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JOURNAL OF PALLIATIVE MEDICINE

Volume 18, Number 4, 2015


ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2014.0270

Curricular Innovations for Medical Students


in Palliative and End-of-Life Care:
A Systematic Review and Assessment of Study Quality

Jennifer DeCoste-Lopez,1 Jai Madhok, MD, MSE,2 and Stephanie Harman, MD1

Abstract
Background: Recent focus on palliative and end-of-life care has led medical schools worldwide to enhance
their palliative care curricula.
Objective: The objective of the study was to describe recent curricular innovations in palliative care for medical
students, evaluate the quality of studies in the field, and inform future research and curricular design.
Methods: The authors searched Medline, Scopus, and Educational Resource Information Center (ERIC) for
English-language articles published between 2007 and 2013 describing a palliative care curriculum for medical
students. Characteristics of the curricula were extracted, and methodological quality was assessed using the
Medical Education Research Study Quality Instrument (MERSQI).
Results: The sample described 48 curricula in 12 countries. Faculty were usually interdisciplinary. Palliative
care topics included patient assessment, communication, pain and symptom management, psychosocial and
spiritual needs, bioethics and the law, role in the health care system, interdisciplinary teamwork, and self-care.
Thirty-nine articles included quantitative evaluation, with a mean MERSQI score of 9.9 (on a scale of 5 to 18).
The domain most likely to receive a high score was data analysis (mean 2.51 out of 3), while the domains most
likely to receive low scores were validity of instrument (mean 1.05) and outcomes (mean 1.31).
Conclusions: Recent innovations in palliative care education for medical students represent varied settings,
learner levels, instructors, educational modalities, and palliative care topics. Future curricula should continue to
incorporate interdisciplinary faculty. Studies could be improved by integrating longitudinal curricula and
longer-term outcomes; collaborating across institutions; using validated measures; and assessing higher-level
outcomes including skills, behaviors, and impact on patient care.

Introduction found that approaches to palliative care education are highly


variable between medical schools, with some schools re-

I n the past two decades, a national focus on the im-


portance of palliative and end-of-life care1 has led medical
schools to enhance their palliative care curricula.2 Since
porting as little as two hours of classroom time, while others
require weeks of training or clinical experience. Given that
medical schools already suffer from overstrained curricula,
2000, the Liaison Committee for Medical Education the authors advocate integrating developmentally appropri-
(LCME), the accrediting body for all allopathic medical ate, basic palliative care competencies into each year of the
schools in the United States and Canada, has required that all medical school curriculum to avoid both neglect of the topic
medical schools include education in palliative care and and educational overload.4 A recent national survey of pal-
communication skills.3 Longitudinal surveys of medical liative care experts arrived at a proposed set of competencies
school administrators over the past 35 years have demon- for medical students.5
strated that overall offerings in palliative care education have As palliative care educators advocate for scarce curricular
been consistently increasing; and since 2000, 100% of U.S. time and select educational methods, it is imperative to
medical schools have had at least some offering regarding identify rigorously tested curricula that can be used. Al-
death and dying.2 However, in their recent review of surveys though previous reviews related to palliative care education
of medical educators in the United States, Horowitz, et al. exist, these have largely focused on the overall state of

1
Department of Medicine, 2Department of Anesthesia, Stanford University School of Medicine, Stanford, California.
Accepted November 24, 2014.

