An Integrated,Developmental Four-Year Medical School Curriculum in Palliative Care: A Longitudinal Content Evaluation Based on National Competency Standards

Abstract

Background:

While palliative care (PC) competencies for medical school graduates have been defined, the lack of established curriculum models and assessment tools hampers curricular evaluation.

Objective:

To describe the scope and content of the University of Rochester's longitudinal, integrated four-year PC curriculum after 17 years of implementation, review student evaluative responses, and compare the curriculum to national competency standards.

Design and Setting:

Combining and reorganizing a published PC curriculum assessment tool and a list of medical school PC competencies, we created a novel nine-topic framework to assess the content coverage of our curriculum. We queried our electronic medical school curriculum database and surveyed course and clerkship directors, as well as PC, pain, ethics, and humanities faculty, to locate where and when PC topics are taught and to collate student responses to these experiences.

Results:

We present a comprehensive list of PC curricular activities over a four-year medical school experience. The curriculum covers all nine PC topics longitudinally in multiple formats. Five in-depth activities cover multiple PC topics in a format that integrates biological, psychological, and social dimensions; these activities have survived and evolved over 17 years in our setting. A majority of year 3 University of Rochester students feel “well” or “extremely well” trained in PC.

Conclusions:

Our four-year PC curriculum provides robust and developmentally appropriate training that addresses all nine evidence-based core topics for PC education. Medical student feedback and their Association of American Medical Colleges (AAMC) survey responses suggest that they find their PC learning experiences rewarding. This curriculum could serve as a model for other schools.

Introduction

Palliative care is widely recognized to be an essential part of medical practice and has entered national conversations about quality healthcare in response to aging of the population, escalating costs of end-of-life (EOL) care, and controversy about pain management practices.^1,2 All physicians need basic palliative care (PC) and EOL skills,³ but these are often neglected in medical school curricula.¹ A 2014 evaluation of PC education across medical schools reported varied and uneven approaches to PC and EOL teaching.⁴

Because PC intersects with many dimensions of healthcare, it is probably best taught longitudinally, with a variety of experiences woven throughout the curriculum.^4–6 A developmental curriculum would have year 1–2 medical students learn basic pain management, followed by more complex discussions of treatment goals in years 3–4.^7–9 However, most year 3 students never observe an advance directive discussion and rarely conduct one themselves.¹⁰ Longitudinal PC learning experiences for students are difficult to design, implement, and evaluate because they need to be integrated into an array of courses that have diverse educational objectives and are run by multiple educators.

The University of Rochester School of Medicine and Dentistry (UR) has a long history of teaching the “biopsychosocial model” of patient care.¹¹ The Double Helix Curriculum, initiated in the late 1990s, weaves fundamental patient care skills through years 1–2 of medical school and extends basic science into years 3–4. As part of this curricular reform, a longitudinal, integrated, biopsychosocial PC curriculum, developed under the leadership of one author (T.Q.), incorporated PC topics and experiences throughout the students' four-year experience. In 2003, Quill et al.¹² reported that this PC curriculum combined lecture, case and ethics conferences, problem-based learning cases with PC components, a home-visit experience, and a formative comprehensive assessment (CA) with standardized patient encounters, including an EOL decision-making case.

This PC curriculum was not formally evaluated in its first years, and methods for assessment of PC education have advanced in the intervening period. In 2000, Meekin et al.¹³ developed the palliative education assessment tool (PEAT) based on existing literature. The PEAT has been used for an analysis of PC content in international undergraduate medical curricula,¹⁴ but its seven domains are very broad and underrepresent some essential topics, while its 83 objectives are cumbersome. In 2014, Schaefer et al. surveyed 70 national PC experts, who identified 18 PC competencies for medical students, based on the competencies previously developed for hospice and palliative medicine fellowships.³ These experts evaluated competencies for importance and relevance and identified seven that they deemed “essential for all” students.³ Schaefer's seven essential competencies, although more manageable than the 83 objectives of the PEAT, did not align well with the seven PEAT domains.

In this study, we aimed to describe the scope and content of the UR PC curriculum after 17 years of implementation and assess student responses to it. The authors created a novel nine-topic framework for curriculum content that combines and reorganizes the PEAT domains/objectives and the Schaefer competencies. We systematically reexamined our longitudinal curriculum and used the framework to map its content to the nine-topic framework.^3,13,15 We identified five in-depth PC learning activities that are valued by most students and assessed student responses to the overall curriculum. This integrated, longitudinal curricular model may be useful to other medical schools interested in enhancing PC education.

