Curricular Innovations for Medical Students in Palliative and End-of-Life Care: A Systematic Review and Assessment of Study Quality

Abstract

Background:

Recent focus on palliative and end-of-life care has led medical schools worldwide to enhance their palliative care curricula.

Objective:

The objective of the study was to describe recent curricular innovations in palliative care for medical students, evaluate the quality of studies in the field, and inform future research and curricular design.

Methods:

The authors searched Medline, Scopus, and Educational Resource Information Center (ERIC) for English-language articles published between 2007 and 2013 describing a palliative care curriculum for medical students. Characteristics of the curricula were extracted, and methodological quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI).

Results:

The sample described 48 curricula in 12 countries. Faculty were usually interdisciplinary. Palliative care topics included patient assessment, communication, pain and symptom management, psychosocial and spiritual needs, bioethics and the law, role in the health care system, interdisciplinary teamwork, and self-care. Thirty-nine articles included quantitative evaluation, with a mean MERSQI score of 9.9 (on a scale of 5 to 18). The domain most likely to receive a high score was data analysis (mean 2.51 out of 3), while the domains most likely to receive low scores were validity of instrument (mean 1.05) and outcomes (mean 1.31).

Conclusions:

Recent innovations in palliative care education for medical students represent varied settings, learner levels, instructors, educational modalities, and palliative care topics. Future curricula should continue to incorporate interdisciplinary faculty. Studies could be improved by integrating longitudinal curricula and longer-term outcomes; collaborating across institutions; using validated measures; and assessing higher-level outcomes including skills, behaviors, and impact on patient care.

Introduction

In the past two decades, a national focus on the importance of palliative and end-of-life care¹ has led medical schools to enhance their palliative care curricula.² Since 2000, the Liaison Committee for Medical Education (LCME), the accrediting body for all allopathic medical schools in the United States and Canada, has required that all medical schools include education in palliative care and communication skills.³ Longitudinal surveys of medical school administrators over the past 35 years have demonstrated that overall offerings in palliative care education have been consistently increasing; and since 2000, 100% of U.S. medical schools have had at least some offering regarding death and dying.² However, in their recent review of surveys of medical educators in the United States, Horowitz, et al. found that approaches to palliative care education are highly variable between medical schools, with some schools reporting as little as two hours of classroom time, while others require weeks of training or clinical experience. Given that medical schools already suffer from overstrained curricula, the authors advocate integrating developmentally appropriate, basic palliative care competencies into each year of the medical school curriculum to avoid both neglect of the topic and educational overload.⁴ A recent national survey of palliative care experts arrived at a proposed set of competencies for medical students.⁵

As palliative care educators advocate for scarce curricular time and select educational methods, it is imperative to identify rigorously tested curricula that can be used. Although previous reviews related to palliative care education exist, these have largely focused on the overall state of palliative care education in the United States, rather than evaluations of discrete curricula or innovations made in the field worldwide.^4,6,7 Furthermore, to our knowledge there has been no systematic assessment of the quality of the evidence supporting such interventions. Therefore, we undertook a systematic literature review to inform curricular development at our own medical school, to understand recent trends in this field, and to evaluate the quality of the literature.

Methods

We conducted this systematic review in adherence with the PRISMA standards⁸ as applied to a systematic review without meta-analysis. Meta-analysis was not pursued, because the literature in this area consists of heterogeneous interventions and outcomes, as well as many pilot or qualitative studies that are not amenable to this methodology.

Questions

These are the research questions we sought to answer:

• What educational interventions have recently been described to teach palliative care topics to undergraduate medical students?

• What is the methodological quality of the studies in this field?

Study eligibility

We included academic articles published in the English language between 2007 and 2013. We chose this date range because a previous review in this topic area reviewed the literature through the end of 2006.⁶ Articles were included if the population of interest was undergraduate allopathic medical students and if the article described the evaluation of a curriculum in a palliative care topic. Articles that described new curricula but did not include evaluation of any learner outcome were excluded.