338
SYSTEMATIC REVIEW OF PALLIATIVE CARE CURRICULA 339

palliative care education in the United States, rather than in which a single intervention was reported in more than one
evaluations of discrete curricula or innovations made in the article, we identified the article that provided the most
field worldwide.4,6,7 Furthermore, to our knowledge there has complete description and excluded the others.
been no systematic assessment of the quality of the evidence
supporting such interventions. Therefore, we undertook a Data extraction
systematic literature review to inform curricular develop-
Study characteristics for each included article were sum-
ment at our own medical school, to understand recent trends
marized, including country, learner level, instructors, setting,
in this field, and to evaluate the quality of the literature.
educational modality, duration of intervention, and palliative
care topics addressed.
Methods
Two authors ( JD and JM) independently tabulated a Medical
We conducted this systematic review in adherence with the Education Research Study Quality Instrument (MERSQI)
PRISMA standards8 as applied to a systematic review with- score9 for all articles that included a quantitative evaluation.
out meta-analysis. Meta-analysis was not pursued, because Disagreements between the two raters were resolved by re-
the literature in this area consists of heterogeneous inter- review and consensus to assign the final score. The MERSQI
ventions and outcomes, as well as many pilot or qualitative was developed by Reed, et al. in 2007 as a measure of meth-
studies that are not amenable to this methodology. odological rigor of medical education studies. The MERSQI
scores studies across six domains: study design, sampling, type
Questions of data, validity of evaluation instrument, data analysis, and
outcomes. These domains are further divided to yield 10 items.
These are the research questions we sought to answer:
Each of the six domains has a maximum score of 3, giving a
 What educational interventions have recently been de- possible score for each study ranging from a minimum of 5 to a
scribed to teach palliative care topics to undergraduate maximum of 18. This scoring system is summarized in the first
medical students? three columns of Table 1.
 What is the methodological quality of the studies in this
field? Results
Trial flow
Study eligibility
Our initial database searches identified 1167 results, and
We included academic articles published in the English after de-duplication, 829 were found to be unique articles.
language between 2007 and 2013. We chose this date range After filtering the results for English language and date of
because a previous review in this topic area reviewed the publication, we reviewed the titles and abstracts of the re-
literature through the end of 2006.6 Articles were included if maining 299. Sixty-eight met our inclusion criteria based on
the population of interest was undergraduate allopathic review of titles and abstracts. Full-text review led to the ex-
medical students and if the article described the evaluation of clusion of an additional 20, yielding a final sample of 48
a curriculum in a palliative care topic. Articles that described articles (see Fig. 1).
new curricula but did not include evaluation of any learner
outcome were excluded. Study characteristics
The included studies describe 48 unique curricula deliv-
Study identification
ered in 12 countries, which are summarized in Appendix 1:
In collaboration with a medical librarian we designed Summary of Curriculum Characteristics.10–57 Twenty-two
searches of Medline via PubMed, Scopus, and Educational articles were from the United States; 7 from the United
Resource Information Center (ERIC) databases for relevant Kingdom; 4 from Canada; 3 from Taiwan; 2 each from
articles. We performed iterative searches in each database to Australia, Croatia, and Germany; and 1 each from Brazil,
optimize the relevance and comprehensiveness of the results. Hungary, India, Ireland, Japan, and Poland. Educational set-
We last performed the searches on January 16, 2014. The ting was most often a mix of classroom and clinical settings
search strings used were: (n = 21, 44%). Seventeen (35%) were in a classroom setting
Medline: ((terminal care OR ‘‘palliative care’’ OR ‘‘palliative only, 7 (15%) in a clinical setting only, and 6 (13%) included
medicine’’ OR ‘‘end of life’’ OR ‘‘end-of-life’’) AND (educa- online instruction.
tion, medical, undergraduate OR ‘‘medical students’’)) The targeted learners were clinical medical students
Scopus: ((‘‘palliative care’’ OR ‘‘palliative medicine’’ OR ‘‘end (I = 27, 56%), preclinical medical students (I = 17, 35%), or
of life’’ OR ‘‘end-of-life’’ OR ‘‘hospice’’) AND (‘‘undergrad- both (n = 3, 6%). Five studies (10%) delivered the interven-
uate medical education’’ OR ‘‘medical students’’)) tion to medical students together with other learners, such as
ERIC: ((‘‘palliative care’’ OR ‘‘palliative medicine’’ OR nursing students, social work students, pharmacy students,
‘‘end of life’’ OR ‘‘end-of-life’’ OR ‘‘hospice’’ OR ‘‘terminal residents, and/or practicing health professionals.
illness’’ OR death) AND (‘‘medical students’’)) Physicians served as instructors for 29 interventions
(60%), including 19 (40%) in which the faculty included
hospice and palliative medicine specialists. It was also very
Study selection
common to involve other health professionals as teachers,
Two authors ( JD and JM) independently screened all ar- most commonly nurses or nurse practitioners (n = 15, 31%),
ticles, first reviewing titles and abstracts and then full texts. social workers (n = 7, 15%), and chaplains (n = 7, 15%). In 12
Conflicts were resolved by consensus. In the three instances articles (25%) the instructors were not specified.
340 DECOSTE-LOPEZ ET AL.

