Training our future physicians: A hospice rotation for medical students Carol F. Knight, EdM Peter F. Knight, MB, BS Mark H. Gellula, PhD Gerald H. Holman, MD
Abstract
Introduction
A required 16 hour hospice clinical rotation was developed as part of a medical studentfamily practice clerkship. The effect ofthe hospice rotation on student beliefs and attitudestowards the care of dying patients was measured by pre- and post-test questionnaires using a Likert scale. Sixty-five completed pre- and post-tests were analyzed using a paired t-test. It was determined that there were statistically significant changes in responses to 15 of23 items. The rotation positively q1 fected student attitudes about hospice care, student attitudes abouta hospice rotation, and beliefs concerningpalliative care. The authors believe that qualified hospice programs can, and should, serve an active role in teaching medical students about the physical and psychosocial aspects of caring for the dying.
The approaching death of a patient can lead to increased stress, self-doubt, and anxiety for the physician involved in care.1’2 In fact, the most intense patient avoidance response on the part of physicians is probably the one evoked by the circumstances and emotional reactions surrounding the patient’s death.3 Physicians tend to distance themselves from their terminally ill patients because they feel they have no skills to offer once investigation, diagnosis, and cure are no longer relevant.4 A1980 survey ofmedical schools in the United States indicated that medical school offerings in death education had increased slightly since 1975 with 80 percent of the schools continuing to offer occasional lectures and short “mini courses” on death education, but 13 percentnow offering full-term courses and only 9 percent offering no formal death education.5 Despite the increase, medical school students indicate that their education does not adequately prepare them to deal with the many issues involved in caring for a terminally ill patient.~8The psychosocial aspects of terminal illness appear to present particular difficulties formedical students6’9 and it has been recommended that medical schools focus on these issues, as well as on physical care, when developingdeath education curricula.’°
Carol F. Knight, EdM, is Education and Research Coordinator, Sr. Anthony’s Hospice and Life Enrichment Program, Amarillo, Texas. Peter F. Knight, MB, BS, isAssociate Professor, Department of Family Medicine, Texas Tech University Health Sciences Center, Amarillo, Texas. Mark f-I, Gellula, PhD. is Coordinator ofCME, MacNeal Hospital, Berwyn, Illinois. Gerald H. Holman, MD, is Chief of Staff, Veteran’s Administration Medical Center, Amarillo, Texas.
The American Journal of Hospice & Palliative Care Downloaded from ajh.sagepub.com at Monash University on June 4, 2015 January/February 1992
Hospice programs offer a unique model of caring for terminally ill patients by providing palliative care and extensive support services to patients for whom curative intervention is no longer appropriate. Unfortunately there is an unspoken but subtly perpetuated idea within the medical profession that the death of a patient
Physiciansfeel they have no skills to offer once investigation, diagnosis, and cure are no longer relevant. always represents a physician failure.3 The hospice concept of care, however, offers a differentview: death is seen as an inevitable and integral part ofthe life cycle. Unfortunately, most hospice programs are located outside teaching institutions and are involved in only a minor way, if at all, with medical student teaching. Therefore, little is known regarding the potential role of a hospice in teaching medical students about the care of the terminally ill patient.11 It has been suggested that early exposure to the concepts of palliation as an alternative to curative treatment in the terminally ill patient
23
could set the stage for the development of new attitudes in medical students.’2 It is the impression of the authors that qualified hospice programs can serve an active role in teaching medical studentsthe concepts of palliative care. To document these impressions the authors developed a required hospice rotation as part of a medical school’s family practice clerkship for fourth year medical students. Since most death education curricula lack adequate experiences working directly with terminally ill patients, a clinical rotation was developed to promote personal contact with dying patients. The study’s aim was to demonstrate that a qualified hospice program can serve an active role in teachingmedical students about the physical and psychosocial aspects of caring for the dying. It has been suggested that the clinical setting is the one in which the most intense and fruitful teaching takes place.9 Despite the recognized importance of teaching in a clinical setting, the format most often used in medical school death education offerings is a combination of lectures and seminars. Formal teaching ofcaring for the dying patient is found less frequently in a clinical setting, particularly as part of a required medical student rotation.9 Goal The over-all goal of the hospice rotation is to provide a structured, clinical rotation for medical students which will increase their awareness, sensitivity and clinical skills when dealing with terminally ill patients and their family members. Objectives • Students will be able to describe the concepts and philosophy of hospice care. • Students will be able to describe effective pain management techniques for the terminally ill.
• Students will be able to describe effective management of common problems of terminal illness.
