Between 2002–2007, reflection essays were gathered from a total of 829 second-year medical students and physician assistant students (Student essays per year = 2002:164. 2003:189, 2004:169, 2005 not included, 2006:148, 2007:159).
Overall Content of Essays
Across all years, the majority of learners chose the essay format to reflect on personal experiences with death. This recounting took many forms: 1) in-depth description of a significant death experience and the student's reaction to it; 2) a chronological inventory of a variety of experiences losing loved ones or friends, or being around patients at the end of life—mirroring information they would have provided in their PDH; or 3) an identification of students' lack of significant exposure to death and the implications of this for their practice as physicians.
The second most common use of the reflection essay was to describe concerns about future encounters with end-of-life issues. These essays focused on contemplation of the student's own death (and the fears and needs at that time) or the death of loved ones and/or patients at the end of life.
The third most common focus of the essays was to address or respond to issues raised in the course lectures, either by recounting their importance and/or reacting to concepts as affirming, new, or controversial.
Many of the essays combined all three of these elements recounting personal experiences, describing future concerns and tying it directly to lecture content.
Major Themes in Student End-of-Life Concerns
Analysis of the content of the essays was condensed to four major themes, described below with representative student examples. (See sidebar: Themes and Concerns
Themes and Concerns
- Emotional responses to caring for the dying
- Own emotional response
- Appropriate emotional sharing and connection
- Failing to portray, or even feel, enough emotion or empathy
- Communicating support
- Shifting emphasis from curing to caring
- Feeling ill prepared
Their concern was both about “losing one's composure” or “crying” in front of patients, family members, even medical colleagues, and how to protect oneself from the pain of grief that could accompany a patient's death.
Emotional Responses to Caring for the Dying
One of the most common student concerns was their own emotional response to involvement with dying patients and their families. These responses fell into three categories. The primary category was personal grief and discomfort about a patient's death. Their concern was both about “losing one's composure” or “crying” in front of patients, family members, even medical colleagues, and how to protect oneself from the pain of grief that could accompany a patient's death.
I will be on the wards in a few months, and somebody might die. Somebody might cry while I interview her. I might cry. What will I do? How will I respond to these things? Will I give the wrong response? I have felt a significant amount of anxiety over these issues in the last year. Last week during the end-of-life care lectures, though, I felt a subtle wave of reassurance come over me.
Learners expressed, as a second category of concern: their struggle to understand the amount of emotional sharing and connection appropriate in end-of-life situations—trying to keep a balance between being emotionally involved and supportive, while maintaining enough objectivity to accomplish the necessary clinical tasks in the context of end-of-life care.
I've heard that you can go into the room of a patient, look her in the eye and tell her she is going to die, and then you can leave the room and go see your next patient and smile at them. How can this be done? How can you not leave part of yourself in that room, in every room, until there is nothing left? And if it is in fact feasible to be caring and compassionate and human while still performing as a physician, how long does it take to get there? How do you protect your soul while you are learning how to master this awful skill? These are not things we learn as part of the core physical. And I am scared they are things I will never learn. That I will try and try, until I get tired of practicing. Then I will numb myself to the pain of others because I cannot handle the learning curve of this job requirement.
The third concern learners expressed was failing to portray, or even feel, enough emotion or empathy for patients and families at the end of life. Some attributed this to their self-perception of not being very emotional, while others anticipated that the demands of providing care may limit their ability or time to express support.
I have always been a little concerned with my lack feeling towards death and have felt that maybe I'm not sympathetic enough, heartless, or just don't have the emotional capacity to handle death appropriately. I have grown to understand that everyone deals with death differently and it is fine that I am not visibly moved by death. I have grown a lot emotionally and spiritually since the last time I was close to a person who died and I am very curious about how I will react to the next death.
Many of the essays contained learners' worries about their ability to provide effective and supportive interactions with patients and families.
I think one of the more difficult challenges I will face in dealing with end-of-life issues as a physician will be knowing how best to provide my support for the family and to find the best way to help them through their grief. It will be hard for me to tell the family that their loved one is gone, partly because I'll be frustrated with the limitations of medicine and I don't like the idea of someone dying under my care: almost as if their death is my failure as a physician. It will take me some time to work through this frustration and realize that not everybody is going to live and I must do all that I can to help them, but it's not necessarily a shortcoming if they do die.