Methods

Analysis of the UR curriculum in PC

In 2016, we used electronic searches and a faculty survey to tabulate all PC curricular activities. We queried the four-year curriculum database to identify student experiences with a central PC theme, using the search terms PC, hospice, pain management, EOL, and advance directives. We surveyed course and clerkship directors and PC, pain, ethics, and humanities faculty through e-mail to identify additional experiences with a PC subcomponent, looking for teaching of general principles of PC, EOL, pain and nonpain symptom management, advance directives, and the emotional impact of caring for patients with severe illness. Respondents were asked whether and how they covered these topics, and if they felt any were covered inadequately. Collating the data, we created a comprehensive table of PC curricular activities, including five in-depth activities. For the latter, course directors were asked for student responses, which were available in various formats from an online evaluation system.

Development of competency tool and curriculum mapping

To analyze our curriculum content in relation to national competency standards, we initially compared and evaluated the full set of 18 PC competencies for medical students of Schaefer et al.³ and the seven domains and 83 objectives in the PEAT.¹³ All authors independently and then jointly reviewed the two tools and identified overlaps and omissions. We combined and reorganized items from both tools to create a framework of nine distinct but partially overlapping PC curricular topics for use in our curriculum content analysis (Table 1). Two authors (E.M.D.-K., T.Q.) then mapped all PC curricular activities to these nine topics (Table 2), reaching consensus by discussion.

Table 1.

Nine Core Palliative Care Curricular Topics for Medical School Curricula, Derived from Objectives and Assessment Tools in the Palliative Care Literature

Core PC topic	Schaefer's palliative care competencies (1–18)³	Palliative education assessment tool domains (I–VII)¹³
1. PC	5—Defines the philosophy and role of PC across the life cycle and differentiates hospice from PC	I—Palliative medicine
1. PC	17—Describes the roles of members of an interdisciplinary PC team, including nurses, social workers, case managers, chaplains, and pharmacists	I—Palliative medicine
2. EOL care	10—Identifies common signs of the dying process and describes treatments for common symptoms at the EOL	VI—Patient/family/caregiver nonclinical perspectives on EOL care
	12—Describes disease trajectories common serious illnesses in adult and pediatric populations
	13 Describes the communication tasks of a physician when a patient dies, such as pronouncement, family notification, and request for autopsy.
	18—Describes normal grief and bereavement and risk factors for prolonged grief disorder
3. Addressing goals of care and advanced directives	4—Explores patient and family understanding of illness, concerns, goals, and values that inform the plan of care	VI—Patient/family/caregiver nonclinical perspectives on EOL care
		VII—Clinical communication skills
	6—Demonstrates patient-centered communication techniques when giving bad news and discussing resuscitation preferences.
	11—Identifies patients' and families' cultural values, beliefs, and practices related to serious illness and EOL care.
4. Patient-centered communication	6—Demonstrates patient-centered communication techniques when giving bad news and discussing resuscitation preferences.	VII—Clinical communication skills
4. Patient-centered communication	11—Identifies patients' and families' cultural values, beliefs, and practices related to serious illness and EOL care.	VII—Clinical communication skills
5. Responding to psychosocial distress	3—Identifies psychosocial distress in patients and families	III—Neuropsychologic symptoms
	3—Identifies psychosocial distress in patients and families	VI—Patient/family/caregiver nonclinical perspectives on EOL care
	9—Demonstrates basic approaches to handling emotion in patients and families facing serious illness
	16—Identifies spiritual and existential suffering in patients and families
	18—Describes normal grief and bereavement and risk factors for prolonged grief disorder.
6. Physician emotional experience and self-care	2—Reflects on personal emotional reactions to patient's dying and deaths	V—Ethics and the law: Professional self-reflection (subgroup B)^a
7. Pain management	7—Assesses pain systematically and distinguishes nociceptive from neuropathic pain syndromes	II—Pain
7. Pain management	8—Describes key issues and principles of pain management with opioids, including equianalgesic dosing, common side effects, addiction, tolerance, and dependence.	II—Pain
8. Nonpain symptom management	14—Describes an approach to the diagnosis of anxiety, depression, and delirium.	III—Neuropsychologic symptoms
		IV—Other symptoms
	15—Assesses nonpain symptoms and outlines a differential diagnosis, initial work-up, and treatment plan	IV—Other symptoms
9. Ethics and law	1—Ethical principles that inform decision making	V—Ethics and the law

Physician emotional experience and self-care were not found in any of the domains, but was found in subgroup B under “Professional self-reflection,” which was found under the ethics and the law domain.