Table 1. Medical Education Research Study Quality Instrument (MERSQI) Scores


for Studies with Quantitative Evaluation
Number Mean Mean
Domain MERSQI item Score of studies (item) (domain)
Study design 1) Study design 1.53 1.53
Cross-sectional or single-group posttest only 1.0 12 (31%)
Single group pretest and posttest 1.5 17 (44%)
Nonrandomized, two-group 2.0 8 (21%)
Randomized controlled trial 3.0 2 (5%)
Sampling 2) Number of institutions studied 0.53 1.74
1 0.5 38 (97%)
2 1.0 0
>2 1.5 1 (3%)
3) Response rate 1.22
Not applicable 0
< 50% or not reported 0.5
50%–74% 1.0
‡ 75% 1.5
Type of data 4) Type of data 1.77 1.77
Assessment by study participant 1.0 24 (62%)
Objective measurement 3.0 15 (38%)
Validity of instrument 5) Internal structure 0.38 1.05
Not applicable 0
Not reported 0 24 (62%)
Reported 1.0 15 (38%)
6) Content 0.59
Not applicable 0
Not reported 0 16 (41%)
Reported 1.0 23 (59%)
7) Relationships to other variables 0.08
Not applicable 0
Not reported 0 36 (92%)
Reported 1.0 3 (8%)
Data analysis 8) Appropriateness of data analysis 0.90 2.51
Inappropriate for study design or type of data 0 4 (10%)
Appropriate for study design or type of data 1.0 35 (90%) 1.62
9) Complexity of analysis
Descriptive analysis only 1.0 15 (38%)
Beyond descriptive analysis 2.0 24 (62%)
Outcomes 10) Outcomes 1.31 1.31
Satisfaction, attitudes, perceptions, 1.0 21 (54%)
opinions, general facts
Knowledge, skills 1.5 14 (36%)
Behaviors 2.0 3 (8%)
Patient/health care outcome 3.0 1 (3%)
Total score 9.91

A variety of educational modalities were employed, in- Topics within palliative care addressed by the curricula
cluding lectures (n = 29, 60%), group discussion (n = 27, included communication (n = 30, 63%), role of palliative and
56%), clinical exposure, which we defined as education that end-of-life care in the health care system (n = 26, 54%), pain
takes place in a clinical setting but does not involve direct and symptom management (n = 22, 46%), clinical assessment
patient care responsibilities (n = 14, 29%), patient care of patients (n = 20, 42%), addressing psychosocial and spir-
(n = 13, 27%), simulation or role play (n = 13, 27%), written itual needs (n = 19, 40%), ethics and the law (n = 18, 38%),
assignment (n = 12, 25%), online module (n = 6, 13%), stu- interdisciplinary teamwork (n = 15, 31%), and self-care
dent presentation (n = 6, 13%), reading assignment (n = 6, (n = 11, 23%). Five studies (10%) did not specify the topics
13%), multimedia (n = 6, 13%), and arts activity or perfor- covered.
mance (n = 2, 4%).
The curricular time spent for the educational interventions
Study quality
ranged from 45 minutes to 25 hours. Some articles described
single teaching sessions, while others evaluated complex Of the 48 studies meeting the inclusion criteria, 39 in-
curricula delivered over longer periods (up to four years). cluded quantitative methods and were assigned MERSQI
SYSTEMATIC REVIEW OF PALLIATIVE CARE CURRICULA 341

FIG. 1. Trial flow for systematic review.

