses were coded.

Results:

Ninety-two students submitted 175 responses to Prompt #1 (educational impact) and 85 students entered 85 responses to prompt #2 (emotional impact) of the HCE. Eleven themes were identified for prompt #1, most frequently focusing on hospice services and goals and hospice providers’ attitudes and skills. Prompt #2 elicited a diverse spectrum of emotional responses, spanning positive and negative emotions. Most often, students reported “no specified emotional reaction,” “sad/depressed,” “difficult /challenging,” “heartened/encouraged,” and “mixed emotions.”

Conclusion:

In an HCE, preclinical students reported learning core aspects of hospice care and experiencing a broad spectrum of emotional responses. These findings may assist educators in the planning of HCEs for preclinical students, including debriefing sessions with skilled clinicians and opportunities for triggered reflection.

Keywords

medical education preclinical students hospice care reflective writing emotional response

Introduction

Significant gaps persist in the care provided to patients and their families near the end of life (EoL).¹ Despite national improvements to increase the availability of hospice services, underutilization of timely hospice care remains an important contributor to deficits in EoL care.^1

–4 Medical school graduates, residents, and practicing physicians continue to report a lack of comfort and skill in communicating effectively with patients about goals of care and the range of treatment options for life-limiting disease, including hospice referral.^5

–11 Physicians’ discomfort or lack of skill in communicating effectively with patients and their families about hospice likely contributes to inadequate or delayed hospice referrals.

With mandates from the Liaison Committee on Medical Education¹² and recommendations from palliative medicine educators,^13
–15 the past decade has seen substantial growth in the inclusion of palliative and EoL care education in medical school curricula.^15
–17 Undergraduate palliative care education varies widely in extent and pedagogic approaches.^15
–17 Some medical schools report effective experiential learning through interactions with terminally ill patients^{15,16,18
–20} and hospice experiences in the clinical years of medical school.^21
–23 In addition to discrete, immersion learning experiences, educators stress the importance of longitudinal, integrated approaches to palliative care curricula extending over the 4 years of medical school.^10,24 Only 2 published investigators have reported implementation of longitudinal, integrated 4-year curricula,^25,26 although the effects of the early year experiences in these programs have not been evaluated.

Analyses of students’ reflections on their experiences during the clinical years with terminally ill and dying patients reveal that these can be emotionally powerful and at times distressing experiences for which students do not feel well prepared.^19,27,28 In a study of preclinical students who were asked to predict their reactions to the deaths of future patients, many reported anticipating negative emotions such as fear, frustration, guilt, and self-doubt.¹¹ Enhanced preclinical education in palliative and terminal care may lay a foundation, which would improve students’ preparedness for subsequent experiences in the clinical years. Most preclinical palliative care education does not include direct patient contact, and concern has been raised about whether preclinical students are developmentally and emotionally prepared for experiences with terminal patients.⁵ However, Wechter et al²⁹ found that a required hospice observational experience resulted in positive effects on MS-1s’ attitudes toward caring for the terminally ill. In addition, several investigators have reported positive findings for preclinical elective hospice experiences for small numbers of students.^30
–32

We previously described the development and evaluation of a longitudinal, integrated 4-year medical school curriculum in palliative and EoL care which aims to align learning objectives and teaching strategies with the developmental stage of the learners.²⁵ Our approach emphasized experiential learning, including in the preclinical years as well as student self-reflection and interprofessional learning.^25,33 The focus of this report is an in-depth evaluation of the second-year hospice care experience (HCE) component of our curriculum. Our goal was to explore through an in-depth thematic analysis of written student reflections how preclinical MS-2s respond both educationally and emotionally to a required HCE.

Methods

Study Design

During the fall semesters of 2 academic years in 2013 to 2014 and 2014 to 2015, all MS-2s at our school participated in a mandatory 3-hour HCE as part of a weekly clinical skills clerkship course. Prior to the HCE, all students participated in a required 2-hour “Introduction to EoL Care Workshop” in the first year of medical school. The goal of this first-year workshop was for students to recognize that physicians in all specialties need to acquire basic competencies and comfort in EoL care to provide patients and families comprehensive high-quality care. Students also had basic patient interview and relationship-building training in the clinical skills clerkship course as well as weekly tutored clinical exposures with patients to practice history taking and physical examination. Some students had additional clinical exposure through extracurricular activities such as volunteering to be a “patient buddy” to a child with serious illness through the pediatric interest group or providing company to patients in a chemotherapy infusion center through the palliative care scholars interest group. A minority of students participated in the “healer’s art” elective in their first year of school, which included facilitated sessions on grief and loss.