EOL, end of life; PC, palliative care.

Table 2.

University of Rochester School of Medicine Four-Year Palliative Care Curriculum Activities by Format and Mapped to Evidence-Based Curricular Topics

		Core PC topic
Curriculum activities as of 2016	Format	1. Palliative care	2. End-of-Life care	3. Goals of care/Advance directives	4. Patient-centered communication	5. Responding to distress	6. Physician emotions and self-care	7. Pain management	8. Nonpain symptom management	9. Ethics and law
Year 1
Introduction to medical humanities and bioethics	Lecture						x			x
Integration conference^a: Introduction to PC and hospice	Lecture + Case conf	x	x	x	x	x	x			x
PBL case: Man with Alzheimer's disease, admitted with dehydration, discusses surrogate role and advanced directives	PBL	x	x	x						x
PBL case: Jehovah's witness with postpartum hemorrhage discusses right to refuse treatment	PBL			x						x
Health disparities day: Ethical case of surrogate decision making around life-sustaining treatment	Case conf			x						x
Introduction to clinical medicine course: Covers patient-centered interview, responding to emotion, physical examination, and clinical reasoning	Course				x	x
Anatomy course: Reflection on the first week of anatomy	Course Comp						x
Anatomy course: Memorial service at end of anatomy (students plan and performance with chaplaincy guidance.)	Course comp						x
Anatomy course: Geri-anatomy discussion re cadavers	Case conf						x
Medical humanities elective: Informed consent	Hum Elec			x						x
Medical humanities elective: Famous cases in bioethics	Hum Elec									x
Year 2
Approach to pain management	Lecture							x
Giving bad news	Lecture			x	x	x	x
Integrative medicine and pain management	Lecture							x
Opioid addiction/dependence/withdrawal	Lecture							x
Depression and suicide	Lecture					x			x	x
Approach to musculoskeletal pain	Lecture							x
Approach to abdominal pain	Lecture							x
Pain pathways, opioid analgesics, and NSAIDs	Lecture							x
Peripheral neuropathies	Lecture							x
Stress, adaptation, and transitions: Pain and anxiety as inputs to the stress response	Lecture					x		x	x
PBL case	PBL	x	x	x				x	x
Example: Man with multiple myeloma who chooses aggressive treatment, but when quality of life worsens, chooses home hospice	PBL	x	x	x				x	x
Home visit experience: Three visits with seriously ill patient, including functional assessment, EOL values, and self-reflection narrative	Home visit		x		x	x	x		x
Integration conferences^a	Case Conf		x	x		x		x	x	x
Examples:
1. Chronic malignant pain
2. ALS: Pathology mixed with requests for assistance in dying
Master clinician rounds: Four student rounds with faculty, practice interviewing, physical examination, differential Dx, and clinical reasoning	Clinical rounds			x	x	x	x
CA: 1-Day SP case on being with a patient after bad news	CA		x	x	x	x	x
Medical humanities elective: The healer's art	Hum elec	x	x				x
Medical humanities elective: Death and dying in modern medicine	Hum elec	x	x				x
Medical humanities elective: Effective communication for the clinical clerk	Hum elec			x	x	x				x
Year 3
Perioperative anesthesia	Lecture							x
Pharmacology of pain	Lecture							x
PBL example:	PBL	x	x	x	x
Septic man in ICU, not improving despite aggressive measures. Goals of care discussion re DNR and ventilator withdrawal.	PBL	x	x	x	x
Book discussion: Diving bell and the butterfly	Case conf					x				x
Neurology-psychiatry joint case conference (students bring cases in PC, ethics, neurology, and psychiatry to faculty)	Case conf	x	x	x		x	x			x
Lecture with reader's theater: Brain death. Students read Richard Selzer's Follow thy Heart	Lecture		x	x		x		x		x
Biomedical ethics case discussion	Case conf									x
Beginning of life ethics case discussion	Case conf									x
Case discussion: Ethics and PC in internal medicine	Case conf	x	x	x			x			x
Case discussion: “Being with Suffering”	Case conf					x	x
PC clinical elective	Clin elec	x	x	x	x	x	x	x	x	x
Clinical ethics elective	Clin elec			x						x
CA:	CA	x	x	x	x	x	x
4-Day longitudinal SP case of terminal illness	CA	x	x	x	x	x	x
Year 4
Discussion: Unexpected death	Case conf	x	x			x	x
Successful interning course:	Course comp	x	x		x		x	x		x
Selectives:
Pain management with opioids
Managing stress in internship
PC clinical elective	Clin elec	x	x	x	x	x	x	x	x	x
Clinical ethics elective	Clin elec			x						x

Electives marked in bold, all other activities are required.

