Palliative Care Bedside Teaching: A Qualitative Analysis of Medical Students’ Reflective Writings after Clinical Practices

Abstract

Context:

A mandatory course in palliative care (PC) is organized for all final-year medical students at the University of Navarre. It consists of 24 lectures, 4 workshops, and 1 scheduled five hour clinical PC service experience at two different sites. In the 48 hours after the visit and related to the clinical experience, each student has to complete a 500-word reflective writing (RW) piece.

Objective:

To investigate how a brief PC clinical experience helps equip the medical student.

Methods:

Qualitative study of RW. Two researchers produced a content analysis of students’ RW. They collaboratively developed themes and categories with a constant review of the classification tree and an exhaustive collection of quotes. Differences between services were analyzed (λ²).

Results:

One hundred sixty-seven RW were analyzed from the 197 students on the course (response rate 85%). Six major themes emerged: All the students identified central aspects of PC work dynamics; students acquired specific PC knowledge (86%); the personal influence of the experience was reported (68%); students described how patients and their caregivers deal with the patients’ illness (68%); students talked about the essence of PC and essential aspects of medicine (42%); students reported spontaneously having changed their assumptions about PC (15%); and they realized that the experience was relevant to all clinical practice. Categories such as teamwork, the expression of patients’ and caregivers’ feelings, and family devotion showed statistical differences between services (λ² p < 0.05).

Conclusion:

A short bedside clinical experience in PC, encouraging student reflection, provides a deeper understanding of PC and even of core medicine values. The data we gather cannot explain only new skill acquisition but seems to suggest a life-changing personal experience for the student.

Introduction

The teaching of palliative care (PC) provides knowledge, skills, and attitudes for the care of end-of-life patients, as well as provides the basic professional competence required by all healthcare professionals. A recent systematic review shows how PC teaching affects the perception of medical students as to their own professional role. Among the things they learned, students identified values related to good medical practice, an appreciation of the importance of practical training within PC teaching, this being both richer and more effective, the greater its first-hand experience.¹

For all medical students, the acquisition of professional competence is fundamental to creating their own professional identity as a physician.² Learning goes beyond acquiring knowledge and technical skills and implies new ways of thinking and relating, all of which make up one's professional identity.³

Reflecting on an experience is a process that brings out feelings and experiences related to a situation and makes one both delve more deeply into and pass judgement on our actions.⁴ This method is an affective, intellectual activity, through which individuals obtain a greater understanding of our experiences,⁵ facilitate deeper learning,⁶ and give greater meaning to experience.^7–9 This is the process by which personal experience is transformed into practice.^10–14 When this reflection is left in written form, it follows precise logic influenced by the setting where it is undertaken, the character (personality and values) of the student doing so, the knowledge base used to resolve the situation, and the deliberation required for its resolution.¹⁵

Reflective writing (RW) involves an exploration and explanation of an event; it involves thinking and writing about anxieties and errors as well as successes in your interactions with an individual or when carrying out a practical task. Through interactive RW—reading and responding to student's reflective narratives—, students are given the chance to slow down and become more aware, during the clinical encounter, as they elicit a patient's story and embark on diagnosis reasoning.¹⁶ RW is the student's response to experience and new information, a way of thinking and to explore their learning, an opportunity to gain self-knowledge, and a way to respond to thoughts and feelings. RW allows students a way of creating meaning out of what is studied and has been used as a teaching method in PC, with good results.^17–21

RW has been researched to explore students’ exposure to theoretical PC classes, their learning to focus on the needs of the end-of-life patient, determining the patient's holistic approach and discovering a new field of professional work.^22,23 Furthermore, when exposed to clinical practice, medical students highlighted their awareness of their own limitations as regards end-of-life patient care and the need to empathize and to show affection, compassion, and respect to patients.¹⁷ PC clinical practice also made students aware that treatment options and therapeutic goals ought to be in accordance with patient needs. It also led them to a deeper understanding of themselves and of others.¹⁸ Somehow, bedside PC teaching humanizes the practice of medicine from the medical students’ point of view.²⁴

Bedside teaching is a vital component of medical education and is one of the most effective ways to learn clinical and communication skills.²⁵ Bedside teaching is defined as teaching in the presence of the patient,²⁶ where students are found to be motivated to engage in clinical reasoning and problem solving if their preceptor, acting as a role model, provides adequate demonstration and guidance.^27–29

At the University of Navarre, during the mandatory Palliative Medicine course, all medical students spend one morning caring for patients, integrated into a PC unit at one of two different sites. To reinforce what this experience supposes to the students, all of them have to send 500 words RW related to that clinical experience.