Study identification

In collaboration with a medical librarian we designed searches of Medline via PubMed, Scopus, and Educational Resource Information Center (ERIC) databases for relevant articles. We performed iterative searches in each database to optimize the relevance and comprehensiveness of the results. We last performed the searches on January 16, 2014. The search strings used were:

Medline: ((terminal care OR “palliative care” OR “palliative medicine” OR “end of life” OR “end-of-life”) AND (education, medical, undergraduate OR “medical students”))

Scopus: ((“palliative care” OR “palliative medicine” OR “end of life” OR “end-of-life” OR “hospice”) AND (“undergraduate medical education” OR “medical students”))

ERIC: ((“palliative care” OR “palliative medicine” OR “end of life” OR “end-of-life” OR “hospice” OR “terminal illness” OR death) AND (“medical students”))

Study selection

Two authors (JD and JM) independently screened all articles, first reviewing titles and abstracts and then full texts. Conflicts were resolved by consensus. In the three instances in which a single intervention was reported in more than one article, we identified the article that provided the most complete description and excluded the others.

Data extraction

Study characteristics for each included article were summarized, including country, learner level, instructors, setting, educational modality, duration of intervention, and palliative care topics addressed.

Two authors (JD and JM) independently tabulated a Medical Education Research Study Quality Instrument (MERSQI) score⁹ for all articles that included a quantitative evaluation. Disagreements between the two raters were resolved by re-review and consensus to assign the final score. The MERSQI was developed by Reed, et al. in 2007 as a measure of methodological rigor of medical education studies. The MERSQI scores studies across six domains: study design, sampling, type of data, validity of evaluation instrument, data analysis, and outcomes. These domains are further divided to yield 10 items. Each of the six domains has a maximum score of 3, giving a possible score for each study ranging from a minimum of 5 to a maximum of 18. This scoring system is summarized in the first three columns of Table 1.

Table 1.

Medical Education Research Study Quality Instrument (MERSQI) Scores for Studies with Quantitative Evaluation

Domain	MERSQI item	Score	Number of studies	Mean (item)	Mean (domain)
Study design	1) Study design			1.53	1.53
	Cross-sectional or single-group posttest only	1.0	12 (31%)
	Single group pretest and posttest	1.5	17 (44%)
	Nonrandomized, two-group	2.0	8 (21%)
	Randomized controlled trial	3.0	2 (5%)
Sampling	2) Number of institutions studied			0.53	1.74
	1	0.5	38 (97%)
	2	1.0	0
	>2	1.5	1 (3%)
	3) Response rate			1.22
	Not applicable		0
	<50% or not reported	0.5
	50%–74%	1.0
	≥75%	1.5
Type of data	4) Type of data			1.77	1.77
	Assessment by study participant	1.0	24 (62%)
	Objective measurement	3.0	15 (38%)
Validity of instrument	5) Internal structure			0.38	1.05
	Not applicable		0
	Not reported	0	24 (62%)
	Reported	1.0	15 (38%)
	6) Content			0.59
	Not applicable		0
	Not reported	0	16 (41%)
	Reported	1.0	23 (59%)
	7) Relationships to other variables			0.08
	Not applicable		0
	Not reported	0	36 (92%)
	Reported	1.0	3 (8%)
Data analysis	8) Appropriateness of data analysis			0.90	2.51
	Inappropriate for study design or type of data	0	4 (10%)
	Appropriate for study design or type of data	1.0	35 (90%)	1.62
	9) Complexity of analysis
	Descriptive analysis only	1.0	15 (38%)
	Beyond descriptive analysis	2.0	24 (62%)
Outcomes	10) Outcomes			1.31	1.31
	Satisfaction, attitudes, perceptions, opinions, general facts	1.0	21 (54%)
	Knowledge, skills	1.5	14 (36%)
	Behaviors	2.0	3 (8%)
	Patient/health care outcome	3.0	1 (3%)
Total score					9.91

Results

Trial flow

Our initial database searches identified 1167 results, and after de-duplication, 829 were found to be unique articles. After filtering the results for English language and date of publication, we reviewed the titles and abstracts of the remaining 299. Sixty-eight met our inclusion criteria based on review of titles and abstracts. Full-text review led to the exclusion of an additional 20, yielding a final sample of 48 articles (see Fig. 1).

FIG. 1.

Trial flow for systematic review.