Integration conference: An educational conference designed to integrate basic science, clinical care, and psychosocial aspects of medicine, usually with a patient or a case presented.

Conf, conference; PBL, problem based learning activity; Comp, component; Hum, humanities; CA, comprehensive assessment; Elec, elective; Clin, clinical; ALS, amyotrophic lateral sclerosis; DNR, do-not-resuscitate order; NSAIDs, nonsteroidal anti-inflammatory drugs; SP, standardized patient.

Results

The UR longitudinal, integrated four-year curriculum

The curriculum database search yielded 29 PC-focused activities, mostly lectures and workshops. The survey (faculty response rate 30/32 = 94%) identified 17 additional activities, yielding a total of 46 PC curricular activities over four years. Table 2 lists and maps these activities to the nine core PC topics. All nine topics were addressed, often in multiple formats each year, with many topics recurring. The PC clinical elective was the only single activity that covered all nine core topics, but five or more topics were covered by home visits, humanities seminars, case conferences, the years 2 and 3 CAs, and the Successful Interning course (elective workshops for year 4 students).

Several course directors identified opportunities for additions to the PC curriculum: pain management in the medicine clerkships, discussion of goals of care and advance directives in the emergency medicine clerkship, and discussion of advance directives during the Successful Interning course.

Five in-depth PC experiences and student responses to them

The UR longitudinal PC curriculum is robust, although loosely structured, with activities in many settings over four years. Table 3 expands upon five PC learning experiences that span the four-year curriculum and offer deeper learning and broader coverage (≥5 core topics). They are patient-centered, highly interactive, emphasize biopsychosocial evaluation, and are developmentally timed for the student's learning level. The in-depth experiences have been sustained over time, receiving positive student reviews since 1999. Table 3 provides representative samples of student responses in 2016–17. Among the five in-depth activities, the most innovative and intense is the CA, which includes exercises on PC (among other topics) for all UR medical students near the end of years 2 and 3. CAs are multiday formative experiences composed of standardized patient encounters, large and small group demonstrations and discussions, computer exercises, self-evaluations, peer evaluations, and multisource feedback.

Table 3.

In-Depth Palliative Care Educational Experiences in the University of Rochester's Longitudinal, Integrated Medical School Curriculum, with Student Response Data

