Lessons From the Development and Implementation of a Palliative Care Elective for Fourth-Year Medical Students: A Pilot Study

Background

Palliative care is widely recognized as an important component of medical school curricula. ¹ However, despite this recognition, US medical schools are only required to include education in end-of-life care, which further contributes to the narrow and problematic association of palliative care with death and dying. ² With the increasing aging population, medical schools have a responsibility to broaden the scope of palliative care education and arm learners with the tools they need to assist this aging population in navigating serious illness at all stages. Existing literature shows that medical students with formal palliative care education are more likely to feel prepared in addressing psychosocial, cultural, and spiritual issues, as well as symptom management and end-of-life care. ¹ Although our institution had some established preclinical palliative care education content, there was no formal clinical elective for medical students. Thus, we sought to develop and pilot a clinical elective with the hopes of enhancing palliative care education for our graduates.

Prior published surveys of medical students report interest in learning self-reflection and emotional coping skills, as well as concern regarding the potential emotional distress of being confronted with terminally ill and dying patients. ³ In addition, review of the literature for existing palliative care curricula reveals that the content and structure of education in the field is widely variable, and US medical school curricula often lack formal outpatient hospice and palliative medicine exposure, ⁴ despite prior literature highlighting its scarcity. ⁵ Based on a generalized needs assessment revealing lack of outpatient palliative care experiences and concern regarding emotional distress, as well as a more targeted needs assessment revealing lack of a formal palliative care clinical elective at our institution, we developed and implemented a palliative care elective for fourth-year medical students incorporating both inpatient and outpatient experiential learning along with formal didactics. Our aim was to not only improve confidence in various competencies within hospital and community based palliative care but also to generate self-reflection techniques to aid in improving attitudes and reducing emotional distress related to caring for seriously ill patients. In this report, we will discuss the implementation and evaluation of this elective and the impact for palliative care education at other institutions.

Methods

Setting, Participants, and Curriculum Design

A pilot clinical elective in palliative care was developed for fourth-year medical students at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Curriculum activities took place in both an inpatient hospital setting and an outpatient clinic. We also partnered with VITAS, a community hospice agency in Los Angeles County, and students spent time shadowing various members of the hospice interdisciplinary team during home hospice visits.

In an effort to integrate inpatient and outpatient community hospice and palliative care exposure, we structured the elective to include 2 weeks of inpatient palliative care with an interdisciplinary consult service and 1 week of outpatient palliative care, consisting of both clinic and home hospice visits. This experiential learning was coupled with formal weekly didactics covering the following topics: (1) communication and goals-of-care discussions, with a focus on developing skills in responding to emotion; (2) pain and symptom management; and (3) self-reflection, resilience, and avoiding burnout. The topics were included based on the recommended core competencies for undergraduate medical students in palliative care. ⁶ The topic of self-reflection was also chosen given the high incidence of burnout among medical trainees, ⁷ as well as the reported literature expressing medical student desire for emotional coping skills in caring for seriously ill patients. ³ A sample schedule is included in Table 1.

OPEN IN VIEWER

Table 1.

Sample schedule for medical students enrolled in the palliative care clinical elective.

	Monday	Tuesday	Wednesday	Thursday	Friday
Inpatient (Week 1 & 2)	Inpatient Consult Team	Inpatient Consult Team Didactics 4-5pm	Inpatient Consult Team	Inpatient Consult Team	Inpatient Consult Team
Outpatient (Week 3)	Home Hospice Visits	Outpatient Palliative Care Clinic Didactics 4-5pm	Home Hospice Visits	Outpatient Palliative Care Clinic	Inpatient Consult Team

Results

In the pilot group, 7 of 14 students filled out the pre- and postelective surveys (50% participation rate). The mean survey scores and corresponding standard deviations are outlined in Figure 1. Significant improvement in self-rated competency was seen in pain and symptom management, t(5) = −11.27, P < .001, communication, t(3) = −18.28, P < .001, and advance care planning, t(3) = 11.31, P < .01, but not in interdisciplinary care, t(1) = −9, P = .07. The average scores before and after the elective correlated with an increase of at least 1 point on the competence scale, with learners rating themselves as “able to perform with minimal supervision” in all categories by the end of the elective (Figure 1). The Thanatophobia Scale survey results also showed statistically significant improvement in attitudes toward caring for dying patients, t(6) = 7.18, P < .001, with lower scores at the end of the elective suggesting reduced emotional distress.

OPEN IN VIEWER

Figure 1.

Results of paired t tests comparing survey response means for self-rated competence before and after the elective. Competence was scored on a 4-point Likert-type scale, where 4 = competent to perform independently, 3 = competent to perform with minimal supervision, 2 = competent to perform with close supervision, and 1 = need further basic instruction.