Study characteristics

The included studies describe 48 unique curricula delivered in 12 countries, which are summarized in Appendix 1: Summary of Curriculum Characteristics.^10–57 Twenty-two articles were from the United States; 7 from the United Kingdom; 4 from Canada; 3 from Taiwan; 2 each from Australia, Croatia, and Germany; and 1 each from Brazil, Hungary, India, Ireland, Japan, and Poland. Educational setting was most often a mix of classroom and clinical settings (n=21, 44%). Seventeen (35%) were in a classroom setting only, 7 (15%) in a clinical setting only, and 6 (13%) included online instruction.

The targeted learners were clinical medical students (I=27, 56%), preclinical medical students (I=17, 35%), or both (n=3, 6%). Five studies (10%) delivered the intervention to medical students together with other learners, such as nursing students, social work students, pharmacy students, residents, and/or practicing health professionals.

Physicians served as instructors for 29 interventions (60%), including 19 (40%) in which the faculty included hospice and palliative medicine specialists. It was also very common to involve other health professionals as teachers, most commonly nurses or nurse practitioners (n=15, 31%), social workers (n=7, 15%), and chaplains (n=7, 15%). In 12 articles (25%) the instructors were not specified.

A variety of educational modalities were employed, including lectures (n=29, 60%), group discussion (n=27, 56%), clinical exposure, which we defined as education that takes place in a clinical setting but does not involve direct patient care responsibilities (n=14, 29%), patient care (n=13, 27%), simulation or role play (n=13, 27%), written assignment (n=12, 25%), online module (n=6, 13%), student presentation (n=6, 13%), reading assignment (n=6, 13%), multimedia (n=6, 13%), and arts activity or performance (n=2, 4%).

The curricular time spent for the educational interventions ranged from 45 minutes to 25 hours. Some articles described single teaching sessions, while others evaluated complex curricula delivered over longer periods (up to four years).

Topics within palliative care addressed by the curricula included communication (n=30, 63%), role of palliative and end-of-life care in the health care system (n=26, 54%), pain and symptom management (n=22, 46%), clinical assessment of patients (n=20, 42%), addressing psychosocial and spiritual needs (n=19, 40%), ethics and the law (n=18, 38%), interdisciplinary teamwork (n=15, 31%), and self-care (n=11, 23%). Five studies (10%) did not specify the topics covered.

Study quality

Of the 48 studies meeting the inclusion criteria, 39 included quantitative methods and were assigned MERSQI scores, while the others were solely qualitative. Table 1 summarizes the MERSQI scoring system and the results for our sample. Scores ranged from 5 to 15 (possible range 5 to 18), with a mean score of 9.9 and standard deviation of 2.7.

The most common study design was single-group pretest and posttest (n=17, 35%). However, 10 studies (21%) involved a control group, including 2 (4%) that randomized their participants.

The domain most likely to receive a high score was data analysis, with a mean of 2.51 out of 3. Twenty-four articles (50%) received the maximum possible score for both appropriateness and complexity of data analysis.

The domains that scored lowest in our sample were validity of the evaluation instrument and outcomes. The mean score for the validity domain was 1.05 out of 3, with 15 articles (31%) scoring zero points on all three items in the domain. The mean score for the outcomes domain was 1.31 out of 3. Twenty-one articles (44%) received the lowest possible score in this domain, indicating that outcomes were measured at the level of satisfaction, attitudes, perceptions, opinions, or general facts, but did not assess knowledge, skills, behaviors, or patient or health care outcomes.

Discussion

Characteristics of palliative and end-of-life care educational interventions

To inform curricular development at our own and other medical schools, we undertook a systematic literature review to describe recent curricular innovations in palliative care education for medical students. We also assessed the quality of the evidence for effectiveness of these curricula. We found that emerging approaches in the field vary widely in scope, ranging from stand-alone didactic sessions to longitudinal four-year curricula. Lecture and group discussion were the most commonly cited educational modalities. However, most interventions employed a mix of modalities, with lecture or group discussions used to prepare for, supplement, or debrief a clinical experience, simulation, or role-play.