The aim of this study is to investigate what the medical students gain from this brief bedside teaching PC clinical experience, through their RW focused on these experiences, while attending the mandatory PC course in the last year at medical school. We hypothesized that previous studies, due to small sample sizes, did not introduce the students into interdisciplinary PC teams, did not explore the experience in different PC units,^17–23 and did not achieve a comprehensive understanding of the experience.³⁰

Methods

Exploratory qualitative study

Context

In Spain, the Medical Degree comprises a six-year training period (the first three years focused on preclinical issues, the three final years combining theoretical subjects with clinical practice) and begins after high school graduation. At the University of Navarre Faculty of Medicine, a PC course is provided in the last year as a compulsory 3-credit theory-practice component and consists of:

• Twenty-four 45-minute theory classes about PC principles, pain and symptom management, neuropsychiatric syndromes, spirituality, and ethics.

• Four 2-hour practical seminars: a video discussion on the patient illness adaptation process, a clinical case pain management workshop, a subcutaneous administration workshop, and a breaking bad news workshop.

• One morning of clinical practice, during which students spend five hours working alongside the professionals from a PC service.

• One RW on clinical practice.

The students undertook a clinical experience in PC at two different centers: the Clínica Universidad de Navarra (CUN) or the Hospital San Juan de Dios (HSJD). At CUN, the PC service is made up of a Hospital Support Team with two doctors, two nurses, and a psychologist; it treats inpatients, outpatients, and day hospital patients. The PC service at HSJD is made up of three Home Care teams, each with a specialist doctor and nurse. It also has a 20-bed PC inpatient Unit. Most of the HSJD students did their training in the Home Care Teams, attending patients in their homes. In this clinical experience, the student is integrated into the team as an observer and at the end of each visit, he or she is asked about the clinical situation of the patient, what they observed, and what they felt. At the end of the morning, the student has a short tutorial with one PC physician.

Population and sample

The population of this study is made up of students who took the subject during the 2014/15 Academic Year. All those documents submitted by the students were analyzed as long as they included written consent for the same.

Ethical considerations

Approval from the clinical research committee was granted. Texts were treated anonymously. In each RW, the student's name was erased and a number was assigned. It also specified which center they had been to and the student's gender.

Data collection

Students were asked to provide a 500-word RW on the clinical experience completed. There were no instructions given on how to do this RW. They were given 48 hours to send it by e-mail, to the person in charge of coordinating the clinical rotations. The reflection was not included in the final subject grade.

Analysis

An exploratory content analysis was undertaken of the content of the RW completed by medical students after having finished the PC clinical experience. Two researchers (R.R. and F.P.) began to read the reflections, without any predetermined topic for identification.

RW were read through and notes were made while reading, to create initial codes. Two junior researchers (R.R. and F.P.) conducted the analysis independently and for every five reflections, two other investigators, experienced in qualitative research, checked the coding process with them (J.M.C. and C.C.). This process was repeated until the junior researchers developed adequate skills for qualitative analysis.

The two junior researchers continued independently with the analysis. Reflections were read through and as many headings as necessary were written down to describe all the aspects of the content. The two lists of categories were discussed, adjustments were made as necessary, and a single list of categories was developed, on the basis of the analysis of 97 reflections. The list of categories was reviewed by the researchers and grouped together under higher-order headings to reduce the number of categories, by “collapsing” some of those that contained similar themes. For example, all the students identified central aspects of PC work dynamics.

Each RW was worked through independently by two researchers with the themes and categories.³¹ Definitions were created for each theme and their categories, to later compare the codification created by the two researchers. The analysis of the rest of the reflections showed that the list covered the content with simple nuances required to be included within categories.