The rotation begins with a lecture and small group discussion concerning the concepts of hospice care • Students will recognize and know how to deal with the symptoms of normal and complicated grief. • Students will recognize common psychosocial issues faced by terminally ill patients and their family members. • Students will recognize common psychospiritual issues faced by terminally ill patients and their family members. • Students will evidence increasedcomfort and decreased anxiety when caring for a terminally ill patient. Description St. Anthony’s Hospice and Life Enrichment Program is a JCAHO accredited, Medicare certified, hospice which has been designated one of two world-wide research and education centers by the International Hospice Institute. It is owned and operated by St. Anthony’s Hospital and consists of a home care program and a 20-bed free-standing inpatient facility. A fulltime medical director providesover-all direction for the care of each hospice patient and either assumes care when a patient is admitted or is available in a consultant capacity to other physicians whose patients have been admitted to the hospice program.
24 Downloaded from ajh.sagepub.com at Monash University on June 4, 2015
Texas Tech University Health Sciences Center is a four year accredited medical school which provides training forits third and fourth year students at the branch campus in Amarillo as well as at other campuses. St. Anthony’s Hospice, in collaboration with the branch campus in Amarillo, developed a required 16 hour hospice rotation for fourth year medical students. During the hospice rotation all medical students who are on theirfamily practice rotation spend four half days, or 16 hours, at St. Anthony’s Hospice learning about and dealing with the clinical issues of caring for dying patients. The students rotate through hospice on a monthly basis in groups of two to four students. Prior to the hospice rotation, students had only received periodic lectures on caring for terminally ill patients. The rotation was established in August 1986 with 76 students participating through December 1989. The following is a description of each session of the rotation. Session One Prior to the initiation of the hospice rotation each student receives an extensive packet of background readings on the physiological mechanisms of pain, pain and symptom control, bereavement, and spiritual and ethical issues. The rotation begins with a lecture and small group discussionconcerning the concepts of hospice care including: • The appropriateness ofhospice care for terminally ill patients; • The interdisciplinary approach to hospice care; and The importance of understanding the physical, psychosocial, and spiritual needs of dying patients and their family members. The medical director ofthe hospice program thenlectures on:
The American Journalof Hospice & Palliative Care January/February 1992
• Pain and symptom management in the terminally ill patient; • Effective intervention strategies for the management of pain; • Thephysiological mechanisms ofpain; • The dimensions and presentation of severe chronic pain; • Pharmacologic control of chronic pain including agents, dosage, and side effects; and • Myths about narcotic analgesics. A detailed lecture is necessary to correct continued misunderstanding concerning the appropriate management of chronic pain in the terminally ill patient. Effective interventions to relieve selectedsymptoms experienced by terminally ill patients are also presented with emphasis on the control of constipation, nausea, vomiting, bowel obstruction, and opiate intoxication. The medical director also describes his role as a member of the interdisciplinary team and the importance of providing team leadership. Although hospice is sometimes viewed primarily as a nursing program, the physician plays a crucial role in hospice care in the areas of pain relief, symptom control, advising on disease outcomes, and serving as a source of information and support for team members and the patientand family.4 The medical director then conducts inpatient rounds during which he discusses diagnosis, treatment, prognosis, psychosocial and ethical issues, and models appropriate communication, body language, and touch with the dying patient and family members. Session Two The second session of the rotation
The American Journal of Hospice & Palliative Care January/February 1992
begins with a brief lecture and discussion of grief and bereavement issues led by the hospice’s counseling and bereavement coordinator. Emphasis is placed on the symptoms and behaviors of normal grief, the dynamics of grief, factors influencing complicated grief and effective treatment interventions, the tasks of grief work, and psychosocial issues commonly faced by the terminally ill patient and family.
likely to gain from participation. Session Three Session Three begins with a brief lecture/discussion led by the hospice chaplain who addresses common spiritual issues faced by the terminally ill patient. Included are: • Immortality; • The unknown; • Forgiveness and acceptance;
The second session begins with a brief lecture and discussion ofgrief and bereavement issues ...
.