One important pattern that emerged from our review is that palliative care curricula tend to employ a broadly interdisciplinary faculty. Of the 36 articles that specified the profession of the instructors, only 9 were taught by physicians alone. The other instructors included not only nonphysician health professionals (nurses, nurse practitioners, social workers, chaplains, psychologists, pharmacists, physical therapists, and massage therapists), but also teachers from nonmedical disciplines such as ethics, law, theology, drama, philosophy, and sociology. Given this wealth of experience in incorporating interdisciplinary faculty, the field of palliative care should serve as a model for how to incorporate nonphysician educators into medical student education to promote interdisciplinary collaboration.

One common limitation of the studies included in this review is that many of the curricula were not described in enough detail to be replicated by other educators. For some articles we were unable to ascertain even basic information such as which palliative care topics were covered or who served as the instructors. As medical educators look to the literature to design their own curricula, this is an important limitation, which likely results from the space constraints of academic journals. One way to address this would be to include online supplemental materials that provide detailed descriptions of educational objectives, content, format, and educational materials. For example, Radwany, et al. addressed this issue effectively even for their complex, longitudinal, four-year intervention.⁴⁰ Within the text of the article they provided a broad curriculum map and general description of the curriculum format and content. They then included two additional files, which contained detailed, replicable descriptions of the components that they considered to be “cornerstones” of their curriculum: a mandatory hospice experience and a case-based group discussion prior to graduation.

Another limitation of the sample is the narrow scope of many of the curricula, most of which evaluate the immediate effect of a single teaching session or circumscribed clinical experience. Because the field of palliative care encompasses such breadth of content that spans many medical specialties, more studies should evaluate palliative care curricula longitudinally as students engage the topics within the context of their general medical curriculum. For example, Morrison, et al. used a waitlist-control crossover design to demonstrate improvements in students' knowledge and attitudes following a palliative care curriculum that spanned the entire third year of medical school.³⁴ Even for smaller-scale interventions, educators should assess the long-term retention of learning objectives whenever possible. For example, Stevens, et al. demonstrated that students who participated in their pain management curriculum performed better on pain management domains of a clinical skills exam 1.5 years later.⁴⁸

Study quality

In recent years, increasing emphasis has been placed on improving the methodological rigor of medical education research. Cook and Bordage have found that many essential elements of scientific reporting are frequently absent from articles describing medical education experiments.⁵⁸ The MERSQI was developed by Reed and colleagues in 2007 as a measure of rigor for experimental studies in medical education, and has been shown to correlate well with expert quality ratings, number of citations, and journal impact factor.⁹ We used this instrument to assess the quality of our sample of recent studies in palliative care.

The studies in our sample had a mean MERSQI score of 9.9 (standard deviation 2.7, range 5–15). This result is quite similar to the mean of 9.95 (standard deviation 2.34, range 5–16) from the first reported MERSQI sample, which was a broad, interdisciplinary sample of 210 medical education studies published between 2002 and 2003.⁹ More recently, systematic reviews of medical education in topic areas unrelated to palliative care that utilized MERSQI have reported mean scores ranging from 9.0 to 11.4.^59–66 Overall, this suggests that palliative care education studies are of similar methodological quality to other medical education studies.

We found that within our sample most studies received high scores in the domain of data analysis. This indicates that the authors go beyond descriptive analysis to assess statistical significance of the effectiveness of their intervention and that the data analysis methods used are appropriate. Another area of strength was the “response rate” item within the sampling domain, indicating that the authors' conclusions are based on a representative sample of the students exposed to the intervention.

However, also within the sampling domain, the item “number of institutions studied” was the MERSQI item most likely to receive the lowest possible score. In fact, only one study in our sample implemented and evaluated their intervention with students from more than one institution. This aspect of study quality has important implications for generalizing study findings, and future researchers should endeavor to collaborate with other institutions to test the intervention in multiple settings or with multiple student populations. While multiple-institution collaboration is extremely difficult for implementing longitudinal, integrated curricula, it would be feasible for short-term, discrete interventions. For example, Tsai, et al. were able to implement a four-hour curriculum including a lecture, a hospice patient visit, communication skills practice, and group discussion with students in attendance from three local medical schools.⁵²