scores, while the others were solely qualitative. Table 1 Discussion


summarizes the MERSQI scoring system and the results for Characteristics of palliative and end-of-life
our sample. Scores ranged from 5 to 15 (possible range 5 to care educational interventions
18), with a mean score of 9.9 and standard deviation of 2.7.
The most common study design was single-group pretest To inform curricular development at our own and other
and posttest (n = 17, 35%). However, 10 studies (21%) in- medical schools, we undertook a systematic literature review
volved a control group, including 2 (4%) that randomized to describe recent curricular innovations in palliative care
their participants. education for medical students. We also assessed the quality
The domain most likely to receive a high score was data of the evidence for effectiveness of these curricula. We found
analysis, with a mean of 2.51 out of 3. Twenty-four articles that emerging approaches in the field vary widely in scope,
(50%) received the maximum possible score for both ap- ranging from stand-alone didactic sessions to longitudinal
propriateness and complexity of data analysis. four-year curricula. Lecture and group discussion were the
The domains that scored lowest in our sample were most commonly cited educational modalities. However, most
validity of the evaluation instrument and outcomes. The interventions employed a mix of modalities, with lecture or
mean score for the validity domain was 1.05 out of 3, group discussions used to prepare for, supplement, or debrief
with 15 articles (31%) scoring zero points on all three a clinical experience, simulation, or role-play.
items in the domain. The mean score for the outcomes One important pattern that emerged from our review is that
domain was 1.31 out of 3. Twenty-one articles (44%) palliative care curricula tend to employ a broadly interdis-
received the lowest possible score in this domain, indi- ciplinary faculty. Of the 36 articles that specified the pro-
cating that outcomes were measured at the level of sat- fession of the instructors, only 9 were taught by physicians
isfaction, attitudes, perceptions, opinions, or general facts, alone. The other instructors included not only nonphysician
but did not assess knowledge, skills, behaviors, or patient health professionals (nurses, nurse practitioners, social
or health care outcomes. workers, chaplains, psychologists, pharmacists, physical
342 DECOSTE-LOPEZ ET AL.

therapists, and massage therapists), but also teachers from similar to the mean of 9.95 (standard deviation 2.34, range 5–
nonmedical disciplines such as ethics, law, theology, drama, 16) from the first reported MERSQI sample, which was a
philosophy, and sociology. Given this wealth of experience in broad, interdisciplinary sample of 210 medical education
incorporating interdisciplinary faculty, the field of palliative studies published between 2002 and 2003.9 More recently,
care should serve as a model for how to incorporate non- systematic reviews of medical education in topic areas un-
physician educators into medical student education to pro- related to palliative care that utilized MERSQI have reported
mote interdisciplinary collaboration. mean scores ranging from 9.0 to 11.4.59–66 Overall, this
One common limitation of the studies included in this re- suggests that palliative care education studies are of similar
view is that many of the curricula were not described in methodological quality to other medical education studies.
enough detail to be replicated by other educators. For some We found that within our sample most studies received
articles we were unable to ascertain even basic information high scores in the domain of data analysis. This indicates that
such as which palliative care topics were covered or who the authors go beyond descriptive analysis to assess statistical
served as the instructors. As medical educators look to the significance of the effectiveness of their intervention and that
literature to design their own curricula, this is an important the data analysis methods used are appropriate. Another area
limitation, which likely results from the space constraints of strength was the ‘‘response rate’’ item within the sampling
of academic journals. One way to address this would be to domain, indicating that the authors’ conclusions are based on
include online supplemental materials that provide de- a representative sample of the students exposed to the inter-
tailed descriptions of educational objectives, content, format, vention.
and educational materials. For example, Radwany, et al. However, also within the sampling domain, the item
addressed this issue effectively even for their complex, lon- ‘‘number of institutions studied’’ was the MERSQI item most
gitudinal, four-year intervention.40 Within the text of the likely to receive the lowest possible score. In fact, only one
article they provided a broad curriculum map and general study in our sample implemented and evaluated their inter-
description of the curriculum format and content. They then vention with students from more than one institution. This
included two additional files, which contained detailed, rep- aspect of study quality has important implications for gen-
licable descriptions of the components that they considered to eralizing study findings, and future researchers should en-
be ‘‘cornerstones’’ of their curriculum: a mandatory hos- deavor to collaborate with other institutions to test the
pice experience and a case-based group discussion prior to intervention in multiple settings or with multiple student
graduation. populations. While multiple-institution collaboration is ex-
Another limitation of the sample is the narrow scope of tremely difficult for implementing longitudinal, integrated
many of the curricula, most of which evaluate the immediate curricula, it would be feasible for short-term, discrete inter-
effect of a single teaching session or circumscribed clinical ventions. For example, Tsai, et al. were able to implement a
experience. Because the field of palliative care encompasses four-hour curriculum including a lecture, a hospice patient
such breadth of content that spans many medical specialties, visit, communication skills practice, and group discussion
more studies should evaluate palliative care curricula longi- with students in attendance from three local medical
tudinally as students engage the topics within the context of schools.52
their general medical curriculum. For example, Morrison, Because trainees’ self-assessments of their skills may not
et al. used a waitlist-control crossover design to demonstrate predict the patient’s assessment of the interaction, it is im-
improvements in students’ knowledge and attitudes follow- portant that educators measure behavioral and patient out-
ing a palliative care curriculum that spanned the entire third comes, rather than relying solely on student assessments to
year of medical school.34 Even for smaller-scale interven- demonstrate the effectiveness of a curriculum. However, in our
tions, educators should assess the long-term retention of sample the vast majority of studies (35 out of 39, 90%) mea-
learning objectives whenever possible. For example, Stevens, sured outcomes either at the level of satisfaction, perceptions,
et al. demonstrated that students who participated in their and attitudes (usually measured by self-assessment on a Likert
pain management curriculum performed better on pain scale) or at the level of knowledge acquisition (usually mea-
management domains of a clinical skills exam 1.5 years sured by multiple-choice examination). Three studies (8%)
later.48 measured student behaviors, with two measuring behaviors in
a simulated patient encounter and one measuring self-reported
communication behaviors. Only one study (3%) assessed a
Study quality
patient outcome: Green and Levi measured patient satisfaction
In recent years, increasing emphasis has been placed on after a medical student assisted the patient in filling out an
improving the methodological rigor of medical education advance directive.22 Because many of the educational inter-
research. Cook and Bordage have found that many essential ventions being studied already involve direct patient care, it
elements of scientific reporting are frequently absent from would likely be feasible in future studies to incorporate patient
articles describing medical education experiments.58 The outcomes into the evaluation.
MERSQI was developed by Reed and colleagues in 2007 as a Finally, validity of the evaluation instrument was a clear
measure of rigor for experimental studies in medical educa- weakness in study quality. Fifteen studies reported no attempt
tion, and has been shown to correlate well with expert quality to establish validity of their instrument regarding internal
ratings, number of citations, and journal impact factor.9 We structure, content, or relationship to other variables. Instead,
used this instrument to assess the quality of our sample of most studies relied upon surveys created by the authors,
recent studies in palliative care. which did not undergo any formal development process. One
The studies in our sample had a mean MERSQI score of positive example in this domain was the study by Chang,
9.9 (standard deviation 2.7, range 5–15). This result is quite et al., who developed their instrument to measure changes in
SYSTEMATIC REVIEW OF PALLIATIVE CARE CURRICULA 343

