Outcomes from a Longitudinal Palliative Care Curriculum for Medical Students

Abstract

Background:

As more medical schools implement longitudinal palliative care (PC) curricula, the need for robust evaluation that demonstrates curricular outcomes has become increasingly important.

Objectives:

The authors prospectively evaluated a PC curriculum at the University of Pennsylvania’s Perelman School of Medicine, using the Context, Input, Process, Product model.

Design:

Between 2021 and 2025, data that provided evidence of value were generated from a variety of sources and stakeholders to address evaluation questions about acceptability, student knowledge and attitudes about PC topics and engagement in PC opportunities. Both qualitative and quantitative data were collected with an assortment of tools including evaluation scores, focus groups, interviews, written reflections, quiz scores, and medical record notes.

Results:

Results of this evaluation indicated that the curriculum achieved the intended outcomes of acceptance to diverse stakeholders, improved student knowledge and attitudes about PC, and increased student engagement in PC. Unanticipated impacts of the curriculum were also captured.

Conclusions:

The evaluation provided multisource evidence of the value of a longitudinal curriculum in PC and may serve as an example for others charged with evaluating longitudinal PC curricula in medical school.

Keywords

context input process product integrated curriculum program evaluation undergraduate medical education

Key Message

The authors prospectively evaluated a longitudinal palliative care (PC) curriculum for medical students using the Context, Input, Process, Product model. Results indicated that the curriculum achieved the intended outcomes of acceptance to diverse stakeholders, improved student knowledge and attitudes about PC, and increased student engagement in PC.

Introduction

Medical schools increasingly incorporate longitudinal curricular themes as part of a larger movement toward “integrated curricula” in medical education. Various definitions of an integrated curriculum have been proposed, but all such curricula include “vertical” integration, or longitudinal content, as well as “horizontal” integration, meaning integration of content across courses at a single timepoint.^1–4 Longitudinal curricula allow medical schools to adhere to accreditation standards, which call for “coordinated and integrated content within and across academic periods of study” and provide opportunities to introduce new and emerging topics.⁵ They also facilitate learning by asking students to retrieve previously learned information from memory (retrieval practice), introducing material when it is contextually relevant to their training (situated learning), and switching between multiple related topics rather than mastering a topic before moving on to the next topic (interleaving).^6–8

Despite these advantages, longitudinal curricula can be difficult to administer. The scope of such curricula is wide, and the variety of learning settings and number of stakeholders pose challenges to those seeking to design and implement longitudinal programs.⁹ Without robust evaluation data providing evidence of the value of longitudinal curricula, medical school leadership may be reluctant to allocate sufficient resources to support them.^10,11 Evaluation experts recommend the use of comprehensive evaluation models that encompass not only data about outcomes but also information about context and process to guide curricular evaluation.^12,13 However, longitudinal curricular evaluations described in the literature often lack comprehensive evaluation models.^14–20 Researchers in fields with longitudinal curricula have advocated for evaluation that is prospective, uses robust evaluation models, and includes the perspectives of multiple stakeholders in order to guide durable curricular change.^21–24

Palliative care (PC) educational content is increasingly recognized as a crucial component of medical student education, and many medical schools deliver PC content through elective or block formats.^25–27 While several schools have implemented mandatory, longitudinal PC curricula, none have prospectively evaluated these programs using evaluation models and multiple sources of data from diverse stakeholders.^17–20 Such robust evaluation is needed in order to sustain and grow longitudinal undergraduate PC programming.

The University of Pennsylvania’s Perelman School of Medicine (PSOM) implemented a longitudinal PC curriculum called CARE-7 in 2021, with concurrent evaluation using the Context, Input, Process, Product (CIPP) model.²⁸ The CARE acronym stands for “Caring, Attention, Responsiveness, and Empathy” and 7 references the educational goals of the curriculum, which correlate to proposed medical student PC competencies (Table 1).²⁹ The curriculum and parts of the evaluation that focused on Context, Input, and Process have been previously described.³⁰ In this article, we focus on Product, or outcomes of our curriculum as a whole, with data collected between 2021 and 2025. To that end, we address three outcome evaluation questions that we determined to be of high importance: (1) Is the curriculum acceptable to students, faculty, and other stakeholders?, (2) Are students gaining the knowledge and attitudes outlined in curricular objectives?, and (3) Is there increased student engagement in PC topics?