Each student spends the remainder of the second session visiting individually with a patient and the patient’s family members. The understanding is that the patient and family members will occupy the role of “teacher” by sharing their experiences during the terminal illness. The student’s function is to listen and to ask questions concerning medical history, results of treatment, effects of painand symptom control measures, psychosocial and spiritual issues, and concerns about dying. It has been our experience that most patients and family members welcome the opportunity to share their experiences and are interested in assisting with the training of physicians. Bloch13 has reported that patients appropriate for use with medical students are those who are aware of their diagnosis, are in reasonable physical condition, are still living at home, and are motivated to engage with a student. Patients exhibiting total denial are unsuitable but those experiencing anger or depression are
Downloaded from ajh.sagepub.com at Monash University on June 4, 2015
• The importance of unconditionalpositive regard and nonjudgmental attitudes when interacting with the patient and family members; • Physician acceptance of various religious views; and • The importance of physician comfort when listening to and discussing spiritual concerns. The remainder of Session Three is devoted to home visits during which each student visits patient homes with a hospice home care nurse. The students are instructed to discuss: • Coping strategies the patients and family members have developed; • Family responsibilityfor home care ofthe patient; • Concerns about the death occurring athome; and • Psychosocial and spiritual issues faced by each patient and family. The control of pain and other symptoms in the home care setting is emphasized. Although bed sores,oral hygiene and constipation are commonly thought of as being minor problems, their treatment is also emphasized because each can greatly decrease quality of life if not appropriately treated.
Session Four The final session consists of informal patient presentations by each student during which pain and symptom control, psychosocialand spiritual concerns, and ethical issues are addressed. In addition the therapeutic relationship and the students’ reactions to being with a terminally ill patient are discussed. The session is led by the medical director.The last session is purposely more unstructuredthanprevioussessions to provide an opportunity for students to share their experiences and explore various issues theyhave confronted. The medical director assigns as an evaluation tool a small group project which consists of a group determination of the 15 drugs the group would take to an “island hospice,” including appropriate routes of administration and side effects. To date the students have enjoyed this evaluation which requires group discussion and consensus. After the list is shared and discussed, each student completes an evaluation of the hospice experience. Evaluation At the outset ofthe hospice rotation and at its conclusion questionnaires based on thosedeveloped bythe Kaiser Permanente Medical Center’4 and the Denver Veterans Administration Medical Center” were administered to 76 students who completed the hospice rotation. The pre- and post-tests were administered to determine: • Changes inattitudes toward the hospice concept of care; • Changes in attitude toward a hospice rotation for medical students; and • Changes in beliefs concerning palliative care. Students responded to the 23 item questionnaire by selecting points on a six point Likert scale continuum from Strongly Agree (1) to Strongly Disagree (6).
Table 1. Summaryof pre- and post-test results. Attitudes toward hospice care. Pretest Mean
Post test Mean
t value
p
A hospice program favorably affects thecareofterminallyillpatients.
1.61
1.16
—5.9
Abstract
Introduction
A required 16 hour hospice clinical rotation was developed as part of a medical studentfamily practice clerkship. The effect ofthe hospice rotation on student beliefs and attitudestowards the care of dying patients was measured by pre- and post-test questionnaires using a Likert scale. Sixty-five completed pre- and post-tests were analyzed using a paired t-test. It was determined that there were statistically significant changes in responses to 15 of23 items. The rotation positively q1 fected student attitudes about hospice care, student attitudes abouta hospice rotation, and beliefs concerningpalliative care. The authors believe that qualified hospice programs can, and should, serve an active role in teaching medical students about the physical and psychosocial aspects of caring for the dying.
The approaching death of a patient can lead to increased stress, self-doubt, and anxiety for the physician involved in care.1’2 In fact, the most intense patient avoidance response on the part of physicians is probably the one evoked by the circumstances and emotional reactions surrounding the patient’s death.3 Physicians tend to distance themselves from their terminally ill patients because they feel they have no skills to offer once investigation, diagnosis, and cure are no longer relevant.4 A1980 survey ofmedical schools in the United States indicated that medical school offerings in death education had increased slightly since 1975 with 80 percent of the schools continuing to offer occasional lectures and short “mini courses” on death education, but 13 percentnow offering full-term courses and only 9 percent offering no formal death education.5 Despite the increase, medical school students indicate that their education does not adequately prepare them to deal with the many issues involved in caring for a terminally ill patient.~8The psychosocial aspects of terminal illness appear to present particular difficulties formedical students6’9 and it has been recommended that medical schools focus on these issues, as well as on physical care, when developingdeath education curricula.’°
Carol F. Knight, EdM, is Education and Research Coordinator, Sr. Anthony’s Hospice and Life Enrichment Program, Amarillo, Texas. Peter F. Knight, MB, BS, isAssociate Professor, Department of Family Medicine, Texas Tech University Health Sciences Center, Amarillo, Texas. Mark f-I, Gellula, PhD. is Coordinator ofCME, MacNeal Hospital, Berwyn, Illinois. Gerald H. Holman, MD, is Chief of Staff, Veteran’s Administration Medical Center, Amarillo, Texas.