Curricular activity	Description	Student response data (2016–17)
Medical humanities seminars: Years 1 and 2	“Selective” seminar: Students must choose one among several in each year, for eight hours total; may choose two per yearSeminars with PC themes:1. Death and dying in modern medicine2. Effective communication around difficult issues3. The healer's art	Death and dying (12 students)Narrative:“I loved that we took trips to different places and got to meet different people and explore different settings. I really enjoyed our discussions, and I found Dr. H's session where we interviewed each other for seven minutes to be particularly enlightening and eye-opening, both in terms of learning things about myself and in terms of learning about my classmates at a much deeper level.”“Seeing the different facets of death and dying, affecting different age groups and people, was very useful. It was useful to learn the language associated with death and dying and to be able to speak one's opinion. It was also useful to see the different routes and roles one can take as a caregiver for the dying (PC in hospital vs. hospice in home).”Suggestions for change: More field trips, keep it conversational
		Effective communication around difficult issues (12 students)Narrative:“The one area that I think could improve this already great seminar is to broaden the scope of some of the SP discussions. While our topics were very useful, I think it would have been great to have more practice with topics like sexuality or death/dying. While we touched death/dying on the last day, I think practicing with a SP would have been useful.”“The most useful parts of the seminar were all of the interactions with the SPs. I thought that it was extremely helpful to be put into those difficult clinical scenarios and know it was a safe environment where we could all mess up and then learn from our mistakes.”
		The healer's art (12 students)Narrative:“I think the small groups were most valuable. It is really nice to be able to get to know an individual faculty member in a personal setting and be able to just talk about general life concerns and concerns about healthcare as a whole.”“Sometimes it felt as if I was grasping at having things to say, because I don't really have that many clinical experiences to talk about. I don't really know how to improve this though, because I also liked this aspect of the class. It made me think about emotional issues that may arise I haven't thought about before.”
Home visit experience: Year 2	Students:• Make three home visits with seriously ill patient (geriatric, palliative, complex medical)• Perform medical, psychosocial assessment, and functional assessment• Assess the patient's values and advance directive planning• Write narrative with self-reflection	51% rated as valuable or extremely valuableComments summary: Rewarding and challenging, brought students out of comfort zone, some worried about safety, felt three visits were excessiveNarrative: “At first it was awkward going into someone's home and asking them very personal questions. I felt out of place and intrusive. I know many of my classmates [had] this same issue and ended up feeling like this the whole time. Fortunately I was able to bond with my patient and really get a lot out of it. At times I felt sort of useless in that I knew my patient was dying and couldn't do anything about it. But in all I really got to appreciate what people might go through during the end of their life and how gracefully some navigate it despite pain.”“I was nervous at first, but it ended up being the best thing about the clerkship!”“I think that the home visit is a valuable exercise in theory. Not only did it give me an opportunity to gain a greater appreciation for the difficult life circumstances that many of our patients face, but I grew close with my patient and I felt like she really enjoyed my visits. However, I do think that the assignment is more dangerous than a school assignment should be. My preceptor trusted my patient completely, and he was right to, but she lived in a fairly desolate area of the city that I did not feel particularly safe in… Though I did find the exercise useful, I felt that the risks probably outweighed the benefits.”
CA: Years 2 and 3	Multiday reflective exercises, including SP encounters, large and small group discussions, computer exercises, and self-, peer-, and multisource evaluationsEmbedded PC case activities:Year 2: Patient just diagnosed with a terminal illness. Student must assess understanding, be present, and address unanswered questions.Year 3: 5-day case of an elder with new metastatic cancer, sharing diagnosis, prognosis, and facilitating goals of care discussion	Year 2 caseStudents ranked PC case as most valuable case in the CA, 87–89% ranking it in top threeNarrative:“These most difficult conversations about the humanity behind medicine and the heart of being a doctor keep us grounded in the reason we came to this profession.”“I will ALWAYS remember this encounter. Easily one of the most powerful experiences I have had in medical school. If you look at my ratings for this case, I said that medical school has prepared us “somewhat” for this encounter. I think the bad news lecture we received in Primary Care Clerkship was invaluable, but one can't really be prepared for this until they have actually practiced it. I now feel much more prepared to help actual patients in such a situation. It just felt so real to me and was a strong reminder of why I am here.”“Although I was apprehensive about this case, I am extremely grateful to have had the opportunity to see this SP. It was extraordinarily valuable to have a controlled environment inwhich to practice simply being present for a patient, and it taught me a lot about how I might demonstrate empathy to similar patients in the future.”Year 3 case(Scale: 1 = no value to 5 = high value)PC component of SP encounters rated very highly 4.37/5Did experience help you know yourself better? 4.1/5Did experience help you develop as a physician? 4.3/5Narrative:“I felt so much more prepared to “deliver bad news” then during CA last year. This was an extremely valuable experience to see how I have progressed and to practice an extremely difficult part of being a physician.”“These were far and away the most useful, challenging, and nuanced SP encounters I've had in medical school.”“Hearing the SP's feedback and how he had seen each of us as students' grow and change in our approaches over the week was really valuable. I learned that if my thoughts were not with the patient (i.e., I was thinking in my head of diagnostic possibilities or what other tests I needed to run, and so on), the patients could sense that. This was an important take away for me. My clinician observer this time around was a family medicine doctor -and his approach to medicine and to delivering bad news and to patient care was amazing. I felt like he understood my struggles and challenges and was humble about how he faced them as well.”
PC clinical elective years 3 and 4	2-week clinical elective on inpatient PC unit and consult service. Students• Are active members of a busy team, working directly with attendings, and seeing new consults and follow-up patients.• Attend PC team meetings, educational sessions, including individualized session with senior clinician on challenging conversations, symptom management, and opioid calculations using Primer of Palliative Care.¹⁶Learning Objectives:1. To identify cases in which PC consultation is appropriate.2. Demonstrate the process of PC consultation, including assessment of uncomfortable symptoms and status of life-prolonging therapies.3. Identify the most common symptoms for patients with advanced illness and basic modalities of treatment4. Demonstrate the ability to speak honestly and compassionately with dying patients and their families.	Overall quality of the elective:Rated above average or excellent by 94%
PC clinical elective years 3 and 4		Quality of teaching in the elective:Rated above average or excellent by 100%100% of students would recommend the elective to others.Narrative:“This elective was absolutely amazing. It was by far my favorite elective of medical school. I loved how independent they let the med students be. Everyone on the PC team is also so kind and supportive.”“I think this gives the chance for a medical student to spend a lot of time with patients… it sort of goes back to serious emphasis on the biopsychosocial aspect of medicine. In addition, this was the BEST learning I have had on pain medication and management.”“I enjoyed being able to work independently and feel like a part of the team. I was able to gain experience in holding goals of care discussions and feel more comfortable doing this now.”
Successful interning course: Year 4	2-week course near end of year 4: Large-group activities and small-group “selectives.”Selectives with PC themes:• Pain management with opioids• Managing stress in Internship• Suggested new topics: Advanced directives, discussing goals of care	Pain managementNarrative: “After this session I feel much more comfortable with opioid prescribing.”
Successful interning course: Year 4		Managing stressNarrative: “It was a very helpful venue to both share and listen to other students' perceptions of intern year.”