In the HCE, groups of 3 to 4 students spent 3 hours at an inpatient hospice facility or on outpatient home hospice care visits at private residential homes, assisted living facilities, or skilled nursing facilities. The students were accompanied and guided by a physician, advanced practice registered nurse, or registered nurse specializing in hospice medicine. To prepare for the HCE, students were encouraged to read 2 pertinent articles concerning palliative and hospice care available on the Yale School of Medicine’s Palliative and End-of-Life Care Education website.³⁴ Upon arrival at the preassigned HCE site, the on-site facilitator provided a brief introduction about the specific site and then students were divided into groups of 3 to 4 to accompany an assigned hospice clinician for visits with 1 to 2 hospice patients and/or their families. Following the patient visits, the hospice clinician conducted a 1-hour debriefing session to discuss the students’ observations and experiences and to address any questions. We encouraged the clinicians facilitating the debriefing sessions to provide empathic support and further explore the challenges and impressions that students shared from their visits with the hospice patients and their families. These facilitators also received training on the learning objectives of the HCE and how this experience fits into the overall curriculum.

The HCE learning objectives for the students were as follows:

learn the key elements of assessment of patients at the EoL, including physical symptoms as well as psychosocial and spiritual aspects of terminal illness;

compare and contrast the elements of history taking and physical examination for patients seeking palliative care and those seeking curative therapies without palliation; and

reflect on the professional and personal challenges of caring for patients at the EoL.

On the evening, the HCE was completed, students received an e-mail invitation with an embedded web link to a Qualtrics survey (Qualtrics, December 2015, Provo, UT, USA) with the following 2 prompts:

Name 1 to 2 things you learned about hospice care you want to be sure to remember when you start your clinical work.

Briefly describe your emotional reaction to seeing a terminally ill patient at hospice.

Students voluntarily submitted anonymous free-text responses to these 2 prompts.

Setting

The MS-2s participated in the HCE at 1 of the 2 not-for-profit hospices, each with inpatient units and extensive home hospice care service programs. One site has 12 inpatient beds with an average daily home care census of 75 patients; the other site has 52 inpatient beds and an average daily home care census of >350 patients.

Study Sample and Analysis of Students’ Reflection Responses

We collected demographic characteristics of the MS-2s who participated in the HCE from the school’s Office of Student Affairs. The students’ survey responses were recorded electronically on Qualtrics and were subsequently imported to Microsoft Excel (2010) for analysis. Given the exploratory nature of the study, inductive coding was used to categorize similar themes to develop a coding key.³⁵ Two authors (C.T. and M.E.) independently read all the responses and identified recurring themes. Each reader performed this independent review without prespecified thematic structures; rather, it was an iterative process that involved multiple of readings of the students’ responses to denote, compare, and consolidate themes that surfaced. The same 2 authors then convened to jointly devise the coding keys for each prompt. The coding keys were then applied independently by the 2 authors to code all of the responses. More than 1 code was allowed for each response. All 3 authors then met to settle any coding variances.

Participation in the study was voluntary, individual respondents were anonymous, and responses were not linked to any personal identifiers. The study was granted a waiver from the school’s human investigation committee (Protocol # 1602017145, 45 CFR 46.101(b)(4)).

Results

The characteristics of the 202 students (each class size was 101) who participated in the HCE are shown in Table 1. Ninety-two students (response rate 46%) provided responses to our e-mailed prompts with responses from 39 students in 2013 to 2014 and 53 students in 2014 to 2015 (Table 2). For prompt #1 (educational response), 92 students entered a total of 175 responses, averaging 1.9 responses per student, and 183 coded labels were applied. For prompt #2 (emotional reaction), 85 students entered a total of 85 responses and 124 coded labels were applied. For both prompts #1 and #2, each response was allowed to receive more than 1 coding label.