palliative care knowledge and attitudes before and after a national survey to define essential palliative care compe-
five-day course. They began with a literature review, piloted tencies for medical students and residents. Acad Med
the initial form of the instrument, retained only the most 2014;89:1024–1031.
reliable items for the final instrument, and calculated the 6. Bickel-Swenson D: End-of-life training in U.S. medical
relationship between attitude scores, knowledge scores, and schools: A systematic literature review. J Palliat Med 2007;
demographic data.13 10:229–235.
7. Case AA, Orrange SM, Weissman DE: Palliative medicine
Limitations physician education in the United States: A historical re-
view. J Palliat Med 2013;16:230–236.
One limitation of this review is that our methods only 8. Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred
assessed the quality of the subset of studies that included reporting items for systematic reviews and meta-analyses:
quantitative analysis. In the fields of medical education and The PRISMA statement. BMJ 2009;339:b2535.
palliative care, qualitative analysis of data such as focus 9. Reed DA, Cook DA, Beckman TJ, et al.: Association be-
groups, interviews, open-answer survey responses, and tween funding and quality of published medical education
written reflections form the core of many studies. In our research. JAMA 2007;298:1002–1009.
sample, 9 of the 48 studies reported qualitative data alone, 10. Auret K, Starmer DL: Using Structured Clinical Instruction
and another 13 studies used mixed quantitative and qualita- Modules (SCIM) in teaching palliative care to undergrad-
tive methods. Our review does not speak to the methodo- uate medical students. J Cancer Educ 2008;23:149–155.
logical rigor of these qualitative analyses. 11. Bell D, Crawford V: ‘‘Murder or mercy?’’ An innovative
Another limitation of our review is that our database module helping UK medical students to articulate their own
searches did not include items published in peer-reviewed ethical viewpoints regarding end-of-life decisions. South
repositories of educational products, such as MedEdPortal, Med J 2011;104:676–681.
which are often used for reporting and dissemination of 12. Brownfield E, Santen S: A short palliative care experience:
curricula across medical schools. Beginning to learn. Med Educ 2009;43:1111–1112.
13. Chang HH, Hu WY, Tsai SS, et al.: Reflections on an end-
Conclusions of-life care course for preclinical medical students. J For-
mos Med Assoc 2009;108:636–643.
Many recent innovations have been made in the field of 14. Chittenden EH, Anderson WG, Lai CJ, O’Sullivan P: An
palliative care education for medical students, representing a evaluation of interactive web-based curricula for teaching
variety of learner levels, settings, educational modalities, and code status discussions. J Palliat Med 2013;16:1070–1073.
topics. One strength of palliative care education is the in- 15. Corcoran AM, True G, Charles N, Margo KL: Geriatric
corporation of interdisciplinary faculty, which should serve palliative care: Do medical students’ narrative reflections
as a model for interdisciplinary collaboration in other parts of after a hospice clinical experience link to geriatric com-
the medical curriculum. Future innovations in the field should petencies? Gerontol Geriatr Educ 2013;34:329–341.
endeavor to collaborate across multiple institutions, integrate 16. Dando N, d’Avray L, Colman J, et al.: Evaluation of an
more longitudinal curricula and study longer-term outcomes, interprofessional practice placement in a UK in-patient
make use of better-validated measures of effectiveness, and palliative care unit. Palliat Med 2012;26:178–184.
assess higher-level outcomes including skills, behaviors, and 17. Ellman MS, Rosenbaum JR, Cherlin E, Bia M: Effective-
impact on patient care. ness of an integrated ward-based program in preparing
medical students to care for patients at the end of life. Am J
Acknowledgments Hosp Palliat Care 2009;26:18–23.
18. Ellman MS, Schulman-Green D, Blatt L, et al.: Using on-
The authors would like to thank Lauren Maggio for her line learning and interactive simulation to teach spiritual
guidance regarding systematic review methodology. This and cultural aspects of palliative care to interprofessional
work was funded by the Medical Scholars program at Stan- students. J Palliat Med 2012;15:1240–1247.
ford University School of Medicine. 19. Gadoud A, Adcock Y, Jones L, et al.: ‘‘It’s not all doom
and gloom:’’ Perceptions of medical students talking to
Author Disclosure Statement hospice patients. J Palliat Med 2013;16:1125–1129.
20. Goldberg GR, Gliatto P, Karani R: Effect of a 1-week
The authors have no conflicts of interest to disclose.
clinical rotation in palliative medicine on medical school
graduates’ knowledge of and preparedness in caring for
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(Appendix follows /)
Appendix 1. Summary of Curriculum Characteristics
Educational
Study Country Learner level Instructors Setting modalities Duration Topicsa MERSQI Scoreb
Auret and Starmer Australia Clinical HPM physicians, non- Classroom Group discussion, 2 hours 1, 2, 3, 6 7
2008 HPM physician, simulation
nurses, pharmacist
Bell and Crawford United Preclinical Physician, nurse, Classroom Lecture, group 20–25 hours (over 5, 6, 7 7.5
2011 Kingdom ethicist, theologian, discussion, written 12 weeks)
attorney assignment, student
presentation, online
module, simulation,
clinical exposure
Brownfield and United States Clinical Unspecified Clinical, classroom Lecture, group 1 week 3, 6 10.5
Santen 2009 discussion, patient
care
Chang, et al. 2009 Taiwan Preclinical HPM physicians, Clinical, classroom Lecture, group 1 week 4, 5, 6, 7 14
nurse, social discussion, clinical
workers, chaplain exposure
Chittenden, et al. United States Clinical None Online Online module 45 minutes 2 14
2013
Corcoran, et al. United States Clinical, preclinical Nurses, social workers, Clinical Clinical exposure 4 hours Unspecified Q
2013 chaplains
Dando, et al. 2012 United Clinical, also Physician, nurse, Clinical Group discussion, 3 weeks 7 5
Kingdom nursing, physical physical therapist patient care

