A One-day Interclerkship on End-of-life Care

Objectives: The convergence of public and professional concern about deficiencies in the care of dying patients raises the question of what medical education can do to better prepare future physicians to provide this care. In 2000, the University of Massachusetts Medical School conducted a focused one-day intervention at the end of the students' third year to address issues arising in care of the dying patient. A multidisciplinary Committee on End-of-life Education designed the intervention to prepare students to: (1) recognize the appropriate time for shifting the care plan from curing disease to providing palliative care; (2) understand resources available to the dying patient within the hospital and in the community; (3) participate in interdisciplinary care of the dying patient; (4) develop an approach to managing common symptoms at the end of life; (5) understand the physician's role in addressing the needs of the dying patient, the patient's family, and society; and (6) begin reflecting on the physician's personal reactions to the care of patients with terminal illness. Description: Eighty-eight students (88% of the class) returned to campus to participate in this selective interclerkship on end-of-life care. The students interacted with terminally ill patients and family members of patients who had died, observed experienced clinicians demonstrating essential skills required for appropriate end-of-life care, and in small-group sessions integrated and applied to “real” cases what they had learned. Small-group sessions focused on symptom management, pediatric death, practical aspects following death, limitation of treatment, and reflection on deaths that they had witnessed during their third year. Course impact was measured by pre- and post-interclerkship written tests on knowledge (12-item multiple-choice), self-assessed attitudes and skills (five-item, five-point Likert scale), and programmatic assessments (seven-item, five-point Likert scale). Data were compared using paired t-tests. Discussion: The students made modest but significant pre-to post-interclerkship gains in knowledge about end-of-life care (7.85 ± 0.17 versus 8.30 ± 0.21, p = .016). More strikingly, their self-assessed skills and attitudes about their readiness to deliver this care shifted from 2.72 ± 0.08 to 3.77 ± 0.05 (p < .001). In particular, they reported a clearer understanding of symptom management, increased understanding of regulations regarding organ donation, greater understanding of “whole patient assessment” at the end of life, and greater confidence in initiating “limitation of treatment” discussions with patients or surrogates. These findings suggest that the interclerkship gave students an opportunity to consolidate and validate knowledge and experiences gained throughout their third-year clinical rotations. These gains were mirrored by the students' enthusiasm for the interclerkship with ≥97% of them agreeing or strongly agreeing that the program focused on a topic essential to medical training, that it integrated the clinical, basic science, and psychosocial aspects of end-of-life care, and that it provided new knowledge and skills not obtained elsewhere in their medical education. Our findings suggest that a focused one-day classroom-based intervention at the end of third year is a highly successfully method for teaching complex issues related to end-of-life care. Based on its success, the Interclerkship on End-of-Life Care will be required for all third-year students.