Trends in Palliative Care Research 2022; Issue #01

Commentary by:

Emily Johnston, BScH, University of British Columbia Medical Student and Research Assistant for the Siden Lab at BC Children’s Hospital Research Institute

Feature Article:

Williams, E., Jarrell, J. A., & Rubenstein, J. (2021). A Week in the Life: Pediatric Palliative Care through the Eyes of a Medical Student. Children (Basel), 8(11).

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At Texas’ Baylor College of Medicine, trainees rotating through pediatric palliative medicine are required to write a reflective piece for their rotation. In this article, Williams, herself a medical student, along with co-authors both discuss the purpose of narrative medicine in enhancing learning, and describe in detail the experience of providing pediatric palliative care. This student spent a week on a rotation in pediatric palliative care and reflected on her experiences with a daily journal.

Selections from her journal are highlighted in the article. During the rotation the author experienced   the interprofessional, team-based nature of palliative care. The student learned about the inherent uncertainties in medicine, along with how clinical decisions then intersect with families’ values and preferences. Major events that impacted this student were the medical, ethical, and personal challenges associated with withdrawal of life-sustaining treatments (WOLST). The article saliently showed the nuances of some of these discussions; one set of parents proceeded with WOLST, while another one was deterred by the medical team after a difficult decision process. The student summed up their pediatric palliative care experience by contemplating their role on the team and the fulfillment they derived by offering support to families.

The paper used this example of narrative writing to discuss the merits of reflection. These reflections can take different forms, for example verbal or written, structured or unstructured. There are benefits for both the writers and readers of narrative reflection.

For the reader, narrative medicine can provide insight to an experience even when it’s not obtained personally. This is perhaps true more than ever with the impacts of COVID-19 on medical training. In my own training that has been much over Zoom, I have still been able to understand the “hard science” of medicine. However, reading experiential accounts like this one have helped me appreciate the complex communication, empathy and ethical skills involved in the profession. While reading and experiencing are not equivocal, an evocative piece of writing can still convey a sense of understanding and feeling. This could help supplement learning when not every trainee gets the opportunity to experience pediatric palliative care. 

For the writer, reflection has been shown in a meta-analysis to amplify learning in medical trainees by supporting empathy, professionalism, and comfort with complex situations (Winkel et al, 2017). Especially at the beginning of one’s career, everything is novel, and everything feels like an event. Written reflection gives a record of one’s perspective during that time stamp and can be longitudinally valuable as a person advances in their training. A systematic review has investigated the idea of an “empathy decline” during medical training and showed a significant decrease in empathy during medical school and during residency (Neumann et al, 2011). The incorporation of reflection and self-awareness into training has been suggested as an intervention to this phenomenon (Shapiro, 2008). Additionally, the “art” of medicine requires a balance between emotion and logic, which is another skill to develop during training. Pediatric palliative care is a specialty with especially heightened emotions due to patient loss and grief. Reflection is a strategy to help process these emotions. Connections created by narrative medicine can then also foster a sense of community.  

This topic could be better supported by more objective data on the impact of reflection, such as behavioural outcomes. While the process of contemplation is inherently personal and different strategies work for different individuals, further establishing the validity could help prove the value of reflection during a busy schedule. I would be interested to see a repository of narratives as an expansion of this idea and continued implementation of reflection-sharing activities in medical education. While this paper only discusses the experience of one individual, I found this example highlights the impacts of both reading and writing reflections in pediatric palliative care.

Neumann, M., Edelhäuser, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., Haramati, A., & Scheffer, C. (2011). Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med, 86(8), 996-1009.

Shapiro, J. (2008). Walking a mile in their patients’ shoes: empathy and othering in medical students’ education. Philos Ethics Humanit Med, 3(10).

Winkel, A. F., Yingling, S., Jones, A. A., & Nicholson, J. (2017). Reflection as a Learning Tool in Graduate Medical Education: A Systematic Review. J Grad Med Educ, 9(4), 430-439.