The computer program used was NVivo version 10.0 for Windows. A frequency comparison analysis was carried out between centers, using the λ² test, to evaluate possible differences depending on the location where the clinical practice was carried out.

Results

Of the 197 enrolled students, 170 gave consent for analysis of their RW, of whom 3 did not hand them in, giving a response rate of 85% (167/197).

The themes that emerged and the frequency with which students referred to them were as follows: (1) central aspects of PC work dynamics (100%); (2) students acquired specific PC knowledge (86%); (3) the personal influence of the experience was reported (68%); (4) the students described how patients and their caregivers deal with the patient's illness (68%); (5) students talked about the essence of PC and essential aspects of medicine (42%); and (6) students reported spontaneously having changed their assumptions of PC and realized that the experience was relevant for all clinical practice (15%).

Theme 1: The student identifies the working dynamics of PC

This topic describes the singularities of PC. All the students identified among the characteristics, PC working methods. Categories such as teamwork, emotional aspects, and willingness for training are common factors in reflections from CUN, whereas accompanying the family, home care, and support for other teams are more frequent in the HSJD reflections (Table 1).

Table 1.

Frequency of Students Referring to the Theme: “The Student Identifies the Working Dynamics of PC”

	Total (n = 167)		CUN (n = 74)		HSJD (n = 93)
Categories	n	%	n	%	n	%	p
Holistic care	94	56	45	60	49	52
Teamwork	87	52	51	68	36	38	^**
Accompanying the family	82	49	28	37	54	58	^**
Being approachable	75	45	30	40	45	48
Showing humanity	37	22	19	25	28	30
Home visits	45	27	0		45	48	^**
Communication	40	24	17	22	23	24
Being present and accompanying	38	23	18	24	20	21
The need for time to attend to the patient	31	19	9	12	22	23
Listening	27	16	14	18	13	14
The quest for excellence	28	17	13	17	15	16
Psychological and emotional patient care	28	17	17	22	11	11
Empathy	25	15	15	20	10	10
Individual care	24	14	10	13	14	15
Examination and physical symptoms	24	14	8	10	16	17
Willingness for training	24	14	16	21	8	8	^**
Availability	14	8	6	8	8	8
The need for specific theoretical knowledge	15	9	5	6	10	10
Support for other teams	12	7	2	2	10	10	^**
Care for the physician's integrity	8	5	4	5	4	4
Spiritual care	7	4	4	5	3	3
Ongoing care	8	5	4	5	4	4
Physician's responsibility	4	2	0	0	4	4	^**
Total n = 167^a			74 (100)		93 (100)

167 (all the students identified methods of PC working dynamics).

Statistically significant (p < 0.05).

CUN, Clínica Universidad de Navarra; HSJD, Hospital San Juan de Dios; PC, palliative care.

Students highlighted the honesty and disposition with which PC professionals approached patients. They see the importance of good communication and knowing when to be around, as a working practice to provide for all the patients’ needs.

HSJD 105. With classes, practices, seminars, revision time, speciality training and other demands, our humanity almost went into hibernation. (…) we were not taught how to see the patient and their family from a holistic point of view. (…) nobody taught us how to give bad news, to accompany and offer relief when no cure was possible and how to attend to the patient's emotional, social and spiritual needs.

They highlighted teamwork, and they describe how this helps them provide better care for the patient and their family.

CUN 109. Teamwork was one of the morning's features and there was continuous contact between palliative care and oncology doctors, the psychologist and nurses. Each person had their particular role in this integrated care, which was aimed at offering everything from symptom treatment to attention toward the family.

Theme 2: What the student learns from the PC specialty

This theme describes what the students learn from the PC practice journey. More than a third of the students highlighted novelties and the necessity of what they learned. The student interns at CUN most frequently mentioned the need for practical PC training, whereas those who undertook training at HSJD referred more to the need for resources (Table 2).

Table 2.