Table 1.

Characteristics of MS-2s in the 2013 to 2014 and 2014 to 2015 Academic Years (n = 202) Participants in Hospice Care Experience.

Characteristic	n (%)
MS-2s	202 (100)
Female	93 (46)
MD/PhD program	34 (17)
Students who completed HCE	202 (100)
Students who completed HCE survey	92 (46)

Abbreviations: MS, medical students; HCE, hospice care experience; MD, doctor of medicine; PhD, doctor of philosophy.

Table 2.

MS-2s responses to the Hospice Clinical Experience Evaluation Prompts in the 2013 to 2014 and 2014 to 2015 Academic Years.^a

	2013	2014	Number of responses	Number of codes	Number of themes^b
Prompt #1 (educational)	n = 39	n = 53	175	183	11
Prompt #2 (emotional)	n = 37	n = 49	86	124	15

Abbreviation: MS, medical student.

^a n = 202.

^b Themes excludes uncodeable responses.

For prompt #1, 11 thematic codes were identified (Figure 1). Apart from these, there were 3 uncodeable responses. Seven of the 11 codes occurred with a frequency of ≥10 times and accounted for about 86% (157 of 183) of the coded responses (Figure 1). The 3 most frequent coded themes for “lessons learned” were (1) hospice eligibility, services, and options (n = 33); (2) hospice care goals, philosophy, and outcomes (n = 28); and (3) provider knowledge, skills, and attitudes about hospice care (n = 24). Illustrative examples of student entries for each of the frequently occurring codes for prompt #1 are shown in Table 3.

Figure 1.

Eleven themes for educational responses emerged from the 175 responses submitted by 92 students (n), averaging 1.9 responses per student. The top 3 themes were “hospice eligibility, services, and options” (36%, n = 33), “hospice care goals, philosophy, and outcomes” (30%, n = 28), and “provider attitudes, skills, and knowledge about hospice care” (26%, n = 24). One hundred eighty-three coded labels were applied, with some responses receiving more than 1 label.

Table 3.

Illustrative Examples of MS2 Responses to Prompt #1 “Name 1-2 things you Learned About Hospice Care You Want to be Sure to Remember when you Start Your Clinical Work,” by Themes.

Lessons learned	Student responses
Hospice care goals, philosophy, and outcomes	“Hospice care is primarily about alleviating symptoms and providing comfort to patients.” “Hospice care is not about giving up hope for the patient but about providing them the best care possible.” “Hospice is an option for all patients and is NOT the end of treatment, just a continuation of treatment in a different form”
Provider attitudes, skills, and knowledge about hospice care	“It’s important to understand the needs of our patients and not simply make assumptions about what they would want.” “As a physician I must be comfortable talking about death with my patients.” “Anticipate the special needs of the end of life- such as needing to have group meetings with the patient & the family”
Hospice care as family care	“Hospice care is organized around the entire family unit.” “Important to support the family as well as the patient because they will carry a lasting impression.” “When you are doing hospice and palliative work, I realize that you are treating the family, just as much as much as you are caring for the patient”
Bedside practice	“I’d like to remember to be attentive when caring for patients.” “Be fully present with the patient—even if it looks like they’re not ‘there’.” “When you see a concerned patient, sit down, give them your full attention, and hold their hand”
Diversity of patients’ reactions, values, and goals at end of life	“Everyone’s values at the end of their lives are different.” “To consider patients in light of their entire lives, rather than their current condition.” “Everyone has a different perspective of what a ‘good’ death is”
End-of-life communication	“Talk to patients like you would talk to your own family if they were having a crisis.” “Goal-setting with patient is important.” “Communicate openly with patients and families”
Importance of family and support systems for patients	“It’s important to find out what support systems the patient has, and whether they feel like there are any unresolved issues in their lives.” “The family status and support can make all the difference.” “Patients live in an interconnected web”
Terminal symptoms and their management	“It is easier to manage symptoms as they arise, rather than trying to play ‘catch up’ when the patient is crashing.” “Feeding tubes are not recommended for hospice patients.” “To make sure to monitor pain”
Hospice care as a team effort	“Hospice care is a team effort with nurses, social workers and others.” “Integration of lots of types of health professionals”
Dying process and experience	“Death can be a gradual decline, not a swift destruction.” “Hearing is one of the last senses to go—so be aware that someone who appears to be unconscious may not be”

Abbreviation: MS, medical student.