Because trainees' self-assessments of their skills may not predict the patient's assessment of the interaction, it is important that educators measure behavioral and patient outcomes, rather than relying solely on student assessments to demonstrate the effectiveness of a curriculum. However, in our sample the vast majority of studies (35 out of 39, 90%) measured outcomes either at the level of satisfaction, perceptions, and attitudes (usually measured by self-assessment on a Likert scale) or at the level of knowledge acquisition (usually measured by multiple-choice examination). Three studies (8%) measured student behaviors, with two measuring behaviors in a simulated patient encounter and one measuring self-reported communication behaviors. Only one study (3%) assessed a patient outcome: Green and Levi measured patient satisfaction after a medical student assisted the patient in filling out an advance directive.²² Because many of the educational interventions being studied already involve direct patient care, it would likely be feasible in future studies to incorporate patient outcomes into the evaluation.

Finally, validity of the evaluation instrument was a clear weakness in study quality. Fifteen studies reported no attempt to establish validity of their instrument regarding internal structure, content, or relationship to other variables. Instead, most studies relied upon surveys created by the authors, which did not undergo any formal development process. One positive example in this domain was the study by Chang, et al., who developed their instrument to measure changes in palliative care knowledge and attitudes before and after a five-day course. They began with a literature review, piloted the initial form of the instrument, retained only the most reliable items for the final instrument, and calculated the relationship between attitude scores, knowledge scores, and demographic data.¹³

Limitations

One limitation of this review is that our methods only assessed the quality of the subset of studies that included quantitative analysis. In the fields of medical education and palliative care, qualitative analysis of data such as focus groups, interviews, open-answer survey responses, and written reflections form the core of many studies. In our sample, 9 of the 48 studies reported qualitative data alone, and another 13 studies used mixed quantitative and qualitative methods. Our review does not speak to the methodological rigor of these qualitative analyses.

Another limitation of our review is that our database searches did not include items published in peer-reviewed repositories of educational products, such as MedEdPortal, which are often used for reporting and dissemination of curricula across medical schools.

Conclusions

Many recent innovations have been made in the field of palliative care education for medical students, representing a variety of learner levels, settings, educational modalities, and topics. One strength of palliative care education is the incorporation of interdisciplinary faculty, which should serve as a model for interdisciplinary collaboration in other parts of the medical curriculum. Future innovations in the field should endeavor to collaborate across multiple institutions, integrate more longitudinal curricula and study longer-term outcomes, make use of better-validated measures of effectiveness, and assess higher-level outcomes including skills, behaviors, and impact on patient care.

Footnotes

Acknowledgments

The authors would like to thank Lauren Maggio for her guidance regarding systematic review methodology. This work was funded by the Medical Scholars program at Stanford University School of Medicine.

Author Disclosure Statement

The authors have no conflicts of interest to disclose.

Appendix 1.