Frequency of Students Referring to the Theme: “What the Student Learns from the PC Speciality”

	Total (n = 167)		CUN (n = 74)		HSJD (n = 93)
Categories	n	%	n	%	n	%	p
New practices	72	43	30	40	42	45
Internships are necessary	57	34	32	43	25	26	^**
Complex patients	56	34	23	31	33	35
The necessity of the PC service	41	25	15	20	26	28
Something can always be done	23	14	10	13	13	14
Each patient is unique	18	11	9	12	9	9
Treatment must be personalized	20	12	7	9	13	14
The need for resources	13	8	0		13	14
Learn theoretical knowledge	6	4	1	1	5	5
A change in the perception of PC	5	3	3	4	2	2
The need for research and dissemination	3	2	2	2	1	1
Total (n = 144)^a			65 (88)		79 (85)

144 (86% of students described concepts learned about PC).

Statistically significant (p < 0.05).

The RW clearly show that PC is perceived as hard, complex work, while being, at the same time, both rewarding and satisfying.

CUN 128. It confirmed to me and helped me see beyond a single ill person, by noticing their humanity, (…) and by feeling the patient's relief in every word, so full of the caring and security transmitted by the doctor, the psychologist and the nurse.

HSJD 55. When patients open their homes, their fears or their needs and I think this is very valuable and very nice. THANK YOU.

The students also perceived the difficulties of this type of work and mentioned the need for PC professionals to care for their own emotional well-being.

CUN 41. Another thing which struck me was that, as opposed to other services, where death is trivialised (…), this is not the case here. All patients are just as important as one another and other strategies are taken on, so as not to have to bear these heavy loads

From the learning experience, students understand that the individual characteristic of each patient means personalized care is required. In addition, they affirm the need to do this clinical practice.

HSJD 73. I feel it is essential to dedicate at least a few hours during our time at the Faculty to visit a Palliative Care Centre, to understand that the focal point of our profession is the patient and not us

Theme 3: “The experiences”

This theme describes the students’ life experience during a PC clinical practice. One out of every three students referred to an emotional experience and feelings of gratitude. This experience is described more by students who were at HSJD (Table 3). The personal experience moves the student and affects both professionalism and personal relationships.

Table 3.

Frequency of Students Referring to the Theme: “Student Experiences During a Day at a PC Unit”

	Total (n = 167)		CUN (n = 74)		HSJD (n = 93)
Categories	n	%	n	%	n	%	p
They expressed feelings	57	34	17	22	40	43	^**
Felt gratitude	51	31	21	28	30	32
A deep personal experience	36	22	14	18	22	23
Reflection on death (own or other's)	20	12	8	10	12	12
Total (n = 114)^a			43 (58)		71 (77)

114 (68% of students described their own experiences of contact with PC).

Statistically significant (p < 0.05).

HSJD 65. I am serious when I say that I was deeply moved, apart from the fact that what struck me was the emotional aspect of our work, and it has made me reflect on our profession and on ideas which are, perhaps, on an even higher plane: the end of life and its meaning.

Many expressed gratitude for the experience.

CUN 20. I would like to thank all the departmental staff (doctors, nurses, carers and admin staff) as well as the patients, who have allowed us to learn from them, “in the field,” without qualms. Due to their efforts, I feel I should be a better professional in the future and of course, take them as my model to imitate when working in our discipline

Theme 4: What does the student observe about the patient and their family?

This theme describes the student's perception of the patient and family's end-of-life experience. Twenty percent of students describe the patient's process of adaptation to death, their gratitude, and the way they open up to PC professionals. To a greater extent at HSJD, they observed the way in which relatives gave their all to patients and how those patients were concerned about and protected their families. They also described the patients’ procession of accepting. The students at CUN placed more emphasis on the need for pain management (Table 4).

Table 4.