The American Journal of Hospice & Palliative Care Downloaded from ajh.sagepub.com at Monash University on June 4, 2015 January/February 1992
Hospice programs offer a unique model of caring for terminally ill patients by providing palliative care and extensive support services to patients for whom curative intervention is no longer appropriate. Unfortunately there is an unspoken but subtly perpetuated idea within the medical profession that the death of a patient
Physiciansfeel they have no skills to offer once investigation, diagnosis, and cure are no longer relevant. always represents a physician failure.3 The hospice concept of care, however, offers a differentview: death is seen as an inevitable and integral part ofthe life cycle. Unfortunately, most hospice programs are located outside teaching institutions and are involved in only a minor way, if at all, with medical student teaching. Therefore, little is known regarding the potential role of a hospice in teaching medical students about the care of the terminally ill patient.11 It has been suggested that early exposure to the concepts of palliation as an alternative to curative treatment in the terminally ill patient
23
could set the stage for the development of new attitudes in medical students.’2 It is the impression of the authors that qualified hospice programs can serve an active role in teaching medical studentsthe concepts of palliative care. To document these impressions the authors developed a required hospice rotation as part of a medical school’s family practice clerkship for fourth year medical students. Since most death education curricula lack adequate experiences working directly with terminally ill patients, a clinical rotation was developed to promote personal contact with dying patients. The study’s aim was to demonstrate that a qualified hospice program can serve an active role in teachingmedical students about the physical and psychosocial aspects of caring for the dying. It has been suggested that the clinical setting is the one in which the most intense and fruitful teaching takes place.9 Despite the recognized importance of teaching in a clinical setting, the format most often used in medical school death education offerings is a combination of lectures and seminars. Formal teaching ofcaring for the dying patient is found less frequently in a clinical setting, particularly as part of a required medical student rotation.9 Goal The over-all goal of the hospice rotation is to provide a structured, clinical rotation for medical students which will increase their awareness, sensitivity and clinical skills when dealing with terminally ill patients and their family members. Objectives • Students will be able to describe the concepts and philosophy of hospice care. • Students will be able to describe effective pain management techniques for the terminally ill.
• Students will be able to describe effective management of common problems of terminal illness.
The rotation begins with a lecture and small group discussion concerning the concepts of hospice care • Students will recognize and know how to deal with the symptoms of normal and complicated grief. • Students will recognize common psychosocial issues faced by terminally ill patients and their family members. • Students will recognize common psychospiritual issues faced by terminally ill patients and their family members. • Students will evidence increasedcomfort and decreased anxiety when caring for a terminally ill patient. Description St. Anthony’s Hospice and Life Enrichment Program is a JCAHO accredited, Medicare certified, hospice which has been designated one of two world-wide research and education centers by the International Hospice Institute. It is owned and operated by St. Anthony’s Hospital and consists of a home care program and a 20-bed free-standing inpatient facility. A fulltime medical director providesover-all direction for the care of each hospice patient and either assumes care when a patient is admitted or is available in a consultant capacity to other physicians whose patients have been admitted to the hospice program.
24 Downloaded from ajh.sagepub.com at Monash University on June 4, 2015
Texas Tech University Health Sciences Center is a four year accredited medical school which provides training forits third and fourth year students at the branch campus in Amarillo as well as at other campuses. St. Anthony’s Hospice, in collaboration with the branch campus in Amarillo, developed a required 16 hour hospice rotation for fourth year medical students. During the hospice rotation all medical students who are on theirfamily practice rotation spend four half days, or 16 hours, at St. Anthony’s Hospice learning about and dealing with the clinical issues of caring for dying patients. The students rotate through hospice on a monthly basis in groups of two to four students. Prior to the hospice rotation, students had only received periodic lectures on caring for terminally ill patients. The rotation was established in August 1986 with 76 students participating through December 1989. The following is a description of each session of the rotation. Session One Prior to the initiation of the hospice rotation each student receives an extensive packet of background readings on the physiological mechanisms of pain, pain and symptom control, bereavement, and spiritual and ethical issues. The rotation begins with a lecture and small group discussionconcerning the concepts of hospice care including: • The appropriateness ofhospice care for terminally ill patients; • The interdisciplinary approach to hospice care; and The importance of understanding the physical, psychosocial, and spiritual needs of dying patients and their family members. The medical director ofthe hospice program thenlectures on:
The American Journalof Hospice & Palliative Care January/February 1992
• Pain and symptom management in the terminally ill patient; • Effective intervention strategies for the management of pain; • Thephysiological mechanisms ofpain; • The dimensions and presentation of severe chronic pain; • Pharmacologic control of chronic pain including agents, dosage, and side effects; and • Myths about narcotic analgesics. A detailed lecture is necessary to correct continued misunderstanding concerning the appropriate management of chronic pain in the terminally ill patient. Effective interventions to relieve selectedsymptoms experienced by terminally ill patients are also presented with emphasis on the control of constipation, nausea, vomiting, bowel obstruction, and opiate intoxication. The medical director also describes his role as a member of the interdisciplinary team and the importance of providing team leadership. Although hospice is sometimes viewed primarily as a nursing program, the physician plays a crucial role in hospice care in the areas of pain relief, symptom control, advising on disease outcomes, and serving as a source of information and support for team members and the patientand family.4 The medical director then conducts inpatient rounds during which he discusses diagnosis, treatment, prognosis, psychosocial and ethical issues, and models appropriate communication, body language, and touch with the dying patient and family members. Session Two The second session of the rotation
The American Journal of Hospice & Palliative Care January/February 1992
begins with a brief lecture and discussion of grief and bereavement issues led by the hospice’s counseling and bereavement coordinator. Emphasis is placed on the symptoms and behaviors of normal grief, the dynamics of grief, factors influencing complicated grief and effective treatment interventions, the tasks of grief work, and psychosocial issues commonly faced by the terminally ill patient and family.