The majority of these statements include concerns about being able to “say the right thing” both to patients and to families. As major concerns, essays addressed not only grief at the loss of a loved one, but also delivering bad news.
Shifting Emphasis from Curing to Caring
The third major theme in learners' essays was when curative therapy is no longer a viable option, examining the clinician's role in providing both physical and emotional support to patients. Thus far through medical school many learners noted that they had thought little about dealing with dying patients, since the curricular emphasis had been on diagnosis and treatment.
I am worried about caring for dying patients. I haven't worked out my own feelings about death and am unsure how to deal with dying patients. Most of my experiences with death have been with quick deaths. If I were more confident about my own beliefs about death and dying, I think I would be more confident with those patients. I am also worried about seeing death as a failure to help/cure the patient. Whenever I thought of medicine, I always pictured treating and healing patients. End-of-life scenarios were not part of my visualized medical career. I now know that is not the reality, but I am still concerned about how I will deal with death and dying.
Learners come to recognize the need to shift from curative to palliative care, many acknowledging the personal discomfort of grappling with it.
Feeling Ill Prepared
Many of the learners expressed, as the fourth theme, feeling unprepared to deal with end-of-life issues, not only in relation to patients, but also in regard to the eventual loss of loved ones and—even facing their own deaths. For many, the PDH was a catalyst and premise for their conclusion that they have had little preparation.
I have concerns about dealing with patients as they die. I have had very little personal experience with death and I am unsure how to comfort someone or his or her family as that patient dies. I also wonder how my first patient death will affect me. I've never been present for someone's death and I don't know how it may change my feelings on mortality and treating patients. It's difficult to know any strong feelings that I have with death because I have never been close to anyone who has died.
Many of these four themes were expressed as interrelated. For example, learners who had little experience also expressed concern about balancing their own emotional responses, about providing appropriate support to patients and their families, and being able to properly shift their emphasis from caring to curing.
Responses to the Curriculum
In addition to identifying areas of student experience and concerns, reflection essays provided an opportunity for learners to directly react to the end-of-life curriculum, positively or negatively, which some chose to do.
To have the end-of-life module built into the first two years of medical school is a privilege. Many of my friends at other medical schools don't have this opportunity to openly discuss and acknowledge the difficult challenges health care professionals and their patients face when confronted with end-of-life issues. I think that it's assumed if you embark on the career of doctoring, that you somehow integrally know how to handle difficult situations, how to protect yourself and your patients and patients' families from the rawness of death. I think that's an enormous leap from what's actually true. I personally have never dealt with the death of a loved one or anyone close.
The Value of Reflection
In some essays, the value of, and opportunity for, reflection on end-of-life issues was directly addressed—most commented on the opportunity for reflection on issues, while a small number commented directly about the value of the reflection essays.
The most important aspect of this lecture series for me was the emphasis on reflection on personal experiences. I find this to be especially important because it would be very difficult to be an effective part of a health care team serving a dying patient and his or her family if you tried to remain entirely objective. To serve your role as a healer you must use personal experience to provide the best possible care.
This probably wasn't the purpose of this assignment but you have no idea how much this has helped me to put down on paper at least a little bit that I went through that has been bottled up. I think these classes are essential to our training. I've found that medical school and our hectic world make it easy to slip into a routine that makes self-reflection next to impossible. I appreciate the chance to take a moment to recalibrate myself and realize that I haven't strayed too far from the person that I was before I got here.
Out-of-Class versus In-Class Reflective Writing
We discovered differences in the overall content of essays between the subset of OC essays compared to IC essays. Although the number of learners discussing personal experiences and future interactions was essentially the same in both formats, more of the IC essays directly responded to lecture content. This appears to be an artifact of the little time to contemplate. Overall, most IC essays were shorter and less polished than OC essays. The OC essays recounting a personal experience had a polished story format—rather than a rough recounting of incidents—and more were written in third person. Conversely, alternative formats to a prose essay were more prominent in the IC writing including bulleted lists of concerns and/or questions, poems, cartoons and even concept maps. The latter two more creative formats were constrained during the required OC online submission process.
Small group evaluation comments revealed that some found the IC writing exercise helpful and even fun; others found it less useful and felt that it limited time for important group interaction. Several learners questioned the utility of the IC and/or the PDH when they were not incorporated into the discussion by individual facilitators. Learners especially appreciated hearing other learners' experiences and concerns. One of the purposes of the reflective writing exercise was to prepare learners for identification and discussion of issues in the small group sessions.