Frequency of Students Referring to the Theme: “Students Describe How the Illness Affected the Patient's and Their family's Life”

	Total (n = 167)		CUN (n = 74)		HSJD (n = 93)
Categories	n	%	N	%	n	%	p
Change in perception of the dying process	45	27	13	17	22	23
Gratitude toward professionals	33	20	16	21	17	18
Opening up of feelings to the PC team	33	20	10	13	23	24
Family devotion to patient and vice versa	29	17	7	9	22	23
Facing up to disease in a positive manner	26	16	7	9	19	20
Awareness of the situation	26	16	10	13	16	17
Trust in healthcare professionals	23	14	7	9	16	17
Importance of pain management	22	13	14	18	8	8	^**
Mood swings	17	10	6	8	11	11
Fear of the process	10	6	4	5	6	6
Need for spiritual support	5	3	3	4	2	2
Request for help to stop suffering	3	2	2	2	1	1
Total (n = 114)^a			44 (59)		70 (75)

114 (68% of students describe the influence of advanced illness on the patient and family).

Statistically significant (p < 0.05).

CUN 34. When we have been around, from room to room, what I have been able to see is that both patients and their families maintain a sense of hope regarding their remains of their lives. (…) they really appreciate the fact that they are being treated just like a hospital's other patients, with the aim of ensuring the best possible quality of life in the situation they find themselves in

HSJD 121. What moved me most during this visit was seeing how a husband and wife took advantage of our presence to say things to each other which they might not have found time to when alone, or might not have known how to. She was very worried about what would happen to her husband if she had died and he could not bear to think that his wife would not have the tranquillity to die peacefully, due to his fault and that he might not find the strength to take care of her at that moment

Theme 5: Students discover essential aspects of PC or of medicine itself

This theme describes the student's insights into becoming better physicians. The students see the ultimate goal of PC and the essence of medicine (Table 5).

Table 5.

Frequency of Students Referring to Themes: “Student Discovers the Essence of Palliative Medicine” and “Changes Prior Perception of Palliative Medicine”

	Total (n = 167)		CUN (n = 74)		HSJD (n = 93)
Categories	n	%	n	%	n	%	p ^**
Essential or profound aspects of PC
Recognition of the essence of medicine	27	16	13	17	14	15
See the aims of PC	31	19	11	14	20	21
Humanity	18	11	11	14	7	7
Holistic approach	10	6	4	5	6	6
Healthcare professional adapts to the patient	5	3	1	1	4	4
The need to provide PC	5	3	1	1	4	4
Total n = 70^a			31 (50)		39 (41)
Contrast with earlier ideas or experiences
Prejudice	12	7	7	9	5	5
Earlier personal experience	7	4	4	5	3	3
Earlier professional experience	5	3	4	5	1	1
Total n = 25^a			14 (19)		9 (12)

70 and 25 (42% of students acknowledged essential aspects of PC, and 15% said they changed their earlier perception of PC).

No statistical differences were found.

HSJD 58. When looking for the right word to define what happened in that little room, full of mementos and ceramic figures, I found this one: Medicine. True medicine.

Treating the sufferer in a humane way and not as an illness.

CUN 35. To me it seems that all specialties should incorporate more elements from palliative medicine. Despite hearing time and again that these are patients and not illnesses, this can be overlooked within the frenetic rhythm of a hospital. (…). After experiencing the warm, close attitude shown by the team this morning, I know that there is no excuse for not adopting this way of treating patients in all medical specialties.

From that morning on, a number of students remembered why they chose to study Medicine.

HSJD 105. They reminded me of the enthusiasm and vocation which made me choose to study Medicine. It brought back some of the initial passion and once again, I made the effort to forget number and my own preoccupations and care for the patient and his family.

Topic 6: Students facing their prior conceptions on PC

Some written pieces expressed preconceptions that some students hold as regards PC, before their practical session (Table 5).

CUN 69. It completely changed my preconceived notion of care, based on therapeutic cocktails and on the information I had studied and at that exact moment, I understood what Palliative Care really meant

HSJD 82C2. In fact, when one believes that one knows almost everything about the subjects studied over five years, the rarest syndromes, the most pathognomonic signs, one comes up against this, so basic and so true, but at the same time, so moving

Discussion

PC clinical practice exposes the student to an enriching experience, which encourages better understanding of the essence of PC and of all medical practice. The specific methods employed permitted a detailed and rigorous exploration of the experience and whether the emphasis on theory-based didactics resulted in reflections that focused more on knowledge gained than on other reactions, as it gives greater meaning to the experience. We cannot verify this change, but we may assume that this PC medical practice provided students with a personal experience that will be transformed into practice. The data gathered cannot explain new skills acquisition alone, but they seem to suggest a life-changing personal experience for the student, which would not be achieved without clinical practice.

