Department of Family Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.
Med Educ. 2010 Apr;44(4):421-8. doi: 10.1111/j.1365-2923.2009.03603.x. Epub 2010 Mar 3.
Many medical students feel inadequately prepared to address end-of-life issues, including patient death. This study aimed to examine medical students' first experiences of the deaths of patients in their care.
Final-year medical students at the Schulich School of Medicine & Dentistry, University of Western Ontario were invited to share their first experience of the death of a patient in their care. The students could choose to participate through telephone interviews, focus groups or e-mail. All responses were audiotaped, transcribed verbatim and analysed using a grounded theory approach.
Twenty-nine students reported experiencing the death of a patient in their care. Of these, 20 chose to participate in an interview, five in a focus group and four through e-mail. The issues that emerged were organised under the overlying themes of 'young', 'old' or 'unexpected' deaths and covered seven major themes: (i) preparation; (ii) the death event; (iii) feelings; (iv) the role of the clinical clerk; (v) differential factors between deaths; (vi) closure, and (vii) relationships. These themes generated a five-stage cyclical model of students' experiences of death, consisting of: (i) preparation; (ii) the event itself; (iii) the crisis; (iv) the resolution, and (v) the lessons learned. 'Preparation' touches on personal experience and pre-clinical instruction. 'The event itself' could be categorised as referring to a 'young' patient, an 'old' patient or a patient in whom death was 'unexpected'. In the 'resolution' phase, coping mechanisms included rationalisation, contemplation and learning. The 'lessons learned' shape medical students' experiences of future patient deaths and their professional identity.
A tension between emotional concern and professional detachment was pervasive among medical students undergoing their first experience of the death of a patient in their care. How this tension was negotiated depended on the patient's clinical circumstances, supervisor role-modelling and, most importantly, the support of supervisors and peers, including debriefing opportunities. Faculty members and residents should be made aware of the complexities of a medical student's first experience of patient death and be educated regarding sympathetic debriefing.
许多医学生觉得自己在处理临终问题方面准备不足，包括患者死亡。本研究旨在探讨医学生首次经历自己照顾的患者死亡的情况。
邀请西安大略大学舒立克医学院的应届医学生分享他们首次经历自己照顾的患者死亡的经历。学生可以选择通过电话访谈、焦点小组或电子邮件参与。所有回复都进行了录音、逐字转录，并使用扎根理论方法进行分析。
29 名学生报告了在自己照顾的患者死亡。其中，20 人选择参加访谈，5 人参加焦点小组，4 人通过电子邮件参与。出现的问题根据“年轻”、“年老”或“意外”死亡的主题进行组织，并涵盖了七个主要主题：（一）准备；（二）死亡事件；（三）感受；（四）临床医师的角色；（五）死亡之间的差异因素；（六）结束；（七）关系。这些主题生成了学生对死亡的经历的一个五阶段循环模型，包括：（一）准备；（二）事件本身；（三）危机；（四）解决，以及（五）吸取的教训。“准备”涉及个人经历和临床前指导。“事件本身”可以分为“年轻”患者、“年老”患者或“意外”死亡的患者。在“解决”阶段，应对机制包括合理化、思考和学习。“吸取的教训”塑造了医学生对未来患者死亡的经历和专业身份的影响。
在经历自己照顾的患者死亡的首次经历时，医学生普遍存在情感关注和专业分离之间的紧张关系。这种紧张关系的处理取决于患者的临床情况、主管的榜样作用，最重要的是主管和同事的支持，包括提供汇报机会。教师和住院医师应意识到医学生首次经历患者死亡的复杂性，并接受同情性汇报的教育。