Summary of Curriculum Characteristics

Study	Country	Learner level	Instructors	Setting	Educational modalities	Duration	Topics ^a	MERSQI Score ^b
Auret and Starmer 2008	Australia	Clinical	HPM physicians, non-HPM physician, nurses, pharmacist	Classroom	Group discussion, simulation	2 hours	1, 2, 3, 6	7
Bell and Crawford 2011	United Kingdom	Preclinical	Physician, nurse, ethicist, theologian, attorney	Classroom	Lecture, group discussion, written assignment, student presentation, online module, simulation, clinical exposure	20–25 hours (over 12 weeks)	5, 6, 7	7.5
Brownfield and Santen 2009	United States	Clinical	Unspecified	Clinical, classroom	Lecture, group discussion, patient care	1 week	3, 6	10.5
Chang, et al. 2009	Taiwan	Preclinical	HPM physicians, nurse, social workers, chaplain	Clinical, classroom	Lecture, group discussion, clinical exposure	1 week	4, 5, 6, 7	14
Chittenden, et al. 2013	United States	Clinical	None	Online	Online module	45 minutes	2	14
Corcoran, et al. 2013	United States	Clinical, preclinical	Nurses, social workers, chaplains	Clinical	Clinical exposure	4 hours	Unspecified	Q
Dando, et al. 2012	United Kingdom	Clinical, also nursing, physical therapy, and occupational therapy students	Physician, nurse, physical therapist	Clinical	Group discussion, patient care	3 weeks	7	5
Ellman, et al. 2009	United States	Clinical	HPM physician, non-HPM physicians	Clinical, classroom	Written assignment, student presentation, patient care	Variable	1, 2, 3, 7, 8	7
Ellman, et al. 2012	United States	Clinical, also nursing, social work, and chaplaincy students	Physician, nurse, social worker, chaplain	Classroom, online	Group discussion, online module, simulation	2 hours	1, 2, 3, 4, 6, 7	10.5
Gadoud, et al. 2013	United Kingdom	Clinical	Unspecified	Clinical	Patient care	Unspecified	Unspecified	Q
Goldberg, et al. 2011	United States	Clinical	HPM physicians, nurse, social worker, chaplain, massage therapist	Clinical, classroom	Lectures, group discussion, patient care	1 week	2, 3, 4	10
Goldsmith, et al. 2011	United States	Clinical	HPM physician, non-HPM physicians, nurses, social workers, chaplains, psychologists, patients	Clinical, classroom	Lectures, multimedia, patient care	12 hours	1, 2, 3, 6, 7	Q
Green and Levi 2011	United States	Preclinical	None	Clinical, online	Online module, patient care	Variable	2, 5	15
Hall, et al. 2011	Canada	Clinical, also interprofessional students	Physicians, nurses, interdisciplinary health professionals	Classroom	Group discussion, simulation	3 hours	1, 2, 3, 4, 5, 7	8
Head, et al. 2012	United States	Clinical	Unspecified	Clinical	Written assignment, patient care	1 week	2, 3, 8	Q
Hegedus, et al. 2008	Hungary	Preclinical, also health care professionals	Unspecified	Classroom	Lectures	Unspecified	2, 3, 4, 6	11
Jacoby, et al. 2011	United States	Clinical	Unspecified	Clinical	Lecture, reading assignments, written assignment, patient care	1 week	1, 2, 6, 7	Q
Jeffrey, et al. 2012	United Kingdom	Clinical and preclinical	HPM physicians, drama educators	Classroom	Drama performance, group discussion, reading assignment, written assignment	2 weeks	2	Q
Kato, et al. 2011	Japan	Clinical	Unspecified	Classroom	Lecture	1 hour	3, 6	10
Kaufert, et al. 2010	Canada	Preclinical	Physicians, patients	Classroom	Lecture, group discussion	4 hours	4, 5	Q
Kitzes, et al. 2008	United States	Clinical	HPM physicians, non-HPM physicians	Classroom	Group discussion	4 hours	1, 2, 3, 4, 5, 6, 8	8.5
Korzeniewska-Eksterowicz, et al. 2012	Poland	Clinical	Physicians, psychologist	Classroom	Lecture, group discussion	10 hours	1, 2, 3, 4, 5, 6, 8	7
Lubimir and Wen 2011	United States	Clinical	Unspecified	Classroom	Group discussion, written assignment, simulation	3 hours	2, 4, 5	6
Mason and Ellershaw 2010	United Kingdom	Clinical	Unspecified	Clinical, classroom	Lecture, group discussion, student presentation, patient care	2 or 4 weeks	2, 5	10.5
Morrison, et al. 2012	United States	Clinical	HPM physicians, interdisciplinary health professionals	Clinical, classroom, online	Lectures, group discussion, written assignment, student presentation, online module, clinical exposure	8 hours (over 46 weeks)	1, 4, 6, 7	13
Murtagh, et al. 2012	Ireland	Preclinical	HPM physicians	Clinical, classroom	Lecture, reading assignments, student presentation, clinical exposure	15 hours (over 10 weeks)	1, 4, 6, 7	11
