On World Hospice Day, final year registrar in palliative medicine Dr Geoff Wells discusses his recent research at BSMS into preparing medical students for dealing with dying patients, and why this is so important.
Dr Geoff Wells, Final Year Registrar in Palliative Medicine
Tell us about your research interests
I’m interested in looking at how we teach students to care for dying patients and their families, and how we prepare them to do this as our future junior doctors.
I remember the first time I was called to see a dying patient and it was quite a frightening experience, but I distinctly remember the nursing staff being very supportive, having been well prepared through experience and repetitive practice.
It’s become apparent that although medical schools are doing their best to teach care of the dying at undergraduate level, we’re not always getting it right. Feedback from junior doctors to the General Medical Council shows they are experiencing a lot of distress and feeling underprepared to care for dying patients and their families. So there’s a gap between what we’re expecting of junior doctors and what we’re teaching them at medical school. It is also important to note that, anecdotally at least, there are those at consultant level who also experience anxiety when caring for dying patients.
Why do you think this is?
The biggest problem, evidenced within the literature, is that undergraduates are not getting enough exposure to dying patients. All BSMS students have a placement at a hospice, but that’s only for a few days and mainly towards the end of their undergraduate training. This exposure is limited due to student numbers, an already tightly packed curriculum and the relatively small number of hospices – and of course it’s not always appropriate to have medical students at the bedside of a dying patient.
When somebody’s dying, it’s only going to happen to them once, and it’s a unique experience for them and their family. We do everything we can in palliative medicine to make that experience as stress-free and comfortable as possible; having several students around the bedside may not always be congruent with that.
What did your research involve?
We looked at determining what level of anxiety exists among our medical students when asked to think about caring for a dying patient and their family, and whether this is affected by their year of study, gender identity, age and whether they had a previous degree.
While second years had a greater level of anxiety (possibly due to anticipation of third year clinical study), overall, the level of anxiety did not change by the fifth year. Age had a significant influence, with older students less likely to be anxious about caring for the dying (greater life experience may have influenced this), but gender identity and degree status exerted no influence.
In a separate study, we looked into how simulation can help prepare medical students for dealing with dying patients. We use simulation to teach many areas of medicine, particularly in managing acute emergencies, and this is known to be an effective teaching tool. As with an emergency situation, with a dying patient you also have a time limit to provide appropriate and competent clinical care – so there are parallels between the two situations.
We used a high-fidelity mannequin as the dying patient, and professional actors as family members, simulating different scenarios based on real-life situations and included discussions around pain management, appropriateness of clinically assisted hydration in the dying phase, and addressing spiritual and religious needs. In some scenarios the patient died irrespective of what the students did, as we wanted to see how they would manage this situation.
We measured students’ confidence levels before they did the simulations, a few days after, then six months after – results showed their confidence levels increased significantly and were maintained over time.
How could this help in terms of benefits to patients and their families?
Studies show that if your doctor has improved confidence and preparedness then that leads to better patient outcomes. Repetitive practice, for example through simulation, can make a difference in students’ learning; things may be a little more familiar and they may be a little less scared when they come to do it for real.
Ultimately, we hope developing simulation in palliative care teaching could reduce distress among junior doctors, with the patient dying comfortably, and with any previously unmet palliative care needs having been addressed.
What do you enjoy most about working in palliative care?
I think there’s something so positive about helping people die in the best way possible as it’s an opportunity to make a difference in a situation where there is no second chance. Palliative medicine is not the depressing specialty people often think it is, but rather a rewarding and interesting job that enables you to really develop skills in complex communication and management of complex pathology with a great deal of crossover and liaison with many other medical and surgical specialties as well as primary care. While individuals may find it upsetting to talk about death and dying, it is something we will all experience throughout life. I feel passionately that care provided to dying patients is as informed as that of any other specialty, and that the social taboos associated with talking about death and dying should not be allowed to act as a barrier to provision of high-quality education in palliative medicine. Ultimately the goal is to improve the care we offer to our dying patients.
Tell us about your current work with BSMS
I have been fortunate enough to continue working with BSMS to integrate my simulations into the future medical school curriculum. We are currently developing a simulated teaching experience for graduates as part of their F0 training in preparation for real-life clinical practice on the wards. These simulations will replicate those used in my research and will aim to distil knowledge on key aspects of care in the dying phase. We are developing a ‘simulation package’ that can be delivered in regional hospice and hospital environments to ensure all F0 trainees receive the same educational experience. This also means there is a real opportunity for further research to be done in evidencing the value of simulation in palliative medicine education. I believe that earlier integration of palliative medicine will be important in undergraduate curricula if we ever hope to develop confidence among graduates to care for those at the end of life, and that will be the next challenge within the undergraduate curriculum.
read the abstract of Dr Wells’ recent research here >