Content analysis is a qualitative technique, useful for processing the information included in communicative activities, such as RW, as it leads to the description, summary, and interpretation of the same. Thanks to this method, we have included a wider range of categories, showing how students gain a deeper understanding of PC, while going through a personal experience that changes their vision about end-of-life care. It helps change misconceptions and in some way, made the students feel comfortable, helped them gain confidence and gratitude, rediscovering the essence of medicine and in some cases, they described the way that this helped them remember why they decided to become physicians in the first place.

Previous studies have shown the utility of RW in the PC learning process, and they have shown that RW is a good method for assessing the importance of practical training within PC teaching for medical students, but until the authors currently know, this work has a larger sample, introduces the students in an interdisciplinary PC team, and explores the issues in different PC units.

If we compare the findings of this work with studies that have only chosen to expose the student to theoretical classes, we see that a course with no clinical practice helps focus on the needs of the end-of-life patient, by seeing the need for a holistic approach to the patient and by showing them a new field of professional work.^22,23,32 Our data suggest that the PC clinical experience allows the student to perceive fundamental aspects of PC working methods, and even more importantly, a hands-on PC experience allows for the personal impact of the situation, the feeling of gratitude or self-reflection on death.

By means of RW after medical students’ exposure to a PC practical session, it can be seen how aspects related to medical professionalism come to the surface. Braun et al.¹⁷ showed how students, after doing a clinical interview under the supervision of a PC physician, when answering a semi-structured survey, highlighted their awareness of their own limitations as regards end-of-life patient care and of the need to empathize and to show affection, compassion, and respect to patients. That survey is confined to mentioning other aspects related to medical professionalism but, in our study, with an open reflection and a greater number of students, other aspects appear, such as teamwork and collaboration with other units, and communication as a tool for work.

There are constant expressions of medical professionalism throughout the RW analyzed. The teaching innovation completed (experience plus reflection) results in achieving Basic Competence Number 3 for medical students, according to Spanish legislation: “all medical students should acquire the ability to gather relevant data from a clinical situation in order make judgments that include reflection on relevant social, scientific or ethical issues”; and Number 27: “recognizing multiprofessional roles, assuming leadership when necessary, both for clinical interventions and health care prevention.”³³ Combining clinical experience and reflection helps the student to enter a more vivid and meaningful approach to a real clinical scenario. This leads to a profound reflection on medical work and on the sense of medicine. Moreover, RW content analysis also shows the accomplishment of many of the learning outcomes of the PC Subject as a positive attitude toward advanced-stage patient care, recognition of complex situations that require a holistic approach, understanding different PC programs, and learning how to deal with own and others’ feelings.

The topics described in this study link the knowledge gained by students on PC and its singularities with their personal experiences, the discovery of the patient and family end-of-life experience, and the student insight on how to become a better physician.

Corcoran et al.¹⁸ analyzed the reflections of medical students who took part in a half-day working experience with a Home Hospice Team for geriatric patients. Students described PC as a new area of knowledge for them, changing their prior disposition as regards this discipline, making them able to understand that it is a valid treatment option, with therapeutic goals in accordance with patient needs. It also led them to a deeper understanding of themselves and of others. As regards our data, this article does not describe the life-changing emotional experience or their self-perception regarding the process of illness for the patient and for the family helping with their care.

Strano-Paul et al.,²⁴ when analyzing RW from 120 medical students after spending half a day with a Home Hospice Team, try to identify how to modulate and transform certain aspects of the students’ professional identity, after being exposed to PC practice. The students described how pleasant the atmosphere was in people's homes, the acceptance of death by the patients, and the importance of interpersonal relationships in giving true support to help with care. Moreover, they describe how PC humanizes medicine and promotes quality of life, putting an end to prior ignorance about PC. When comparing this with our data, these ideas reinforce the way that PC practice affects fundamental aspects of medical practice and of the essence of medicine. In our study, the students also noticed the trust built up between the PC team and the patient. It is fundamental to develop teaching methods that reinforce the students in this learning process. New teaching designs and research in the learning outcomes of these designs are mandatory for medical humanism.