Table 1.

CARE-7 Goals and Objectives

Goals	Objectives
1. Caring for patients throughout their disease process through knowledge of specialist palliative and hospice care	a. Defines the philosophy and role of palliative care (PC) across the life cycle and differentiates hospice from PC b. Describes the rationale behind the interdisciplinary nature of the PC team and describes the roles of various team members c. Describes disease trajectories for common serious illnesses
2. Effective communication that incorporates the patient’s values, cultural context, and goals	d. Explores patient and family understanding of illness, goals, values, and cultural beliefs and practices that inform the plan of care e. Identifies and responds to emotion in patients and families facing serious illness f. Demonstrates patient-centered communication techniques when giving bad news and discussing medical decisions
3. Consideration of psychosocial and spiritual distress and bereavement in the care of seriously ill patients and their families	g. Identifies grief and psychosocial distress in patients and families h. Identifies spiritual and existential suffering in patients and families
4. Connecting with one’s own emotional response to patients with serious illness	i. Reflects on personal emotional reactions to encountering patients with serious illness
5. Comprehensive pain management for patients with serious illness	j. Describes an approach to pain management in serious illness, including knowledge about opioid initiation and titration k. Assesses pain systematically and distinguishes nociceptive from neuropathic pain
6. Providing comfort through excellent symptom management	l. Describes an approach to the evaluation and management of common nonpain symptoms such as constipation and nausea
7. Care of the patient at the end of life	m. Identifies common signs of the dying process and describes treatments for common symptoms at the end of life n. Describes tasks prior to and after a patient dies, including rationale behind medical decision making, anticipatory guidance, death pronouncement, and family notification

Curriculum Description and Evaluation Model

PSOM’s medical education program is a four-year program with an average class size of 150 students; CARE-7 spans all four years and consists of discrete sessions integrated into existing courses. The curriculum consists of 10 mandatory sessions (22 hours of content) taught by over 85 interdisciplinary educators. Two of these sessions, “Discussing Serious News” and “Pain and Symptom Management,” make up the PC Skills Practicum Day, a full day of PC content during the clerkship year. Two elective offerings are available for students who wish to gain additional experience (Table 2). CARE-7 emphasizes a lifelong learning approach to the material with an intentional focus on formative rather than summative assessment.

Table 2.

CARE-7 Curricular Sessions

Session title	Description	Placement in the medical school curriculum	Mandatory versus elective
Introduction to Palliative Care (PC) part one	Didactic session introducing the field of PC and basic communication frameworks	Pre-clerkship	Mandatory
Introduction to PC part two	Didactic session introducing more complex topics such as disease trajectories and PC across settings	Pre-clerkship	Mandatory
Palliative medicine experience	Clinical immersion experience where students spend an afternoon shadowing an interdisciplinary PC team member followed by a reflection assignment and small group debrief	Pre-clerkship	Mandatory
Pain and symptom management	Asynchronous didactic on pain and symptom management in serious illness, followed by a synchronous small group interactive video simulation case	Clerkship	Mandatory
Discussing serious news	Didactic followed by small group skills practice using interactive video simulation cases	Clerkship	Mandatory
Coping with serious illness and end-of-life	Small group sessions during medicine clerkship where students discuss a poem and share personal responses to encountering patients with serious illness	Clerkship	Mandatory
PC assessment	Assignment to do a PC holistic assessment on a patient during surgical clerkship with the goal of understanding their experience of serious illness and practicing skills	Clerkship	Mandatory
Nuts and bolts of end-of-life care	Didactic followed by small group session on caring for patients at end-of-life including anticipatory guidance, symptom management, and death pronouncement	Post-clerkship	Mandatory
Goals of care conversations: drills	Didactic followed by a small group with cases to foster discussion on the process of shared decision making	Post-clerkship	Mandatory
Goals of care conversations: skills	Small group virtual sessions using live simulated patients and deliberate practice using methodology from VitalTalk, a communication training and train-the-trainer program	Post-clerkship	Mandatory
PC clinical elective	Two-week clinical elective on an inpatient palliative care consult service	Post-clerkship	Elective
PC area of concentration	Students complete various requirements, including online modules, the PC clinical elective, attendance at PC conference series sessions, and a capstone project	Concurrent	Elective

