Teaching and Learning Forum 97 [ Contents ]

Facilitating communication and interactional skills with terminally ill patients:

A preceptorship learning model for undergraduate medical students

Dianne Barrington
Doreen Murrie
Faculty of Medicine and Dentistry
The University of Western Australia
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.

Introduction

In spite of the change that has occurred in medical education and medical practice in recent years certain clinical skills remain constant. These continue to be defined as essential because they cannot be separated from the operational definition of the clinician. One of them is the ability to effectively communicate and interact with patients, relatives and members of the health care team.

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.

Aim

To develop a teaching model that could provide undergraduate medical students with a period of contact with terminally ill patients during which interaction at various levels could provide a range of opportunities for students to explore their communication difficulties.

Method

Study Design

A short, prospective, descriptive study was undertaken. A medical student was matched with an experienced nurse preceptor in a palliative medicine setting at one of two sites - St John of God Hospital, Subiaco and St John of God Hospital, Murdoch in Perth, Western Australia. Students worked alongside the nurse preceptor during three standard morning shifts. The participants were visited and supported daily by a project officer who undertook observation, debriefing and documentation of critical incidents. Data were collected using a pre and post experience, self administered, 100 mm visual analogue questionnaires and critical incidents were recorded during 1:1 feedback with the project officer.

Sampling

Twenty year 5 medical students were released for three consecutive days (Tuesday - Thursday) from their 4 week clinical gynaecology rotation to undertake a pilot study. The participants, who represented half of the overall group, were allocated to the study by the course coordinator while the time table for the rotation was being prepared.

Details of the Questionnaire

Participants were asked to indicate their level of comfort along a continuum from 'very anxious' to 'very comfortable' for 17 individual questions that were grouped into 4 main themes: issues in diagnosis, issues in prognosis, issues in management and issues in ongoing care (see figure 1). Responses from 50 - 0 indicated increasing levels of anxiety and those from 51 - 100 indicated increasing levels of comfort.

I would feel (very anxious to very comfortable) in relation to:
    Issues in Diagnosis
    1. using the actual word cancer to impart the diagnosis
    2. using euphemisms such as lump, mass, tumour to impart the diagnosis
    3. knowing how much information (about the diagnosis) to impart.
    4. explaining the diagnosis in lay terms.
    5. gauging if the information has been understood by the patient and/or relative(s)

    Issues in prognosis

    1. the patient's question 'how long do I have to live'?
    2. discussing 5 year survival rates in general
    3. the patient's question 'will there be much suffering/pain'?

    Issues in management

    1. discussing surgical options (in general) for treatment
    2. discussing radiotherapy options (in general) for treatment
    3. discussing chemotherapy options (in general) for treatment
    4. discussing the fact that there is no treatment option that will provide benefit in this particular case.
    5. my level of knowledge of the origins and management of common symptoms experienced in patients with terminal cancer.
    6. prescribing appropriate and adequate pain control medication for patients with terminal cancer
    7. my knowledge of the therapeutic and side effects of narcotic analgesic agents.

    Issues in ongoing care.

    1. providing hope and encouragement to patients with a terminal illness and their families.
    2. raising the issue of palliative care with patients and their families

Figure 1. The Questionnaire.

Data Management

All questionnaire data were collected at the time of responding and critical incidents were recorded at daily debriefing sessions. Questionnaire data were grouped into 10 mm cohorts and managed by hand due to the small numbers and their descriptive nature. No statistical methods have been applied.

Results

The five example questions that follow are presented in descriptive terms only. The full data set is available on request.

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).

    Communication
      Successful doctor/patient relationships (observed)
      Unsuccessful doctor/patient relationships (reported by patients)
      Successful nurse/patient relationships (observed)
      Successful participant/patient relationships (experienced)

    Physical Realities of Palliative Care

      Awareness of the severity of some pain in some patients
      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

      Terminating active treatment
      Requests from relatives to terminate life
      How to balance pain control without respiratory compromise

    Family Dynamics

      Families who don't want dying relatives at home
      Family disagreement about treatment
      Distress for family members

    Emotional Issues

      Sorrow for young people dying especially when were children involved
      Witness to a death
      Having to confront own feelings
      Anger with patient's choice for alternative therapies

Figure 2. The Range of Critical Incidents

Discussion

When small sample numbers and self reporting are used it is not possible to generalise. However, this study has exposed several key issues in the undergraduate training of medical practitioners: the importance of context, the value of collaborative health professional education and role modelling, and the importance of reflecting upon experiences.

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.

Conclusions

As far as is possible to determine, this small pilot study has demonstrated that providing experiential opportunities for medical students, where they are actively engaged, can have positive influences on learning and skill development, particularly if certain skills such as communication are targeted. However, any positive effects are likely to be short lived without repeated opportunities to practise and reinforce the skills. For this particular group it is not possible to determine what, if any, lasting effects this short exposure might have on communication with terminal patients. In spite of its apparent success, the project was logistically difficult to organise, even for small numbers, and this factor will need to be considered in planning future experiences.

Acknowledgments

Without the care and cooperation of the nursing and administrative staff at St John of God Hospitals Subiaco and Murdoch this project could not have occurred. Funding was provided through an Innovative Teaching Grant from the University of Western Australia.

References

Allbrook, D. (1991). Palliative care in the 1990s? Medical Journal of Australia, 155: Sept 2, 286-287.

Bates, E. M., Hinton, J., Wood, T. (1973). Unhappiness and discontent: a study of junior resident medical officers. Medical Journal of Australia, 2: 606-612.

Buchanan, J., Millership, R., Zalcberg, J., Milne, J., Zimet, A. & Haines, I. (1990). Medical education in palliative care. Medical Journal of Australia, 152: January 1 27-29.

Charlton, R. (1992). The philosophy of palliative medicine: a challenge for medical education. Medical Education, 26: 473-477.

Dally, P., Ewan, C., Pitney, W. (1984). Assessment of an Australian medical internship. Medical Education, 18: 181-186.

Field, D. (1995). Education for palliative care: formal education about death, dying and bereavement in UK medical schools in 1983 and 1994. Medical Education, 29: 414-419.

Finlay, I., Maughan, T. & Webster, D. (1994). Portfolio learning: a proposal for undergraduate cancer teaching. Medical Education, 28: 79-82.

Firth-Cozens, J. (1987). Emotional distress in junior house officers. Medical Practice, 295: 533-535.

Forbes, J. F. & Allbrook, D. (1991). Education and palliative care: a different approach. Recent Results in Cancer Research, 121: 414-422.

Hull, F. (1991). Death, dying and the medical student. Medical Education, 25: 491-496.

Maguire, P. (1984). Teaching communication skills. Medical Teacher, 6, 4: 128-133.

Schonwetter, R. & Robinson, B. (1994. Educational objectives for medical training in the care of the terminally ill. Academic Medicine, 69, 8: 688-690.

Smith, A. (1994). Palliative medicine education for medical students: a survey of British medical schools, 1992. Medical Education, 28: 197-199.

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


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