This is the most comprehensive study carried out on the subject up to the present, due to the number of participants (with a low no-response rate of 15%) and the only one to be carried out in units from different settings (consultant unit, inpatient unit, and home care). The homogeneity of the data collected among students that had the practice experience in CUN or HSJD shows the relevance of the experience in spite of the setting of the PC units, minimizing the likelihood of results based in the characteristics of a specific unit or professional.

To perform an accurate interpretation of the data, it is necessary to apply certain considerations related to methodological issues. Unfortunately, Content Analysis cannot reveal the underlying motives for the observed patterns. Other methods, such as Grounded Theory, may reveal those patterns, but the research team has to admit the limitations of the data (RW extension, one morning clinical practice, PC subject context), and methodological congruence does not allow us a deeper analysis. Another issue is the fact that the subject lecturer (C.C.), as part of a training experience, commented that RW might imply a possible complacency risk bias. To mitigate this risk, the RW requested from students were not handed in to the lecturer responsible for teaching and evaluation, but to the person in charge of the practical training component of the subject, with clear indications that they would not count toward final grades. Moreover, to mitigate the implication of the subject teachers in the analysis, the project head researchers and those in charge of analyzing the texts were not people who had taken part in the teaching of the subject itself. Furthermore, one of the RW reviewers (R.R.) was among the physicians who accompanied students during the one-day clinical rotation, whereas all RW were anonymous. Analysis triangulation, discussion of the same by the whole research team, and an ongoing process of reflection were the strategies pursued to ensure the quality of the analysis performed.

With the design and methodology used, we can see changes in student disposition but it is not possible to measure the impact of these RW over time against the students’ attitudes and aptitudes. We are conscious that this is an initial approach of the influence on future physicians of a practical PC rotation and that a complete appraisal would require a more complex study. An examination with a quantitative approach to the aspects identified by this and by other studies in relation to PC clinical practice, in addition to longitudinal design studies, which allow the evaluation of impact over a longer period, may provide relevant knowledge in this field. On the other hand, more in-depth qualitative approaches, by mean of semi-structured interviews, for example, or discussion groups, might complement these works with analysis with a more interpretative element.

Conclusions

Reflection on PC clinical practice helps the medical student to complete their learning cycle in PC. Students perceive such useful practices to allow them to face up to patient care at the end of life and as a model that encompasses the essence of medicine, applicable to any clinical practice.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

Centeno

, Rodríguez-Núñez

: The contribution of undergraduate palliative care education: Does it influence the clinical patients care?. Curr Opin Support Palliat Care, 2015; 9:375–391.

Holden

, Buck

, Clark

, et al.: Professional identity formation in medical education: The convergence of multiple domains. HEC Forum, 2012; 24:245–255.

Goldie

: The formation of professional identity in medical students: Considerations for educators. Med Teach, 2012; 34:e641–e648.

Carr

: Rival conceptions of practice in education and teaching. In: Dunne

, Hogan

(eds): Education and Practice: Upholding the Integrity of Teaching and Learning. Oxford: Blackwell Publishing, 2004, pp. 102–115.

Cossart

, Fish

, Hillman

: Clinical reflection: A vital process for supporting the development of wisdom in doctors. Curr Opin Crit Care, 2012; 18:712–717.

Boud

, Keogh

, Walker

, eds.: Reflection: Turning Experience Into Learning. London, UK: Kogan Page, 1985.

Mathens

, Challis

, Howe

, Field

: Portfolios in continuing medical education—Effective and efficient?. Med Educ, 1999; 33:521–530.

Plack

, Driscoll

, Blissett

, et al.: A method for assessing reflective journal writing. J Allied Health, 2005; 34:199–208.

Mann

: Reflection: understanding its influence in practice. Med Educ, 2008; 42:468–475.

10.

Mamede

, Schmidt

, Penaforte

: Effects of reflective practice on the accuracy of medical diagnosis. Med Educ, 2008; 42:468–475.

11.