The year 2 CA includes a 4-hour PC clinical practicum with a simulated 45-year-old mother just diagnosed with a life-limiting disease. Students assess the patient's understanding of her disease, respond to her emotions, and discuss her uncertain future. They receive immediate feedback from the patient-actor and view self-selected video recorded segments of their encounter with two student peers. Finally, the entire class explores the encounter as a large group.

The year 3 CA includes a 5-day longitudinal encounter with a simulated 73-year-old patient with a new diagnosis of disseminated cancer. Each student meets individually with the patient-actor and family member daily for three PC discussions as follows: preparing for potential “bad news”; sharing the actual bad news, including prognosis; and facilitating a goals-of-care discussion. Each step is followed by an oral presentation; multisource feedback from patient-actors, clinician observers, and peers; and a large group demonstration and discussion. Responses to the CA are shown in Table 3.

Students' overall evaluations of PC training

Evaluation of the overall curriculum is shown in Table 4. First, students self-assessed their preparedness for the years 2 and 3 CA encounters described above. The majority reported feeling well prepared: 54% in year 2 and over ≥70% in year 3. Students' self-appraisals during the year 3 CA are unique in our curriculum in asking students to take a broad and deep look at their PC education over time. In addition, broader curriculum evaluation data are provided by results of the Association of American Medical College's (AAMC). The AAMC is the association of academic medical centers, which manages the admissions processes for medical students and residents as well as administering a graduate questionnaire (GQ) for medical students, providing valuable feedback to medical schools on the effectiveness of their training programs. In 2013, the last year when these questions were included in the survey, the vast majority of UR medical students felt that their instruction in PC was appropriate and not excessive: 94% for pain management and 95% for EOL care (Table 4). These questions are too broad to allow detailed evaluation of the curriculum, but responses suggest that the UR PC curriculum has been valued by its graduates. Regrettably, more recent data are not available from this source.

Table 4.

Student Evaluations of Overall Palliative Care Curriculum, with Data from Comprehensive Assessments and the Association of American Medical Colleges Graduate Questionnaire

End of 2017 CAs (years 2 and 3) ^a
	Question: How well did your medical school education prepare you to…	Not at all or little prepared (%)	Somewhat prepared (%)	Well or extremely well prepared (%)
Year 2 CA
n = 102/104 (98% response)	Follow-up on a patient grappling with bad news	11	34	54
Year 3 CA	Deliver bad news	3	24	73
n = 103/104 (99% response)	Respond to patient emotions	1	17	83
	Discuss concerns and fears about dying	5	25	70
	Discuss advance care planning	7	22	71
	Negotiate resuscitation preferences	7	21	72

2013 AAMC survey on PC and EOL instruction
	Question: Do you believe that our instruction in the following areas was inadequate, appropriate, or excessive?	Inadequate	Appropriate	Excessive
PC/pain management
	University of Rochester	3.0	94.1	3.0
	All medical schools	19.4	78.8	1.8
EOL care
	University of Rochester	3.0	95.0	2.0
	All medical schools	18.2	80.0	1.9

Responses are from a required postcourse assessment, with questions matched to expectations of the case-based learning activity.

