Proper preparation and planning… part 2

I have blogged previously about the readiness of medical students to take on the role of a doctor when they exit medical school.

The previous paper I looked at highlighted that a significant proportion of medical students felt unprepared for the jobs they were ostensibly trained for, and that this proportion was variable across the different medical schools in the UK.

In this month’s PMJ a new paper continues this theme of preparedness.

The authors designed a questionnaire for all medical students at one UK medical school who had recently completed their elective attachment.  The students had gone to a variety of locations around the globe on their electives, and their experiences of death whilst abroad were compared with their experiences in the UK on other placements.

As one might expect, students who travelled to less developed countries were exposed to a greater number of young patients dying, and less elderly patients. Those students who travelled to less developed countries were also exposed to resuscitation attempts in greater numbers, and a high percentage (26%) were involved in solo resuscitation attempts – which would be incredibly unusual in a healthcare setting in the UK.

The impact of this direct exposure to death amongst medical students was explored with supplementary questions about the availability of time to reflect on the experience of being close to death, and if talking to others (and whom) was useful.

The free text responses to the questionnaire are revealing about how the hidden curriculum of the medical profession is at play in this sphere of clinical practice – with one medical student commenting that, having witnessed a resuscitation attempt, ‘I had partaken in what I thought to be a very important part of practical medical training’

This ‘rite of passage’ is undoubtedly an important part of becoming a medical practitioner – and I would consider a vital experience to have at medical school, rather than finding oneself at a cardiac arrest call for the first time when expected to play a vital role within the arrest team.

Another response quoted in the paper exposed the raw emotions which affect students who witness death : ‘shock—never seen anyone die before’  It is this reaction which should perhaps prompt us to examine how we train medical students and how involved we allow them to become in our clinical teams.

The proportion of deaths which take place in hospital varies widely throughout the UK – as low as 45% of deaths in some areas, and as high as 70% in others(see this interactive atlas for more information) However it is likely that medical students will be working on wards where there are patients who are approaching the end of their life, or are living with incurable or progressive long-term conditions.

Very often – and I know I do this myself, these patients are protected from the parade of medical students looking for ‘signs’ and examination practice.  As such, I wonder if we somehow sterilise the clinical experiences of our students, and create the conditions which pre-dispose our students to unpreparedness for facing death in practice.  If we are to train the next generation of physicians and surgeons who will be skilled enough to discuss end of life care issues, help facilitate advanced care planning and ultimately enable patients to die as they wish to, then we must consider how we can allow medical students to become more familiar with death and dying.

I am certainly not suggesting that we thrust medical students into the mix at the end of a patients life just so that they can ‘experience’ this aspect of care, but we certainly should be bringing death and dying into our conversations with medical students more, and looking to develop learning around death and dying when medical students are attached to firms whose patients may be approaching the end of their lives.

Charities like Dying Matters, the Natural Death Centre, and The National Council for Palliative Care work hard to develop resources for patients, families and professionals who are dealing with end of life issues.  We need to ensure that we bring some of this knowledge into training for our medical students.

It is a shame that  87% of medical students on one course felt that they were unprepared to deal with the death of a patient, and I suspect that this would be a similar finding on other courses.  It is beholden on all who train the next generation of doctors to ensure that our most junior colleagues are equipped with the tools to do the job they are being trained to do – not just up to, but including tending to the needs of patients who are approaching the end of their lives.