Nwosu, et al. 2013	United Kingdom	Clinical	Physician	Online	Written assignment	11–59 minutes	Unspecified	7
Oliver and Jezek 2013	Croatia	Preclinical	HPM physician	Classroom	Lectures, group discussion, multimedia	3 days	1, 2, 3, 4, 6	7.5
Philip and Remblabeevi 2010	India	Preclinical	Nurses, hospice volunteers	Clinical, classroom	Lecture, group discussion, simulation, multimedia, clinical exposure	3 days	2, 6, 7	6
Pinheiro, et al. 2010	Brazil	Unspecified medical students, also residents	Not specified	Clinical	Reading assignments, written assignment, patient care	Variable	Unspecified	Q
Radwany, et al. 2011	United States	Clinical and preclinical	Physicians, interdisciplinary health professionals	Clinical, classroom	Lectures, group discussion, simulation, written assignments, clinical exposure	4 years	1, 2, 3, 4, 5, 6, 7, 8	6.5
Sanchez-Reilly, et al. 2007	United States	Clinical	HPM physicians, nurses, social workers, chaplains, psychologists, patients	Clinical, classroom	Lectures, written assignments	8 hours (over 4 weeks)	1, 2, 6, 7, 8	13
Schillerstrom, et al. 2012	United States	Preclinical	HPM physicians, psychiatrists, psychologists, interdisciplinary health professionals	Classroom	Lecture, group discussion	4 hours	6	9
Schulz, et. al. 2013	Germany	Clinical	Unspecified	Clinical, classroom	Lectures, group discussion, simulation, written assignment, clinical exposure.	23 hours (over 2 semesters)	1, 2, 3, 6, 7, 8	10.5
Shih, et al. 2013	Taiwan	Preclinical	HPM physicians, interdisciplinary health professionals	Clinical, classroom	Lectures, simulation, multimedia, clinical exposure	1 day	1, 2, 5, 7	13
Silk, et al. 2009	United States	Clinical	Unspecified faculty, nurses	Clinical, classroom	Lecture, group discussion, simulation, multimedia, clinical exposure	7.5 hours	2, 6	9
Sorta-Bilajac, et al. 2007	Croatia	Preclinical	Physician, ethicist, theologian, philosopher, sociologist, attorney	Classroom	Lectures, multimedia, written assignment, student presentation	7.5 hours	4, 5, 6	10.5
Stecho, et al. 2012	Canada	Preclinical	Nurse, hospice volunteers	Clinical, classroom	Lectures, patient care	30–40 hours	Unspecified	10
Stevens, et al. 2009	United States	Preclinical	HPM physicians, non-HPM physicians, nurses	Classroom	Lectures, group discussion, simulation	10 hours	1, 2, 3	14
Tai, et al. 2013	Australia	Clinical	Unspecified	Clinical, classroom	Lectures, group discussion, patient care	1 week	3, 4, 5	12
Tan, et al. 2013	Canada	Clinical	None	Online	Online module	Variable	1, 3, 4	11
Tchorz, et al. 2013	United States	Clinical	Non-HPM physicians, ethicist	Classroom	Group discussion, multimedia, simulation	2 hours	1, 2, 3, 4, 5	11
Tsai, et al. 2008	Taiwan	Preclinical	HPM physicians	Clinical, classroom	Lecture, group discussion, reading assignment, clinical exposure	4 hours	2, 5, 6	14
von Gunten, et al. 2012	United States	Clinical	HPM physicians, nurses, social workers, chaplains	Clinical, classroom	Lectures, simulation, patient care	4 days (over 4 weeks)	1, 2, 3, 4, 5, 6, 7, 8	13
Weber and Mascagna 2008	United States	Preclinical	HPM physician	Clinical, classroom	Arts activity or performance, group discussion, written assignment, student presentation, clinical exposure	Unspecified	6	Q
Weber, et al. 2011	Germany	Preclinical	HPM physicians	Clinical, classroom	Lecture, group discussion, clinical exposure	1.5 hours	4, 6, 8	9.5
Wechter, et al. 2013	United States	Preclinical	HPM physicians	Clinical, classroom	Group discussion, reading assignments, clinical exposure	4 hours	2, 4, 5, 6, 8	9.5
Yardley, et al. 2013	United Kingdom	Clinical	Unspecified	Classroom	Lecture, group discussion, simulation	7 hours	1, 2, 3, 5, 6	7

Palliative and End-of-Life Care topics are listed only if they were specifically reported in the article. Coding is as follows: 1=patient assessment, 2=communication, 3=pain and symptom management, 4=addressing psychosocial and spiritual needs, 5=ethics and the law, 6=role in the health care system, 7=interdisciplinary teamwork, 8=self-care.

Q indicates that the study was qualitative, and did not receive a MERSQI score.

HPM, hospice and palliative medicine; MERSQI, Medical Education Research Study Quality Instrument.

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