In its first few years, CARE-7 was donor-funded and supported by three directors who oversaw curricular design and implementation, three coaches who served as educators and mentors, and an administrator. A separate curriculum advisor acted as a liaison to the Dean’s Office. A curriculum committee consisted of the directors, advisor, and PSOM faculty with experience in curriculum evaluation; the authors of this article consist of the members of the committee.

We chose to evaluate CARE-7 using the CIPP model, an evaluation model that considers the curricular environment (Context), designs content based on the environmental context (Input), monitors early rollout (Process), and evaluates the outcomes (Product) while emphasizing stakeholder involvement and a continual improvement approach.^28,31 We were also guided by the program evaluation standards of utility, feasibility, accuracy, and fairness.³² Thus, we strove to capture data that would be feasible to collect, provide accurate information, involve diverse stakeholders, and provide actionable information to improve the curriculum.

Curricular Outcomes

A variety of methods were used to evaluate outcomes for our curriculum. For each of our three evaluation questions below, we describe the methods used and summarize the findings. We also describe several unexpected impacts of CARE-7. Our evaluation protocol was submitted to and deemed exempt by the Penn Institutional Review Board.

Is the CARE-7 curriculum acceptable to students, faculty, and other stakeholders?

We addressed this question through student focus groups, evaluations, and stakeholder interviews. For clarity, we use the term “session” to refer to curricular sessions, as described in Table 2.

Student focus groups

Methods

We held 5 session-specific focus groups covering 7 of the 10 mandatory sessions from 2021 to 2023. Because third and fourth year students had received most of the curriculum by 2025, we added two more focus groups to capture their experience of the curriculum as a whole (Table 3). We provided question guides (Supplementary Appendix) to focus group facilitators, who were a combination of student volunteers, CARE-7 directors, and members of the curriculum committee. We collected deidentified notes for all focus groups. While no formal qualitative analysis was done, major takeaways and representative or noteworthy quotes (italicized in the findings section) were added to the evaluation database.

Table 3.

Student Focus Groups

Sessions covered	Focus group date	Number of students	Student year
Palliative medicine experience	June 3, 2022	14	First year
Pain and symptom management, discussing serious news	July 5, 2022	6	Third year
Palliative care assessment	October 7, 2022	2	Third year
Coping with serious illness and end-of-life	May 1, 2023	2	Third year
Goals of care: drills, goals of care: skills	December 11, 2023	5	Fourth year
All applicable content	January 16, 2025	7	Third year
All applicable content	February 28, 2025	6	Fourth year

Findings

In terms of curricular content, students reported that CARE-7 topics were high-yield, particularly noting pain and symptom management and end-of-life care as highly practical subjects. They shared that CARE-7 helped them “level up” in their communication skills. While some students were skeptical about the use of communication frameworks early on, they agreed that “once you are faced with these conversations in the clinical setting, it becomes very real, and a lot of folks have realized how helpful frameworks and practice can be.” Students said that they “couldn’t imagine having medical school without the curriculum,” primarily because of the knowledge and skills they gained about how to respond to and process patients’ suffering. They also felt that PC content included “requisite skills for being a physician” and that there was nowhere else in medical school where they would have learned these skills.

In terms of curricular structure, students valued having PC as one of their first clinical experiences in medical school because it modeled humanistic, interdisciplinary care in a welcoming setting. Nearing the end of medical school, students shared that CARE-7 had a clear through line that made sense to them.

