Death in medical training

 is a medical student in the Class of 2020 at Western University

 

Nearing the end of my first year in Medical School, I am amazed by the wealth of knowledge acquired during such a short time. There have even been several moments throughout the year where picturing myself as a fully licensed physician seemed slightly less daunting. I have become comfortable with routine physicals, certain diagnoses, different drugs, and management of a wide range of illnesses. I have no doubt I will encounter each of these facets of healthcare during my career. However, there is one unavoidable aspect of medicine that has been discussed very little: death.

The discussion of death is, understandably, quite sensitive; thus, discussing it with such a diverse demographic of students requires a certain amount of skill and reserve. But after learning about concepts such as palliative care and patient-physician relationships, it seems unjust to gloss over one of the most vital roles of a physician — the ability to comfort patients in their most troubling times. I believe discussions around death are often avoided because there is no risk stratification, drug regimen, or medical device to guide physicians in approaching it. When the vast majority of patients are nearing their final breath, it is neither their creatinine levels nor their oxygen saturation that a physician is concerned with; rather, it is their fear, uncertainty, and spirituality that should be tended to. In order to train competent physicians, schools must ensure trainees are comfortable with these discussions. Fortunately, there are several potential avenues to increase integration of these discussions into curriculum.

Group discussions: Group discussions promote a comfortable and less intimidating environment for students to ask questions and engage with their peers about current topics they are studying. Furthermore, these small group sessions — often facilitated by a physician — provide a setting ideal for sensitive discussions. Questions should be asked of the group that invite them to think about how terminal illnesses would alter their approach to medical care. A patient in the final stages of Alzheimer’s would have different needs from a patient suffering from heart failure. A patient on high doses of pain medication would require different supports from one who is receiving parental nutrition. Challenging students to integrate in-class learning with the social aspects of medicine will help ensure they understand the consequence of their decisions. Further, it will make students more comfortable discussing these consequences with their patients when suggesting possible therapies. A certain intervention may prolong a patient’s life by several months, but if these months are filled with debilitating vomiting, nausea, and pain then that is something our future physicians should feel comfortable talking about. Integrating these realistic scenarios into our academic discussions will help students gain a new perspective on the illnesses they traditionally learn about.

Patient interviews: Patient interviews are slowly being integrated into medical curricula. Physicians will sometimes bring in patients and give them a platform to discuss their illness and its physiological impact. However, these discussions often revolve around the patient’s symptoms, the required drugs, and potential side effects. Many students are afraid to ask sensitive questions in front of their entire class, unsure of how the patient might respond or if the question is even appropriate. One way to optimize these patient discussions could be to allow students to submit questions online before class. Additionally, physicians could make a concerted effort to ask the patient to describe the social impact of their illness experience. The patient should be invited to talk about what they wish their doctors had told them before starting a treatment regimen, which aspects of the illness they were most fearful of, and how they dealt with these. Probing the illness experience can provide students with more meaningful learning and a deeper appreciation for various diagnoses.

Site visits: In all likelihood, not every student in the classroom is going to be motivated to learn about end-of-life discussions and care. This may be due to several factors: finding the topic emotionally distressing, not valuing it as an important part of medical education, or feeling overwhelmed by other parts of the curriculum. In order to accommodate the students who do wish to learn about this very crucial part of medicine, physicians should be encouraged to organize site visits. Organizing individual observerships can yield similar results, but it is often impractical to arrange these for large groups of students. Attending clinic sand speaking to patients with terminal diagnoses as a group may allow students to feel more at ease having these discussions in future practice. On-site visits can also shed light on how different aspects of the medical system influence patients’ experiences during their final months. A popular sentiment many students have heard is that patients don’t want to spend their final days in a hospital bed, hooked up to an assortment of IV lines and other machinery. By experiencing the environment in a hospital and its effect on patients, students may become motivated to see what can be done to improve the hospital setting. 

As the scope of medicine and the needs of patient evolve, having an education system that remains stagnant is troublesome. One area of medicine that must be further integrated into the curriculum involves end-of-life discussions and care. The next generation of physicians is going to be faced with an aging demographic; this patient population will require them to be both technically proficient and compassionate in their care.  Teaching medical students to become comfortable having these vital discussions will ultimately enable them to better serve their communities.