346
therapy, and
occupational
therapy students
Ellman, et al. 2009 United States Clinical HPM physician, non- Clinical, classroom Written assignment, Variable 1, 2, 3, 7, 8 7
HPM physicians student presentation,
patient care
Ellman, et al. 2012 United States Clinical, also Physician, nurse, social Classroom, online Group discussion, 2 hours 1, 2, 3, 4, 6, 7 10.5
nursing, social worker, chaplain online module,
work, and simulation
chaplaincy
students
Gadoud, et al. 2013 United Clinical Unspecified Clinical Patient care Unspecified Unspecified Q
Kingdom
Goldberg, et al. United States Clinical HPM physicians, Clinical, classroom Lectures, group 1 week 2, 3, 4 10
2011 nurse, social worker, discussion, patient
chaplain, massage care
therapist
Goldsmith, et al. United States Clinical HPM physician, non- Clinical, classroom Lectures, multimedia, 12 hours 1, 2, 3, 6, 7 Q
2011 HPM physicians, patient care
nurses, social
workers, chaplains,
psychologists,
patients
(continued)
Appendix 1. (Continued)
Educational
Study Country Learner level Instructors Setting modalities Duration Topicsa MERSQI Scoreb
Green and Levi United States Preclinical None Clinical, online Online module, patient Variable 2, 5 15
2011 care
Hall, et al. 2011 Canada Clinical, also Physicians, nurses, Classroom Group discussion, 3 hours 1, 2, 3, 4, 5, 7 8
interprofessional interdisciplinary simulation
students health professionals
Head, et al. 2012 United States Clinical Unspecified Clinical Written assignment, 1 week 2, 3, 8 Q
patient care
Hegedus, et al. Hungary Preclinical, also Unspecified Classroom Lectures Unspecified 2, 3, 4, 6 11
2008 health care
professionals
Jacoby, et al. 2011 United States Clinical Unspecified Clinical Lecture, reading 1 week 1, 2, 6, 7 Q
assignments, written
assignment, patient
care
Jeffrey, et al. 2012 United Clinical and HPM physicians, Classroom Drama performance, 2 weeks 2 Q
Kingdom preclinical drama educators group discussion,
reading assignment,
written assignment
Kato, et al. 2011 Japan Clinical Unspecified Classroom Lecture 1 hour 3, 6 10
Kaufert, et al. 2010 Canada Preclinical Physicians, patients Classroom Lecture, group 4 hours 4, 5 Q
discussion
Kitzes, et al. 2008 United States Clinical HPM physicians, non- Classroom Group discussion 4 hours 1, 2, 3, 4, 5, 6, 8 8.5
HPM physicians

