Every day, medical students are intensely focused on learning to identify diseases, how they work and how to beat them. In other words, they’re learning how to help people live and not die.
However, for a day during their Family Medicine clerkships, the focus shifts to dealing with the imminent death of a patient. In 2000, Robert Frank, M.D., interim vice dean of Faculty Affairs, was instrumental in creating a program in which third-year medical students are required to spend one full day in a hospice or palliative care setting.
Juliann Binienda, Ph.D., an assistant professor in the Department of Family Medicine and Public Health Sciences, has helped coordinate the hospice rotation since its beginning.
“Students had a lot more anxiety and hesitation about the program just six or seven years ago,” said Dr. Binienda. “Today, students say, ‘Yeah, we need it.’”
The School of Medicine partners with Angela Hospice, Henry Ford Hospice, Hospice of Michigan, Karmanos Hospice and Mercy Hospice to provide the rotation.
Typically, students begin that designated day by sitting in on an interdisciplinary team meeting in which health care teams consult on the patients who will be seen that day and then spend their day following a nurse or a physician visiting patients in their homes, a hospice center or a hospital wing. Dr. Binienda said that 80 percent of patients are dying of cancer, and that students are often surprised when they meet a 17-year-old dying of leukemia or a 35-year-old of AIDS.
Craig Bilbrey, a third-year student from Brighton, Mich., spent a day in January visiting two patients in their homes with a nurse from Hospice of Michigan. Bilbrey said one of the patients, a man in his early 40s with late-stage cancer, was in considerable discomfort, however he declined pain medications so that he could fully enjoy visiting with him and the nurse, calling it the highlight of his day. After spending a couple of hours drinking Turkish coffee and tea together, at the patient’s insistence, Bilbrey came away impressed with how the man had come to terms with his situation.
“In the third year, we are so focused on the pathology and prevention of disease that I think we can forget to look at our patients as actual human beings,” Bilbrey said. “Let’s face it, that’s why we all went into medicine, to help people. That was put back in the forefront with the hospice experience.”
Dr. Binienda said “We hope that by learning about hospice and pain management, students will refer to hospice earlier once they’re practicing. Doctors often refer to hospice too late because they’re afraid to talk about it. Calling hospice the day before a patient dies doesn’t do them or their families any good.”
The program had the desired effect on Leslie Phillips, a third-year student who recently shadowed a nurse from Henry Ford Hospice in Macomb County.
“We want patients to live; that’s our job,” Phillips said. “But we all die, and at a certain point we should help people die in as little pain as possible. That day was very taxing and emotionally challenging, but we made our patients and their families feel better and that made up for everything else.”
At the end of students’ Family Medicine clerkship there is a de-briefing in which students are asked to share a story from their hospice experience with their classmates.
Jim Boal, M.D., medical director of Angela Hospice, said the experience helps students work around the cultural taboo of dying and shows students that some people can have good experiences at the end of their lives.
“They need to recognize that goals are different at the end of life,” Dr. Boal said. “Death is to be expected, and care is focused on comfort, not cure. Constipation in hospice is usually more of a concern than an irregular heart rhythm.”
In addition to their dedicated hospice day, Mike Stellini, M.D., assistant professor of Medicine and chief of Palliative Medicine, said medical students are exposed to end of life issues throughout all four years. At the end of the first year there is a ceremony recognizing cadavers dissected in anatomy classes. In second year, medical ethics are introduced and in fourth year during the ambulatory medicine month a series of seminars cover topics that include delivering bad news, medical marijuana and existential suffering.
“The importance can be summed up simply with a question I ask each fourth-year student in the seminars,” said Dr. Stellini. “‘When you are out in practice, what percent of your patients will die?’ When we first started this seminar series about eight years ago, the responses were quite varied – students would contemplate what specialty they were entering and consider risk of death from their specialty related illnesses. Now, I get an almost universal – and correct – response: 100 percent. I think the end-of-life curriculum has influenced students, so that by the time they get to fourth year they have a bit of insight.”