Student evaluations

Methods

PSOM collects standard evaluations for many of its sessions. We requested evaluation data for all CARE-7 sessions where such data were available. Sessions are rated on a 5-point rating scale of 0—“Poor,” 1—“Fair,” 2—“Good,” 3—“Very Good,” and 4—“Excellent.”

Findings

For the eight mandatory CARE-7 sessions where evaluation data were collected, including the two sessions that make up the PC Skills Practicum Day, CARE-7 sessions were highly rated, ranging from 3.28 to 4.00 (Table 4). The PC Skills Practicum Day as a whole also received an evaluation score and was consistently one of the highest rated of the seven total practicum days. The average PC Skills Practicum Day score was 3.30 (N = 352) for the years 2023–2025, which was higher than the average practicum score of 3.12 (N = 1555) for the same period. In general, CARE-7 sessions were rated close to or above the average for comparable sessions at PSOM.

Table 4.

Student Evaluations of CARE-7 Sessions

Sessions	Academic year	Number of evaluations	Mean score^a
Introduction to Palliative Care (PC) part one	2024	45	3.68
Introduction to Palliative Care (PC) part one	2025	21	3.50
Introduction to PC part two	2024	8	4.00
Introduction to PC part two	2025	33	3.88
Palliative medicine experience (small group)	2024	113	3.78
Palliative medicine experience (small group)	2025	25	3.84
Pain and symptom management (small group)	2024	89	3.47
Pain and symptom management (small group)	2025	134	3.42
Discussing serious news (small group)	2024	89	3.44
Discussing serious news (small group)	2025	135	3.28
Coping with serious illness and end-of-life	2023	172	3.60
Coping with serious illness and end-of-life	2024	178	3.66
Goals of care conversations: drills (lecture)	2024	125	3.51
Goals of care conversations: drills (lecture)	2025	43	3.86
Goals of care conversations: drills (small group)	2024	66	3.92
Goals of care conversations: drills (small group)	2025	48	4.00
Nuts and bolts of end-of-life care (lecture)	2025	64	3.89
Nuts and bolts of end-of-life care (small group)	2025	60	3.88

Scores are based on a 5-point scale: 0—“Poor,” 1—“Fair,” 2—“Good,” 3—“Very Good,” and 4—“Excellent.”

PC, palliative care.

Stakeholder interviews

Methods

CARE-7 directors conducted informal interviews with CARE-7 educators to obtain feedback on specific sessions, both after initial implementation and following significant changes. Interviews were generally unstructured, though an interview guide was available for reference (Supplementary Appendix). We also solicited feedback from directors of medical school courses in which CARE-7 sessions were embedded. We provided annual updates to the CARE-7 donor and received feedback via email. In January 2025, we met with the co-chair of the Patient and Family Advisory Council and the program manager for Patient and Family Centered Care at our hospital to obtain feedback from stakeholders representing patients and caregivers.

Findings

Based on the feedback from interviews, educators appreciated the opportunity to teach CARE-7 sessions and believed that sessions were of high quality. While the lack of protected time for teaching was a concern, educators expressed gratitude for being involved in meaningful work. Directors of other courses in which CARE-7 sessions were embedded expressed positive regard for CARE-7, and some attributed changes in the learning environment to CARE-7. For example, medicine clerkship directors heard less distress from students around difficult clinical scenarios once the session on “Coping with Serious Illness and End-of-life” was implemented. The co-chair of the Patient and Family Advisory Council, the program manager for Patient and Family Centered Care, and the CARE-7 donor all valued the curriculum’s emphasis on lifelong learning, communication skills, and humanistic care of patients.

Are students gaining knowledge and attitudes outlined in curriculum objectives?

We addressed this question through quiz analysis, review of electronic medical record (EMR) notes, and analysis of student reflections.