Three students were able to participate in the focus group following their elective experience. The most highly valued learning theme identified by the students was the direct observation and feedback received during their inpatient weeks on the palliative care consult service. Students reported they were not experiencing this type of learning on other clinical rotations. Other high-value learning themes included obtaining communication tools for future practice, enhanced interdisciplinary learning, and a sense of ownership and empowerment from the inpatient experiences (Figure 2). These benefits were less appreciated in the outpatient setting, which was cited as more of a shadowing experience.

OPEN IN VIEWER

Figure 2.

High-value learning themes from medical student focus group (N = 3).

Discussion

Overall, our curriculum showed improvement in self-rated competency in communication, pain and symptom management, and advance care planning, as well as improved attitudes toward caring for terminally ill patients. However, the high-value learning points that emerged from the qualitative data did not fully correlate with expectations.

Interestingly, although the outpatient experience was hypothesized to be a major benefit of our curriculum, the learners cited their outpatient time as more of a shadowing experience and therefore less valuable than their inpatient time. The most valued component of the elective was the significant amount of direct observation and feedback received during their inpatient weeks, leading to rapid improvement and refinement of communication skills and a sense of empowerment that they are capable of leading difficult conversations with patients and families. The quality of this immediate, observational feedback is inherent to an interdisciplinary palliative care service, where learners are observed in patient encounters with different members of the interdisciplinary team, naturally leading to more immediate, diverse, and abundant feedback than they are receiving in other clinical environments. This suggests that any institution with an interdisciplinary palliative inpatient team could lead a clinical elective, with or without the outpatient experience or formalized didactics, and still likely generate a rich learning environment based on direct observational feedback. This also highlights the importance of training palliative care faculty and interdisciplinary team members in giving high-quality and timely feedback to ensure that the learning experience remains uniquely robust. At our institution, all faculty who taught these medical students either received or helped develop materials for faculty development that include roughly 3 hours of training in direct observation and feedback, in addition to individual coaching for junior faculty throughout the year. While this training was not an intentional part of our clinical elective development, we suspect it greatly contributed to enhancing the learning experience and highlights the importance of “training the trainers” when implementing new curricula.

Another interesting outcome is that although the interdisciplinary component was noted as a high-value benefit during the focus group, our pre- and postelective surveys did not show statistical improvement in the provision of interdisciplinary care. This is likely because learners were already rating themselves highly in this category prior to completing the elective, potentially as a result of prior exposure to interdisciplinary care in medical school through other interprofessional education efforts. It is also possible that the study was not powered to detect a difference, given the small sample size and higher baseline scores for this domain.

The evaluation of our curriculum was limited by small sample size and possible self-selection bias both in those who signed up for the elective and in those participants who filled out the survey and attended the focus group. Furthermore, it is unclear how self-rated competency correlates with objective evaluation of competency and if the improvements in self-rated competence will be retained over time. In future, more objective assessments would be helpful, perhaps through more standardized rubrics for evaluating communication skills in real or standardized patient encounters and more objective knowledge-based assessments. Our study could be further strengthened by including another medical school, which would provide interesting comparative data and a greater sample size to be able to evaluate demographics and other factors more fully.

Furthermore, because direct observation and feedback stood out as such a powerful part of the learning experience, it may be a challenge to expand the elective to more students in the future, without losing this high-value, one-on-one learning opportunity. In addition, the outpatient educational environment remains a challenge on multiple levels, both in seeking a more standardized outpatient experience (eg, students were rotating with a variety of hospice providers with inconsistent patient volume and structure) and in making the outpatient experience more empowering and high yield, as opposed to a shadowing experience. It remains to be seen whether enhancing the outpatient experience would add value to the inpatient learning experience for early learners in palliative care.

Conclusion

In summary, our 3-week clinical elective blending inpatient and outpatient experiences in palliative and hospice care demonstrated significant improvement in students’ self-rated competence across multiple domains in palliative care, in addition to reducing emotional distress ratings in caring for seriously ill and dying patients. However, despite the presence of what was hypothesized to be a unique blend of inpatient and community palliative care, along with formalized didactics targeting our learners, the most valued component of the curriculum was actually the process of direct observation and feedback during the inpatient experience. The learners highlighted the quality and timeliness of feedback as the most unique and powerful component of their rotation, contributing to their growth in communication skills and increased comfort around caring for terminally ill patients and their families. These findings reinforce the importance of prioritizing training palliative care faculty and team members in giving high-quality and timely feedback. Although formalized didactics and outpatient curricula likely add value and deserve attention and efforts toward improvement, our findings will hopefully empower other teaching hospitals with an inpatient palliative care team to integrate learners and begin to generate an effective learning environment based on direct observational feedback, even in the absence of other formalized curricula.