We analyzed survey data from 380 graduating medical students to examine the relationship between exposure to death and attitudes and knowledge about end-of-life care. Most students reported both personal experience with death and experience with death and dying patients during medical school. Students had positive attitudes about physicians' responsibility and ability to help dying patients and their families, but reported negative emotional reactions to end-of-life care. In the classes of 2005–2006, for which pre-/post-medical school data was available, we found that students' attitudes toward end-of-life care became more positive and their knowledge about end-of-life care increased over the course of medical school. Both personal experience with death and exposure to death during medical school were associated with more positive attitudes and higher knowledge about end-of-life care.
Our findings are interesting in the context of two important concerns raised in the literature about undergraduate end-of-life care education. First, reports and national surveys raise concern that students are sheltered from death and dying patients, and as a result may leave medical school without being involved in the care of dying patients.1,35
Although most of our students cared for at least 1 dying patient or witnessed at least 1 death during their third-year clerkships, 27% of students cared for no dying patients, and there was marked variability in the numbers of dying patients for whom students cared. Second, past studies describe a hidden or informal curriculum during which students undergo an acculturation process in medical school where they learn negative attitudes about end-of-life care from their supervising residents and faculty.11,22,37,38
This did not seem to be the case for the students in our survey, who acquired positive attitudes and knowledge about end-of-life care over the course of medical school.
That exposure to death was associated with more positive attitudes and higher knowledge provides empiric evidence to guide end-of-life care curriculum development. First, the association supports the recommendation that clinical care of dying patients should be a required part of every medical school curriculum.10,42
Second, that exposure to death and dying patients during the third year of medical school was associated with positive attitudes indicates that effective end-of-life care education can be provided by integrating end-of-life care education into existing courses and rotations. This approach is much more feasible than creating new courses and rotations given the limited time that is available in medical school curricula.43
That knowledge about end-of-life care was associated with the total number of dying patients students helped care for over the course of medical school but not with their exposure to death and dying patients during their third year indicates that some students learned about end-of-life care in the context of caring for dying patients during a fourth-year elective or other setting. Based on this result, it seems that a more intensive exposure to death is required to impact knowledge. This finding, along with the variability in the number of dying patients for which students cared, underscores the importance of curricular efforts to ensure that all students care for dying patients.
The fact that students reported negative emotional reactions to care of dying patients and their families is also an important consideration for curriculum development. Our results mirror the findings of a national sample of medical students, residents, and faculty,35
and indicate that lack of emotional coping skills is a significant barrier to comfort with end-of-life care. Physicians and students alike have emotional reactions to patients' deaths,44–50
and physicians who do not learn coping skills are at risk for stress and burnout.51,52
Experiencing death in a supportive environment is an opportunity for students to learn emotional coping skills that become healthy habits for the rest of their careers.45,53
However, studies to date indicate that students do not feel supported when their patients die, and as a result do not learn how to relate with their own emotions.45–50,54
Future work should explore ways to teach students about death and dying in emotionally supportive settings.
In interpreting our findings, it is important to consider the effect of the strong hospital-based consultation service at the University of Pittsburgh Medical Center.39,40
A central goal of the Palliative Care Program has been to address the informal/hidden curriculum at the institution. Students interact with palliative care consult faculty during their third-year clerkships and learn from residents who have been influenced by the service. Thus, our results may not be generalizable to settings in which students are not exposed to a palliative care program.10,33,35
Our study has several limitations. First, our response rate was only 47%, and we do not have data on the students who did not respond. Thus, our results may include a selection bias if the students who responded to the survey were systematically different from those who did not. We only had paired pre-/post-medical school data for two of the six classes included in our analysis. In the paired analysis of the classes of 2005 and 2006, exposure to death during medical school was not associated with student interest in learning about end-of-life care at medical school entry. However, it is possible that an unmeasured confounding variable was associated both with students' exposure to death and their knowledge and attitudes. Second, although the instrument we used to assess attitudes and knowledge was developed for fourth-year medical students, it has not been validated and data are not available to compare students' performance on the knowledge items to other cohorts. Third, we used students' report to measure personal and professional exposure to death, so it is possible that a recall bias affected our results. It is also unclear where students were exposed to death outside of their third-year clerkships, as our dataset did not include information about students' participation in fourth-year electives. Only an average of 9 students participated in the fourth-year palliative care elective each year, indicating that students participated in other electives where they learned to care for dying patients, e.g., in the intensive care unit or oncology service. Finally, the outcomes we used to assess student's preparation to provide end-of-life care were attitudes and knowledge. These outcomes are necessary but not sufficient for students to provide quality end-of-life care. A skills-based assessment such as watching students interview and make clinical decisions about a real or standardized patient in an Objective Structured Clinical Examination setting would provide a more accurate reflection of students' ability.
In summary, our finding that exposure to death is associated with positive attitudes and greater knowledge about end-of-life care in graduating medical students supports the recommendation that all students should participate in the clinical care of dying patients. Teaching students end-of-life care during the course of their clinical clerkships is an effective way to improve attitudes about end-of-life care. Negative emotional responses to end-of-life care may be significant barriers, so schools should focus on developing emotionally supportive settings in which to teach students about death and dying.