Quizzes

Methods

We administered quizzes on the topic of pain management in serious illness before and after a recorded didactic on the topic, as preparation for the session on “Pain and Symptom Management.” Quizzes consisted of six multiple-choice questions. A post-test consisted of six separate questions that tested similar teaching points and were estimated by curriculum directors to be comparable in difficulty. We collected and compared mean quiz scores using t-tests for three classes of students from 2022 to 2024.

Findings

In total, 759 quizzes were collected, including 386 pre-quizzes and 373 post-quizzes. There was a statistically significant increase in the mean quiz scores from 3.16 (53%) to 3.90 (65%) (p < 0.001), demonstrating knowledge acquisition.

Medical record notes

Methods

The “PC Assessment” in the Surgical Clerkship required that students complete a comprehensive PC assessment with a patient with a serious illness and write a note in the EMR summarizing findings and making pertinent recommendations. The six domains that students were asked to assess included pain, nonpain symptoms, function, psychosocial assessment, spiritual assessment, and medical knowledge/decision making. Students received a note template that included a drop-down menu with possible recommendations in the plan section. We reviewed all 161 medical student notes from 2023 after de-identifying student and patient information, noting how many PC domains each student evaluated and tabulating their recommendations.

Findings

Of the 167 students enrolled in the surgical clerkship, 96% (N = 161) submitted completed EMR notes. Notes showed that students generally assessed the recommended PC domains and suggested medically appropriate interventions to improve the care of their patients. Of the 161 notes reviewed, 63% of students assessed all six PC domains, 30% assessed five domains, and 7% assessed four or fewer domains. Many students made multiple recommendations in their plans. In total, there were 89 recommendations to continue conversations about goals, values, and preferences as the clinical course evolves; 52 recommendations to improve pain or symptom management, 29 to consult PC; 30 to consult pastoral care; 15 to involve social work; and 19 for no follow-up needed. While those recommendations were from the templated options, there were also smaller numbers of student-written recommendations; for example, eight notes included recommendations for ways to improve communication.

Analysis of student reflections

Methods

Two CARE-7 sessions, the “Palliative Medicine Experience” in the pre-clerkship phase and the “PC Assessment” in the clerkship phase, required written reflections. We took a general inductive approach to analyze a sample of de-identified reflections.³³ Sixty-eight “PC Assessment” reflections were collected over 10 months in 2022 and 2023; 138 “Palliative Medicine Experience” student reflections were collected over 3 months in 2023. All reflections were coded independently by two to three investigators (composed of learners and co-directors), and topic areas were derived from clusters of coded data.

Findings

Details of the various topic areas are described elsewhere; here, we discuss take-home points from our inductive analysis.³⁴ Students reported a greater understanding of the content and substance of PC as a field, including its interdisciplinary nature, after the “Palliative Medicine Experience.” As this was one of their first clinical experiences in medical school, students wrote that the experience prompted them to reflect on systems-level considerations in medical care as well as consider their own professional identity and find meaning in medicine.

Students used “PC Assessment” reflections to further reflect on the patient and family experience of serious illness and appreciated that the assignment allowed them to get to know their patients in more depth. They shared that it was emotionally challenging to delve into their patients’ experiences of serious illness; nevertheless, students saw it as a privilege and shared that it highlighted the importance of core PC skills. Taken together, these student reflections demonstrate not only knowledge about PC topics but also an appreciation for the benefits of PC, both as a specialty and a set of skills that can add value to one’s medical practice.

Is there increased student engagement in PC topics?

We addressed this question through monitoring of students participating in CARE-7 electives.

Elective monitoring

Methods

CARE-7 electives consisted of a PC area of concentration (AOC) initiated in 2022 and a two-week clinical elective on an inpatient PC consult service for third and fourth year students. AOC and elective requests and completion rates were collected by CARE-7 directors. At the time of enrollment, AOC students completed a brief survey of demographic information, interests in medicine, and future training plans; they completed an exit survey when they finished the AOC.

