New medical graduates are concerned about communication with dying patients and their relatives and the more general problem of breaking bad news. An experiential learning project was designed in an effort to address some of these issues. Individual year 5 medical students were attached to a nurse preceptor on a palliative care ward for three working shifts. This allowed them to interact with terminally ill patients at several different levels: (1) as a 'carer' providing immediate comfort needs, (2) as a learner, and (3) and as a member of the health care team. The interaction provided opportunities to develop rapport with the patients which subsequently permitted an exploration of some of the more sensitive issues related to the illness, diagnosis, prognosis and dying. The experience highlighted a number of critical incidents that influenced the students' perspectives in relation to some aspects of palliative care.
Most medical curricula contain communication skills instruction. Despite this, many medical graduates have persisting interpersonal difficulties when confronted with terminally ill patients, death and dying during their internship and subsequent years (Field 1995, Finlay et al 1994, Charlton 1992, Firth-Cozens 1987, Dally et al 1984, Maguire 1984, Bates et al 1973). This suggests that current educational strategies are inadequate. Communication is a fundamental skill in the practice of palliative medicine, or the care of the terminally ill (Smith 1994). It therefore seems sensible to consider educational opportunities for better preparation of new graduates in the skills of communication with terminally ill patients and their relatives, within formal courses of palliative medicine.
Teaching strategies for addressing the communication issues in palliative medicine include lectures, small group discussion, videotape presentations, role play and simulations (Field 1995, Forbes & Allbrook 1991, Buchanan 1990). However, medical schools are increasingly using hospices for short term student placements (Field 1995, Smith 1994, Allbrook 1991, Forbes & Allbrook 1991, Hull 1991) and the range of teaching staff is widening to include general practitioners, hospice doctors, oncologists and nursing staff (Field 1995).
In the School of Medicine at the University of Western Australia, undergraduate palliative medicine instruction occurs over two years. Communication skills are emphasised during year 4, and this is reinforced in year 6 with a short visit to a patient in their home. Being aware of the fact that this is likely to be inadequate for addressing the problems faced by new graduates, it was decided to explore a learning opportunity that might address some of the issues.
I would feel (very anxious to very comfortable) in relation to:
Issues in prognosis
Issues in management
Issues in ongoing care.
Figure 1. The Questionnaire.
When asked how comfortable they would feel using the word 'cancer' in conversation or consultation with patients, there was a 50% increase in the 71 -100 range following the preceptorship placement and overall, 80% of participants felt that their comfort level had increased as a result of the exposure. In relation to being able to gauge if information has been understood by patients and relatives, 85% of all post placement responses were in the 61 - 100 range, but overall 55% of individuals felt less comfortable with this area after the placement.
In responding to the patient's question 'how long do I have to live', 70% of pre placement responses are in the 0-50 range and 40% of individuals felt that the placement had not improved comfort in this area. In relation to the patient's question 'will there be much suffering/pain', 75% of post placement responses were in the 71-100 range and 85% of participants felt that their comfort in this area was increased by the placement. In relation to prescribing adequate pain control medication for cancer patients, 95% of post placement responses were in the 61-100 range and 85% of individuals felt more comfortable in this area post placement.
Overall, 44 critical incidents were identified. These were categorised as issues in communication (14), the physical realities of palliative medicine (15), ethical and moral dilemmas (3), patient/family dynamics (7) and issues causing the participants to confront their own emotions (5). (See Figure 2).
Unsuccessful doctor/patient relationships (reported by patients)
Successful nurse/patient relationships (observed)
Successful participant/patient relationships (experienced)
Physical Realities of Palliative Care
Pain control can be very difficult in some patients
The problems of narcotic side effects especially constipation
Distasteful sights, sounds and smells (fungating tumours, Cheyne Stoke respirations and extreme cachexia)
What has to be done when a patient dies
Physical demands on the carers
Ethical and moral issues
Requests from relatives to terminate life
How to balance pain control without respiratory compromise
Family disagreement about treatment
Distress for family members
Witness to a death
Having to confront own feelings
Anger with patient's choice for alternative therapies
Figure 2. The Range of Critical Incidents
Students at our medical school seemed to be spending much of the time dedicated to dealing with communicating bad news and death and dying, in non contextual teaching sessions, rather than in experiential settings where they might have opportunities to see examples of good skills, develop a range of strategies for themselves and practice some of the strategies. During clinical attachments medically qualified staff are the supervisors and teachers. Their own clinical obligations often limit their availability for guiding student experiences and learning. Nor are they necessarily the best role models when communication and interaction with patients is the focus of the learning. As well, it is difficult to talk to patients about highly sensitive issues unless a degree of rapport has been established.
As far as it is possible to tell, all of these issues appear to have been addressed by the chosen study method. The setting, the supervision and the requirement of the students to work within a preceptorship model with an experienced palliative care nurse exposed them to real patients with sensitive problems. Students were able to use the nursing duties in which they participated to develop rapport with the patients. This then provided an entrŽe for exploring some of the more sensitive and personal issues related to diagnosis, prognosis, management and dying.
The nurse preceptors were 'buddies' - students were not left to confront difficult situations alone. They also modelled a range of communication and coping skills, sometimes very different from the medical model. As well, they supported and trained students in a range of practical skills (eg administering injections and wound care) when opportunities arose.
Recording of critical incidents on a daily basis was felt to be one valid way of obtaining insights into the nature of the experience for each participant. These were defined as instances, either directly involving the participants or relayed to them (usually by the patients), that had a significant influence on the participant's perspective of some aspect of palliative medical care. It was also recognised that some students might find it difficult to reflect upon the overall experience without some questioning and probing. Reflection and debriefing was felt to be essential for all students, but especially so, should experiences prove profoundly disturbing for some.
It is interesting to reflect upon why some elements of the experience should have created greater discomfort for some participants. In one sense it is not surprising. The sights, sounds and smells of a palliative care unit can be distressing for the most experienced practitioner and some of these issues were raised in the critical incidents. One further explanation for lower post experience comfort levels may be that the experience challenged assumptions, as in the following example. Just prior to commencing the placements the students had completed a course in clinical pharmacology and felt quite confident with their level of knowledge and understanding in this area. However some assumptions were challenged when they were faced with issues such as the difficulty of controlling pain in some patients, the massive doses of narcotic that might be required and the difficult problems of side effects.
In general, all students found something of value in this limited contact with terminally ill cancer patients. Although the main aim was to create opportunities for them to explore their communication difficulties, other experiences proved as valuable, or more so, for some. It may be that the experience - just being there - was more valuable than any perceived learning.
Participant criticisms that arose were unrelated to the project per se and likewise, the nurse preceptors revealed high satisfaction levels with the project, their role and the student participation.
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|Please cite as: Barrington, D. and Murrie, D. (1997). Facilitating communication and interactional skills with terminally ill patients: A preceptorship learning model for undergraduate medical students. In Pospisil, R. and Willcoxson, L. (Eds), Learning Through Teaching, p16-20. Proceedings of the 6th Annual Teaching Learning Forum, Murdoch University, February 1997. Perth: Murdoch University. http://lsn.curtin.edu.au/tlf/tlf1997/barrington.html|