Medical Students Feel Moderately Prepared to Deliver End-of-Life Care, But Negative ‘Hidden’ Curriculum Can Devalue Care Principals.

A national survey of 1455 fourth-year medical students randomly sampled from all regions of the country in 2001 has found that students feel “moderately well prepared” for a majority of end-of-life care tasks, and have been taught “most aspects” of this care in both the formal and informal (clinical) curricula, according to a report published in the Journal of Palliative Medicine.

However, note the authors, there is a third or “hidden” curriculum, in which unintended messages are inferred by students while observing the behavior of residents and attending physicians. “Negative attitudes or poorly modeled behaviors may have detrimental effects on trainees’ appreciation and delivery of care to dying patients…and may lead to ‘ethical erosion’ or an undermining of students’ idealized values.”

• Negative messages inferred by students from the hidden curriculum included:
• Working with dying patients is “not at” or only “a little” rewarding (60% of respondents).
• Dying patients are not good teaching cases for students (45%).
• Treating psychosocial needs of dying patients is not a core clinical competency (41%).
• Death is a medical failure (21%).

The messages received from this hidden curriculum were found to be negatively associated with students’ perceived preparation for and attitudes toward caring for the dying, and with their perceptions of the equality of their medical education.

FINDING BOTH ‘ENCOURAGING’ AND ‘TROUBLING’

ss="MsoNormal">Compared to data published over 12 years previously by members of this same research team, “the current study is notable for a dramatic increase in the amount of palliative care content included in medical school curricula,” comments senior associate editor R. Sean Morrison, MD, in his accompanying commentary. While Morrison considers this improvement in the formal curriculum to be “highly encouraging,” the data concerning the implicit, negative messages received by medical students he deems “troubling.” His article outlines several policy initiatives for strengthening support for palliative care educators and for encouraging young physicians to choose this career path.

“Whereas there is one cardiologist for 71 persons experiencing a myocardial infarction and one oncologist for every 141 patients diagnosed with cancer, there is only one palliative medicine physician for every 31,000 persons living with a serious and life threatening illness.”

Source: “Determinants of Medical Students’ Perceived Preparation to Perform End-of-Life Care, Quality of End-of-Life Care Education, and Attitudes Toward End-of-Life Care,” Journal of Palliative Medicine; March 2010; 13(3):319-326. Billings ME, et al; Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle. “Bringing Palliative Care to Scale in Our Nation’s Medical Schools,” ibid.; pp. 223-234. Morrison RS, senior associate editor, Journal of Palliative Medicine.