likely to gain from participation. Session Three Session Three begins with a brief lecture/discussion led by the hospice chaplain who addresses common spiritual issues faced by the terminally ill patient. Included are: • Immortality; • The unknown; • Forgiveness and acceptance;
The second session begins with a brief lecture and discussion ofgrief and bereavement issues ...
.
Each student spends the remainder of the second session visiting individually with a patient and the patient’s family members. The understanding is that the patient and family members will occupy the role of “teacher” by sharing their experiences during the terminal illness. The student’s function is to listen and to ask questions concerning medical history, results of treatment, effects of painand symptom control measures, psychosocial and spiritual issues, and concerns about dying. It has been our experience that most patients and family members welcome the opportunity to share their experiences and are interested in assisting with the training of physicians. Bloch13 has reported that patients appropriate for use with medical students are those who are aware of their diagnosis, are in reasonable physical condition, are still living at home, and are motivated to engage with a student. Patients exhibiting total denial are unsuitable but those experiencing anger or depression are
Downloaded from ajh.sagepub.com at Monash University on June 4, 2015
• The importance of unconditionalpositive regard and nonjudgmental attitudes when interacting with the patient and family members; • Physician acceptance of various religious views; and • The importance of physician comfort when listening to and discussing spiritual concerns. The remainder of Session Three is devoted to home visits during which each student visits patient homes with a hospice home care nurse. The students are instructed to discuss: • Coping strategies the patients and family members have developed; • Family responsibilityfor home care ofthe patient; • Concerns about the death occurring athome; and • Psychosocial and spiritual issues faced by each patient and family. The control of pain and other symptoms in the home care setting is emphasized. Although bed sores,oral hygiene and constipation are commonly thought of as being minor problems, their treatment is also emphasized because each can greatly decrease quality of life if not appropriately treated.
Session Four The final session consists of informal patient presentations by each student during which pain and symptom control, psychosocialand spiritual concerns, and ethical issues are addressed. In addition the therapeutic relationship and the students’ reactions to being with a terminally ill patient are discussed. The session is led by the medical director.The last session is purposely more unstructuredthanprevioussessions to provide an opportunity for students to share their experiences and explore various issues theyhave confronted. The medical director assigns as an evaluation tool a small group project which consists of a group determination of the 15 drugs the group would take to an “island hospice,” including appropriate routes of administration and side effects. To date the students have enjoyed this evaluation which requires group discussion and consensus. After the list is shared and discussed, each student completes an evaluation of the hospice experience. Evaluation At the outset ofthe hospice rotation and at its conclusion questionnaires based on thosedeveloped bythe Kaiser Permanente Medical Center’4 and the Denver Veterans Administration Medical Center” were administered to 76 students who completed the hospice rotation. The pre- and post-tests were administered to determine: • Changes inattitudes toward the hospice concept of care; • Changes in attitude toward a hospice rotation for medical students; and • Changes in beliefs concerning palliative care. Students responded to the 23 item questionnaire by selecting points on a six point Likert scale continuum from Strongly Agree (1) to Strongly Disagree (6).
Table 1. Summaryof pre- and post-test results. Attitudes toward hospice care. Pretest Mean
Post test Mean
t value
p
A hospice program favorably affects thecareofterminallyillpatients.
1.61
1.16
—5.9