Plak

, Driscoll

, Marquez

, et al.: Assessing reflective writing on a pediatric clerkship by using a modified Bloom's taxonomy. Ambul Pediatr, 2007; 7:285–291.

12.

Epstein

, Hundert

: Defining and assessing professional competence. JAMA, 2002; 287:226–235.

13.

Stern

, Papadakis

: The developing physiscian—Becoming a professional. N Engl J Med, 2006; 355:1794–1799.

14.

Gracey

, Haidet

, Wranch

, et al.: Precepting humanism: Strategies for fostering the human dimensions of care in ambulatory settings. Acad Med, 2005; 80:21–28.

15.

Branch

, Kern

, Haidet

, et al.: Teaching the human dimensions of care in clinical settings. JAMA, 2001; 286:1067–1074.

16.

Wald

, Reis

: Beyond the margins: Reflective writing and development of reflective capacity in medical education. J Gen Intern Med, 2010; 25:746–749.

17.

Braun

, Gill

, Teal

, Morrison

: The utility of reflective writing after a palliative care experience: Can we assess medical students’ professionalism?. J Palliat Med, 2013; 16:1342–1349.

18.

Corcoran

, True

, Charles

, Margo

: Geriatric palliative care: Do medical students’ narrative reflections after a hospice clinical experience link to geriatric competencies?. Gerontol Geriatr Educ, 2013; 34:329–341.

19.

Maxwell

, Passow

, Plumb

: Experience with hospice: Reflections from third-year medical students. J Palliat Med, 2002; 5:721–727.

20.

Gadoud

, Adcock

, Jones

: “It is not all doom and gloom”: Perceptions of medical students talking to hospice patients. J Palliat Med, 2013; 16:1125–1129.

21.

Fins

, Gentilesco

, Carver

, et al.: Reflective practice and clinical education: A clerkship responds to thr informal and hidden curricula. Acad Med, 2003; 78:307–312.

22.

Ballesteros

, Centeno

, Arantzamendi

: A qualitative exploratory study of nursing students'assessment of the contribution of Palliative Care learning. Nurse Educ Today, 2014; 34:e1–e6.

23.

Centeno

, Ballesteros

, Carrasco

, Arntzamendi

: Does palliative care education matter to medical students? The experience of attending an undergraduate course in palliative care. BMJ Support Palliat Care, 2014 [Epub ahead of print]; DOI: 10.1136/bmjspcare-2014-000646.

24.

Strano-Paul

, Lane

, Wei-Hsin

, Chandran

: Impact of a Home Hospice Visit Program on Third-Year Medical Students: A qualitative analysis of student reflections. J Palliat Care, 2015; 31:5–12.

25.

Chipp

, Stoneley

, Cooper

: Clinical placements for medical student: Factors affecting patients’ involvement in medical education. Med Teach, 2004; 26:114–119.

26.

Janicik

, Fletcher

: Teaching at the bedside: A new model. Med Teach, 2003; 25:127–130.

27.

LaCombe

: On bedside teaching. Ann Intern Med, 1997; 126:217–220.

28.

Kroenke

, Omori

, Landry

, Lucey

: Bedside teaching. South Med J, 1997; 90:1069–1074.

29.

Qureshi

, Maxwell

: Has bedside teaching had its day?. Adv Health Sci Educ Theory Pract, 2012; 17:301–304.

30.

Elo

, Kääriäinen

, Kanste

, et al.: Qualitative content analysis: A focus on trustworthiness. SAGE Open, 2014; 1–10.

31.

Burnard

: A method of analyzing interview transcripts in qualitative research. Nurse Educ Today, 1991; 11:461–466.

32.

Kearsley

, Lobb

: “Workshops in healing” for senior medical students: A 5-years old overview and appraisal. Med Humanities, 2014; 40:73–79.

33.

University of Navarre Faculty of Medicine [Web site]. Pamplona: University of Navarre; 2016 [Updated 5 de September de 2015: Access 27 de Junio de 2016]. Datos y documentación oficial. Competencias del Grado en Medicina. www.unav.edu/documents/4588799/4589852/competencias-grado-medicina-1009.pdf (last accessed June 27, 2016).