For prompt #2, 15 thematic codes were identified (Figure 2). Apart from these, 3 responses were uncodeable. Six of the 15 themes occurred with a frequency of ≥10 and accounted for about 69% (86 of 124) of the coded responses (Figure 2). The 3 most frequent coded themes for emotional reactions were (1) no specified emotional reaction (n = 26); (2) sad/depressed (n = 17); and (3) difficult/challenging, heartened/encouraged, mixed emotions (each occurring with an equal frequency of n = 11). Among the codes with lower frequencies, emotions in the positive realm (peace/calm; impressed; happy/joy; total n = 14) had a greater frequency compared to those in the negative realm (anxious/nervous; troubled; afraid/scared; total n = 6). Illustrative examples of student entries for each of the frequently occurring codes for prompt #2 are shown in Table 4.

Figure 2.

Fifteen emotional reactions emerged from the 85 responses submitted by 85 students (n). The majority of students reported no specified emotional reaction (30%, n = 26), followed by “sad/depressed” (20%, n = 17), “difficult/challenging” (13%, n = 11), “heartened/encouraged” (13%, n = 11), and “mixed emotions” (13%, n = 11). One hundred twenty-four coded labels were applied, with some responses receiving more than 1 label.

Table 4.

Illustrative Examples of MS-2 Emotional Responses to Prompt #2 “Briefly Describe Your Emotional Reaction to Seeing a Terminally Ill Patient at Hospice,” by Themes.