Discussion

We present a novel framework for PC curriculum analysis using nine core topics derived from national, evidence-based PC assessment tools and competencies. With over 46 PC-related experiences in the curriculum, some redundancy is inevitable, but students did not feel training was excessive. We highlight five innovative, in-depth PC activities that have survived curriculum changes over 17 years and are positively evaluated by students. This study has demonstrated that the UR PC curriculum is consistent with national competency standards in scope and content. It appears to satisfy students, and it met AAMC GQ standards with excellent results through 2013. Our diverse PC curricular activities offer a broad model and specific examples for other programs to consider for their own PC curricula.

Students appear to benefit from repeated exposure to the nine core PC topics, with an array of teaching modalities spread over four years. In particular, numerous activities emphasize the importance of physicians' emotional self-awareness and self-care (PC Core topic 6), a domain of learning that prepares physicians for resilience when caring for patients who are suffering or dying. Providing biopsychosocially competent patient care is the dominant theme of our Double Helix Curriculum and its integrated PC experiences, as demonstrated by the emphasis on PC skills in CA cases in years 2 and 3. The PC curriculum also includes a balance of teaching modalities, with more didactic learning in the early years and increasingly complex clinical applications in the later years. Elective experiences in the last two years are designed to enhance students' evolving interests.

The core elements of the UR PC curriculum have remained remarkably intact since 1999; their persistence suggests sustained acceptance by course directors and students. Students' recent comments on and ratings of several PC experiences (Tables 3 and 4) suggest that they remain satisfied with their education in PC. Given the many changes in leaders, faculty, and educational agendas that have influenced our curriculum over 17 years, we believe that the ongoing retention of these PC learning activities indicates sustained perceived value by faculty and students.

Completion of the PC curriculum analysis was challenging, because integrated experiences are difficult to systematize and track.⁶ Course directors found it difficult to answer the survey without spending significant time reviewing each activity for PC content, and the administration expressed concern about educator and student evaluation burden. However, the curriculum review process was helpful for both the course directors and the PC faculty: some areas worthy of increased exposure were identified. For example, in the Successful Interning course, practical hands-on experiences with pain management and advance directive conversations were implemented in 2017. This systematic curriculum analysis will likely foster more improvements over time.

A longitudinal integrated curriculum is challenging to evaluate when it crosses four years of educational experiences, with multiple courses and directors. Course-specific evaluation of the PC curriculum by students has been limited, because in individual courses or activities, student evaluations were not focused on PC experiences, and courses used differing formats and rating scales. A notable exception is the CA in years 2 and 3. We aim to strengthen assessments of students' learning and responses to instruction across our other in-depth experiences, using more systematic, competency-based evaluation methods.

To assist other programs in developing PC curricula, the authors share key lessons learned from our curriculum implementation, based on our long collective experience with curriculum development and evaluation.

(1) Introduce PC topics at developmentally appropriate times. Lectures in year 1 that introduce basic PC concepts and patient-centered communication can set the stage for learning about pain pharmacology in the year 2 and discussing an unexpected adverse diagnosis in year 3. We believe that our students' continuing exposure to opportunities for self-reflection when facing difficult clinical situations enhances their emotional insight as they encounter increasingly challenging patients.

(2) Seize opportunities to integrate your curriculum in new ways. Over time, our PC faculty have volunteered to replace lecturers, small group facilitators, and course directors, and these roles have empowered them to introduce new PC learning opportunities. Dr. Quill has remained active in student teaching since the curriculum was launched and has recruited new faculty (E.M.D.-K. and R.H.) who share his deep commitment in education. One co-author (R.H.) was given the opportunity to direct the years 2 and 3 CAs, and he expanded the cases and self-reflection with PC themes. This study (led by E.M.D.-K.) has prompted addition of new elective workshops to the Successful Interning course.

(3) Work to develop new and better evaluation methods. Evaluations of longitudinal curricula are challenging, but are needed to promote and disseminate PC education nationally. When one author (R.H.) became course director for the CA, he revised and created new cases that enable formative evaluation of students' PC learning. In the future, qualitative analysis of students' written comments from the CAs will provide enhanced data on their learning outcomes. Another author (E.M.D.-K.) has been appointed to oversee and evaluate our longitudinal PC curriculum (resulting in this study). Clearly the robust institutional support for sustaining and improving the PC curriculum has been a key to the success of our program.