347
Korzeniewska- Poland Clinical Physicians, Classroom Lecture, group 10 hours 1, 2, 3, 4, 5, 6, 8 7
Eksterowicz, psychologist discussion
et al. 2012
Lubimir and Wen United States Clinical Unspecified Classroom Group discussion, 3 hours 2, 4, 5 6
2011 written assignment,
simulation
Mason and United Clinical Unspecified Clinical, classroom Lecture, group 2 or 4 weeks 2, 5 10.5
Ellershaw 2010 Kingdom discussion, student
presentation, patient
care
Morrison, et al. United States Clinical HPM physicians, Clinical, classroom, Lectures, group 8 hours (over 46 1, 4, 6, 7 13
2012 interdisciplinary online discussion, written weeks)
health professionals assignment, student
presentation, online
module, clinical
exposure
Murtagh, et al. Ireland Preclinical HPM physicians Clinical, classroom Lecture, reading 15 hours (over 10 1, 4, 6, 7 11
2012 assignments, student weeks)
presentation, clinical
exposure
Nwosu, et al. 2013 United Clinical Physician Online Written assignment 11–59 minutes Unspecified 7
Kingdom
Oliver and Jezek Croatia Preclinical HPM physician Classroom Lectures, group 3 days 1, 2, 3, 4, 6 7.5
2013 discussion,
multimedia
(continued)
Appendix 1. (Continued)
Educational
Study Country Learner level Instructors Setting modalities Duration Topicsa MERSQI Scoreb
Philip and India Preclinical Nurses, hospice Clinical, classroom Lecture, group 3 days 2, 6, 7 6
Remblabeevi volunteers discussion,
2010 simulation,
multimedia, clinical
exposure
Pinheiro, et al. 2010 Brazil Unspecified Not specified Clinical Reading assignments, Variable Unspecified Q
medical students, written assignment,
also residents patient care
Radwany, et al. United States Clinical and Physicians, Clinical, classroom Lectures, group 4 years 1, 2, 3, 4, 5, 6, 7, 8 6.5
2011 preclinical interdisciplinary discussion,
health professionals simulation, written
assignments, clinical
exposure
Sanchez-Reilly, United States Clinical HPM physicians, Clinical, classroom Lectures, written 8 hours (over 4 1, 2, 6, 7, 8 13
et al. 2007 nurses, social assignments weeks)
workers, chaplains,
psychologists,
patients
Schillerstrom, et al. United States Preclinical HPM physicians, Classroom Lecture, group 4 hours 6 9
2012 psychiatrists, discussion
psychologists,
interdisciplinary
health professionals