Emotional reactions	Student responses
No specified emotional reaction	“It didn’t feel too different from seeing any other patient.” “I did not have a strong emotional reaction to seeing the terminally ill patient. The patient could not communicate, and was in an altered state of conscious. This, and because I have seen dying patients before, meant that I found little to react strongly to”
Sad/depressed	“The environment and our tutors made it such that seeing a terminally ill patient was not distressing, but rather an educational experience. Reflecting on the experience and the patients we saw is sad, but I think recognizing that sadness is also a critical experience for becoming good doctors.” “I was sad and not happy to have to face the reality of end of life.” “Deep sadness for the inevitable”
Difficult/challenging	“ … I could tell that he and his family were avoiding the elephant in the room, and chose to focus on the possibility of his recovery rather than on his imminent death. It was challenging for me to see someone who was not ready to give up yet, but still so clearly in terrible health condition.” “I only saw family members, because our patient was not conscious anymore. I found it to be a pretty difficult experience, but overall a good one and a good learning experience.” “I saw a 27 y/o male this summer, seeing him again a few months later with massive disease progression was difficult. He went from a happy, albeit sick, kid to a lethargic shell of a human in such a short amount of time. It was hard to resolve the marked difference between what, in my life, was such a short amount of time”
Heartened/encouraged	“It was encouraging to see that not all hospice patients were depressed and hating spending their last minutes of life in a healthcare setting.” “There was a great sense of respect—one that unfortunately you do not see all the time in the hospital, which is replete with hustle and bustle. I was very glad to know there is a place where patients can be comfortable in their last days.” “I saw an elderly woman with dementia at her home. She seemed comfortable and very well cared for … It made me feel good to see a terminally ill patient in comfort and well cared for”
Mixed emotions	“It was both comforting and saddening to see them rely so heavily on family that loves them.” “While death is a terrible and awful thing to face, the hospice is a wonderful place and makes it as easy as possible. From what I saw everyone was kind and patient. Everything was done to accommodate the patient and the family. The patient I met with seemed at peace. It makes the best out of a truly terrible circumstance. I think it was emotionally difficult, but peaceful.” “In the beginning of the visit, I found that the patient was quite excited and willing to speak with us. I felt that his enthusiasm brought about sense of emotional joy within me. Even in the end of his days, his positive outlook eliminated any feelings of sadness and despair that I anticipated I would I experience. However, as I reflect on this experience I’m finding that the positivity of the patient and his wife made the whole situation much more tragic. Their recently rekindled marriage and her preparedness for his passing were stark contrasts and I find myself unsure of whether I should be happy that they’re ready for his death, or if I should be sad that their beautiful story together is coming to an end”
Moved/awed	“I was moved by our patient’s poise, upbeat attitude, awareness of her condition, and conviction to take things into her own hands. She was very brave and selfless.” “It was a very moving experience to speak with the patient that I did. It wasn’t simply the fact that she is dying, but that she had beautiful, profound things to say about her life and how to live life in general.” “The patient was incredibly peaceful, friendly, and in good spirits. I was impressed and awed at her ability to accept her future and her calmness”
Surprised	“I was surprised the patient looked like she was in pretty good condition and sounded like she was doing pretty well considering her plethora of complaints and advanced age.” “The patient we visited did not seem very ill, and I was surprised to know that she is.” “I was quite surprised as the stillness and easy going manner of the patient, and was also aware of the nonchalant accepting attitude she had about her impending death”
Peace/calm	“Our patient was pretty much out of it, but holding her hand and being with her was somehow peace-invoking and meditative. It kind of helped put things in life in perspective and makes you more attuned to the importance of relationships in life.” “It was surprisingly calm and even relaxing at the hospice. I felt sad, but I think the patients were remarkably at peace.” “It was a surprisingly peaceful and pleasant experience. Our patient was not having too many physical symptoms at the time of our visit, but seemed to be coping well with”
Impressed	“I was encouraged by her story and how she has taken control of her life. Although fragile, she showed a lot of character and I was impressed by her command of her own health matters.” “I was sort of expecting to be depressed about it, but I ended up being impressed in a sense. The 2 patients I saw were actually quite ‘spry’ (as someone put it), and they still seemed to be enjoying life. If I didn’t know better, I would have believed they were just any regular elderly person that I might see in assisted living”
Happy/joy	“I felt happy because the patient and family seemed peaceful and accepting of dying …” “I actually felt happy because the patient was very upbeat and sociable …” “In the beginning of the visit, I found that the patient was quite excited and willing to speak with us. I felt that his enthusiasm brought about sense of emotional joy within me. Even in the end of his days, his positive outlook eliminated any feelings of sadness and despair that I anticipated I would I experience …”
Empathetic	“The hospice experience with PCC triggered memories and emotions from other recent (4-5 years ago) experiences with both outpatient and inpatient hospice situations involving close family members. It was very helpful to experience this setting from the perspective of the health care provider, but it was also good that I had an opportunity to share my own previous experiences with the nurse before going in, because that ended up preparing me better for when my memories were reanimated during the encounter. Because of my past experiences, I felt a high level of empathy with the patient and her family members, and I understood their current mindsets and needs.” “I felt empathy towards the patient; it was encouraging to see that she was actually doing fairly well for her old age”

Abbreviation: MS, medical student.

Discussion

To our knowledge, ours is the first study to report on both the educational and the emotional responses of preclinical MS-2s to a required HCE. Our in-depth thematic analysis of students’ prompted written reflections elucidated a range of the educational and emotional responses to an early hospice exposure. We found that a required, time-limited HCE facilitated by a hospice clinician was a feasible and impactful learning opportunity for preclinical students.

Regarding the learning impact of the HCE, a majority of students reported learning core aspects of hospice services, goals, and care. A variety of other self-reported learning points were defined, including aspects of bedside practice, diversity of patients’ response to dying, EoL communication, the importance of family, and the management of terminal symptoms.

Students reported a broad spectrum of emotional reactions, in both the positive and the negative realms as well as mixed emotional responses to seeing terminally ill patients. Notably, positive types of emotional reactions exceeded negative types, and if one considers the responses in the categories of “sad/depressed” and “difficult/challenging” to be expected and appropriate, only a small minority of coded responses (6 of 124) reported negative emotional reactions (anxious/nervous; troubled; and afraid/scared) which would be of more concern to educators. Debriefing opportunities with experienced hospice clinicians were deliberately built into the experience to facilitate discussion and processing of students’ emotional reactions.