Findings

Nine students enrolled in the AOC in its first three years. Of these, three felt it was likely they would pursue a PC fellowship after residency. The PC clinical elective was the only session that predated the implementation of CARE-7. In the seven years prior to CARE-7 implementation, the elective averaged 12 students per year. From 2021, when CARE-7 began its rollout to 2024, the elective averaged 18 students per year and declined an average of 6 students per year due to the lack of space. In part, the increase in students may be due to the addition of two elective sites in 2021.

Unexpected impacts

In addition to the intended outcomes reported above, CARE-7 had several unexpected impacts both within and beyond our health system. First was the founding of a new health-system-wide communication skills training program; because we trained so many faculty to teach communication skills through CARE-7, we were able to extend training sessions to practicing clinicians across our health system. Second, CARE-7 was used by the medical school for recruitment and promotional purposes. Prospective students mentioned CARE-7 as a unique asset during interviews, and some students said it was one of the major draws to PSOM. Finally, early dissemination of our curricular evaluation enabled us to support PC educators at other institutions; one institution shared that they implemented a new PC AOC modeled after the CARE-7 AOC.

Discussion

Comprehensive evaluation data for longitudinal PC curricula are scarce; our curriculum outcomes dataset helps address this gap by describing our prospective, multisource evaluation of the outcomes of a longitudinal PC curriculum and providing evidence of its value to diverse stakeholders.^35–39 Interviews, focus groups, and evaluations speak to a curriculum that is valued highly by students, educators, and other stakeholders. Review of student work in the form of quizzes, medical record notes, and reflections demonstrates that students gain intended knowledge and attitudes. PC electives show robust student engagement. Finally, a review of unexpected impacts of CARE-7 shows that its influence expanded beyond PSOM to affect educational programming for practicing clinicians in our health system and for other medical schools.

Our outcomes data builds on previous studies by highlighting the importance of the longitudinal nature of the curriculum. Notably, students shared that their relationship with the curricular content changed over time; while they felt that early integration of CARE-7 content was essential, many students acknowledged that it was not until the later years of training that they fully recognized its value. Students also commented on the utility of different teaching modalities at different times in their training; for example, they appreciated the use of videos rather than simulated patients in earlier communication sessions, as they felt this to be less stressful, but valued hands-on skills practice with a simulated patient in their fourth year. Thus, the longitudinal nature of the curriculum allowed for reinforcement of knowledge and skills in a developmentally appropriate manner and allowed students to more fully process the content as they matured as clinicians.

We acknowledge several limitations in our data. First, quantitative evaluation scores were not available for all CARE-7 sessions, and response rates were not available to explain variation in evaluation numbers. Next, we acknowledge the lack of objective skills measurements such as an Objective, Structured, Clinical Examination, while also keeping in mind that we made deliberate decisions to prioritize formative assessment. We also acknowledge that some interviews and focus groups were run by CARE-7 directors, who admittedly had a stake in the success of the curriculum. At the same time, those individuals were knowledgeable about CARE-7 sessions and thus were agile facilitators. Finally, we did not talk to patients or families themselves but were in contact with patient/family advocates in our health system.

Lessons learned in our experience of evaluating an integrated PC curriculum across four years of medical school include the utility of being guided by an evaluation model that focused on the process of curricular development as well as outcomes, attention to evaluation standards, and the involvement of multiple stakeholders in the curricular design and evaluation process. Taken together, we provide multisource evidence of the value of a longitudinal curriculum in PC and an example for others hoping to evaluate such curricula.

Footnotes

Acknowledgments

The authors express their special thanks to the many people involved in CARE-7 development, implementation, and evaluation, including the following people who aided in outcomes evaluation: Bridget Durkin, MD, MBE; Ann Soliman, MD; Caitlin Merley, MD; Danielle Feffer, MD; Lindsay Kumble, MD; Aidan Crowley; Lillian Wieland; and Suzanne Rose, MD, MSEd.

Author Disclosure Statement

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

Funding Information

The CARE-7 curriculum is generously funded by a Penn Medicine Board member and spouse of the late Henry A. Jordan, MD, a Penn alumnus (M’62 from the School of Medicine).

Supplemental Material

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