Limitations

Generalizability of this study may be limited, as it was conducted at one institution with a long-standing focus on the biopsychosocial model, a well-established PC program, and PC clinicians who are involved in multiple aspects of our medical school curriculum. Hence our environment may be more supportive of PC education than other academic settings.

Our survey of course and clerkship directors was productive, but was likely subject to recall bias, or in some cases, reluctance of the respondent to take time for a comprehensive response. So we may have missed some PC-related activities in our analysis.

The absence of an explicit PC evaluation process at our institution is a limiting factor in evaluating our PC curriculum. Despite the value of the CA as a formative assessment tool, our current medical school course evaluations and graduate surveys do not directly address PC education, and additional evaluation burdens on course leaders and students are discouraged. AAMC survey data on student views of their PC training are no longer collected. Recent student ratings of several PC experiences suggest satisfaction, but a more comprehensive approach to curriculum evaluation is needed. In addition to qualitative analysis of students' written comments from the CAs, we will add comments on postgraduate surveys to assess how graduates' PC learning influences future practice. Improving evaluation of our other in-depth PC experiences will also address this shortcoming.

Conclusion

Content analysis shows that the UR four-year PC curriculum provides robust, diverse, and developmentally appropriate training that addresses all nine evidence-based core topics for PC education. Students' feedback from their key PC learning experiences and on their responses on the AAMC survey suggests that they find that their PC education meets their perceived educational needs. Our longitudinal approach to integration of PC content into the curriculum and our innovative in-depth PC experiences could serve as a model for other medical schools, but need a more comprehensive evaluation process in the future.

Footnotes

Acknowledgments

Thank you to David Lambert, Christopher Mooney, Andria Mutrie, and all the course directors of the UR Medical School for help in accessing curricular data for this article.

Author Disclosure Statement

No competing financial interests exist.

References

Chiu

, Cheon

, Lutz

, et al.: Inadequacy of palliative training in the medical school curriculum. J Cancer Educ, 2014; 30:749–753.

Dowell

, Haegerich

, Chou

: CDC guidelines for prescribing opioids for chronic pain—United States, 2016. JAMA, 2016; 315:1624–1645.

Schaefer

, Chittenden

, Sullivan

, et al.: Raising the bar for the care of seriously ill patients: Results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med, 2014; 98:1024–1031.

Horowitz

, Gramling

, Quill

: Palliative care education in US Medical Schools. Med Educ, 2014; 48:59–66.

Walters

, Greenhill

, Richard

, et al.: Outcomes of longitudinal integrated clinical placements for students, clinicians and society. Med Educ, 2012; 46:1028–1041.

Ellman

, Fortin AH

, Putnam

, et al.: Implementing and evaluating a four-year integrated end-of-life care curriculum for medical students. Teach Learn Med, 2016; 28:229–239.

Fraser

, Kutner

, Pfeifer

: Senior medical students' perceptions of the adequacy of education on end-of-life issues. J Palliat Med, 2001; 4:337–343.

Billings

, Engelbert

, Curtis

, et al.: 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. J Palliat Med, 2010; 13:319–326.

Anderson

, Williams

, Bost

, et al.: Exposure to death is associated with positive attitudes and higher knowledge about end-of-life care in graduating medical students. J Palliat Med, 2008; 11:1227–1233.

10.

Rabow

, Gargani

, Cooke

: Do as I say: Curricular discordance in medical school end-of-life care education. J Palliat Med, 2007; 10:759–769.

11.

Engel

: The clinical application of the biopsychosocial model. Am J Psychiatry, 1980; 137:535–544.

12.

Quill

, Dannefer

, Markakis

, et al.: An integrated biopsychosocial approach to palliative care training of medical students. J Palliat Med, 2003; 6:365–380.

13.

Meekin

, Klein

, Fleischman

, et al.: Development of a palliative education assessment tool for medical student education. Acad Med, 2000; 75:986–992.

14.

Schiessl

, Walshe

, Wildfeuer

, et al.: Undergraduate curricula in palliative medicine: A systematic analysis based on the palliative education assessment tool. J Palliat Med, 2013; 16:20–30.

15.

Plaza

, Draugalis

, Slack

, et al.: Curriculum mapping in program assessment and evaluation. Am J Pharm Educ, 2007; 71:Article 20.

16.

Quill

, Bower

, Holloway

, et al. Primer of Palliative Care, 6th ed. Chicago, IL: American Academy of Hospice and Palliative Medicine, 2014.