One striking finding in this analysis was that despite the explicit instructions in prompt #2 to report on their emotional reactions to seeing a terminally ill patient, nearly one-third of students (26 of 85) either reported overtly that they had no specified emotional reaction (5 students) or we found that their responses lacked any emotional content (21 students). We speculate that this may reflect that rather few occasions exist in the curriculum prior to the HCE when students are triggered to reflect on their own emotions. However, we acknowledge that further investigation is warranted to understand what factors may underlie this observation and what triggers are adequate for students’ self-reflection.

Our analysis of students’ educational and emotional responses complements the findings of previous studies. Wechter et al²⁹ found that a program where MS-1s directly observed EoL care had positive effects on the students’ attitudes toward the care of dying persons. Our study’s findings also showed some thematic similarities with previous studies of hospice-based electives which included preclinical students. For example, Mott et al³² reported on the thematic content of MS-1s’ reflective essays written after volunteering with assigned hospice patients. These essays showed 5 salient themes: perceptions of hospice patients, personal feelings and reactions, amazement at normalcy of dying at home, impact of witnessing death and dying, and ideas for improving the EoL care curriculum. Shunkwiler et al³⁶ found that MS1-4s who elected to participate in volunteer training followed by hospice patient visits reported increased comfort levels of being with and talking to patients at the EoL.

The spectrum of emotional reactions to seeing terminally ill patients in our study stands in contrast to a study of preclinical students’ anticipated affective responses to the death of a future patient.¹² These anticipated responses often included fear, frustration, guilt, and sadness.¹² Our study found that observing actual hospice patients elicited positive, negative, and mixed emotions. A preclinical observational program allows students to interact with hospice patients in a “nonclinical” capacity, without concerns of having to focus on clinical management as in the later years of training. An early HCE may alter students’ preconceptions about caring for the terminally ill and thereby enhance their engagement with these patients during their clinical years. In this way, an early HCE that exposes students to hospice care and facilitates reflection on their emotional responses may help to mitigate students’ feelings of lack of preparedness for the difficult emotional reactions they experience when caring for dying patients in the clinical years.^19,37,38 Similarly, by equipping students with an understanding of the goals and benefits of hospice care, an early HCE may “inoculate” them against the negative effects of challenging EoL cases in future clinical rotations. We have anecdotally observed students who completed the HCE take the lead in suggesting the option of hospice care for terminally ill inpatients to their ward team.

The HCE contains many of the features promoted in optimal palliative care education: It is required, integrated, supervised, experiential, and dedicates time for debriefing and self-reflection. Reflective learning may enhance students’ development of professionalism^39
–41 and is particularly relevant for preparing students for competency in palliative and EoL care.^10,15,24 Emotion influences reflection itself: When emotion is the object of reflection, it can foster self-awareness in the learner.⁴² Enhancing self-awareness contributes to improving skills in challenging clinical communication⁴³ and developing mindful practice, which can reduce the risk of burnout.⁴⁴

Limitations

Although we analyzed 260 responses from 85 students, the reflection response rate was <50%, so we would take caution when generalizing the findings to all MS-2s. In addition, we are unable to ascertain whether a specific hospice site or clinician influenced the thematic content of the students’ reflections. Nonetheless, we found consistency of educational and emotional themes to prior studies of hospice educational interventions.^29,32,36

Conclusion

An early HCE can introduce preclinical medical students to the core aspects of hospice care and philosophy. Students demonstrated a wide spectrum of emotional responses when spending time in the presence of terminally ill patients. These results provide support for introducing an HCE in the preclinical years and can aid educators in anticipating the spectrum of students’ educational and emotional reactions to an early HCE. We believe debriefing opportunities combined with self-reflection are important components of any experiential, learner-centered palliative or EoL curriculum. This type of early HCE may help prepare students for EoL care experiences in the clinical years by promoting the acquisition of more comfort with and knowledge about hospice care.

Footnotes

Acknowledgments

The authors thank Dr. W. Scott Long, Dr. Joseph F. Andrews, and all the clinicians and administrators at The Connecticut Hospice; Dr. William H. Zeidler and all the clinicians and administrators at the Middlesex Hospital Hospice and Palliative Care Program; the Yale Medical Students; and Dr. Margaret Bia, former director of Clinical Skills at Yale School of Medicine.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Alexandra K. Munroe Fund, Yale School of Medicine.

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