348
Schulz, et. al. 2013 Germany Clinical Unspecified Clinical, classroom Lectures, group 23 hours (over 2 1, 2, 3, 6, 7, 8 10.5
discussion, semesters)
simulation, written
assignment, clinical
exposure.
Shih, et al. 2013 Taiwan Preclinical HPM physicians, Clinical, classroom Lectures, simulation, 1 day 1, 2, 5, 7 13
interdisciplinary multimedia, clinical
health professionals exposure
Silk, et al. 2009 United States Clinical Unspecified faculty, Clinical, classroom Lecture, group 7.5 hours 2, 6 9
nurses discussion,
simulation,
multimedia, clinical
exposure
Sorta-Bilajac, et al. Croatia Preclinical Physician, ethicist, Classroom Lectures, multimedia, 7.5 hours 4, 5, 6 10.5
2007 theologian, written assignment,
philosopher, student presentation
sociologist, attorney
Stecho, et al. 2012 Canada Preclinical Nurse, hospice Clinical, classroom Lectures, patient care 30–40 hours Unspecified 10
volunteers
Stevens, et al. 2009 United States Preclinical HPM physicians, non- Classroom Lectures, group 10 hours 1, 2, 3 14
HPM physicians, discussion,
nurses simulation
Tai, et al. 2013 Australia Clinical Unspecified Clinical, classroom Lectures, group 1 week 3, 4, 5 12
discussion, patient
care
(continued)
Appendix 1. (Continued)
Educational
Study Country Learner level Instructors Setting modalities Duration Topicsa MERSQI Scoreb
Tan, et al. 2013 Canada Clinical None Online Online module Variable 1, 3, 4 11
Tchorz, et al. 2013 United States Clinical Non-HPM physicians, Classroom Group discussion, 2 hours 1, 2, 3, 4, 5 11
ethicist multimedia,
simulation
Tsai, et al. 2008 Taiwan Preclinical HPM physicians Clinical, classroom Lecture, group 4 hours 2, 5, 6 14
discussion, reading
assignment, clinical
exposure
von Gunten, et al. United States Clinical HPM physicians, Clinical, classroom Lectures, simulation, 4 days (over 4 1, 2, 3, 4, 5, 6, 7, 8 13
2012 nurses, social patient care weeks)
workers, chaplains
Weber and United States Preclinical HPM physician Clinical, classroom Arts activity or Unspecified 6 Q
Mascagna 2008 performance, group
discussion, written
assignment, student
presentation, clinical
exposure
Weber, et al. 2011 Germany Preclinical HPM physicians Clinical, classroom Lecture, group 1.5 hours 4, 6, 8 9.5
discussion, clinical
exposure
Wechter, et al. 2013 United States Preclinical HPM physicians Clinical, classroom Group discussion, 4 hours 2, 4, 5, 6, 8 9.5
reading assignments,
clinical exposure

349
Yardley, et al. 2013 United Clinical Unspecified Classroom Lecture, group 7 hours 1, 2, 3, 5, 6 7
Kingdom discussion,
simulation
a
Palliative and End-of-Life Care topics are listed only if they were specifically reported in the article. Coding is as follows: 1 = patient assessment, 2 = communication, 3 = pain and symptom
management, 4 = addressing psychosocial and spiritual needs, 5 = ethics and the law, 6 = role in the health care system, 7 = interdisciplinary teamwork, 8 = self-care.
b
Q indicates that the study was qualitative, and did not receive a MERSQI score.
HPM, hospice and palliative medicine; MERSQI, Medical Education Research Study Quality Instrument.
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