“The Patient as Teacher” - thematic analysis of undergraduate medical students’ experiences with an experiential learning project in Palliative Care

“The Patient as Teacher” - thematic analysis of undergraduate medical students’ experiences with an experiential learning project in Palliative Care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “The Patient as Teacher” - thematic analysis of undergraduate medical students’ experiences with an experiential learning project in Palliative Care Stephanie Stocklassa, Susan Block, Piret Paal, Frank Elsner This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4777087/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Oct, 2024 Read the published version in BMC Palliative Care → Version 1 posted 12 You are reading this latest preprint version Abstract Background : Experiential learning holds high potential for medical students’ education in palliative care. At RWTH Aachen University in Germany, medical students can participate in the course “The Patient as Teacher” offering a one-to-one exchange with a terminally ill patient over a period of several weeks complemented with four supervision sessions and writing of a reflective essay. The course had run from 2005-2020 before it was paused due to the Covid-19 pandemic. This study aimed to assess the course's value as a palliative care teaching tool by investigating students’ motivation and experiences over the years 2005-2020. Methods : A stratified sample of 24 essays was taken from all submitted essays (n = 78), eight essays from the years 2005-2009, 2010-2014, and 2015-2020. Subsequently, a thematic analysis of the selected essays was conducted. Results : The students felt motivated by the opportunity to gain more experience in palliative care, to improve their communication skills and to decrease insecurities in interaction with terminally ill patients. They learned about the patient’s biography and medical history, and encountered physical, psychological, social, and spiritual dimensions of living with a life-limiting disease. Moreover, they experienced relationship building and communication with a terminally ill patient outside their role as future doctors. Ultimately, they considered their participation as a beneficial experience on both a personal and professional level. Conclusions : The course “The Patient as Teacher” presents a valuable tool for experiential learning in palliative care, which has elicited an unceasingly positive response among the students who participated over the years. It has facilitated medical students in overcoming insecurities in dealing with terminally ill patients and supported them in further developing their professional identity. palliative care undergraduate medical students teaching experiential learning reflective writing Background Given global demographic change and the rising rate of non-communicable diseases, the demand for comprehensive palliative care will continue to rise [1]. Therefore, the European Association for Palliative Care has argued that all medical professionals should be capable of providing appropriate palliative care as they will encounter patients in need of palliative Care from primary care to tertiary hospitals [2]. Consequently, increased demands are placed on the education and training of medical professionals today. In this context, undergraduate medical students’ access to palliative care education has been significantly expanded at German universities over the past few decades [3,4]. Since 2009, it has been a legal requirement that all medical students in Germany are trained in the provision of palliative care (ÄApprO as of 03.07.2002, last amended in 31.07.2009, §27 and supplement 15 to §29 sect. 3 sentence 2) [5]. Simultaneously, it has been acknowledged that practical training and clinical exposure are essential for teaching students how to interact adequately with terminally ill patients and their families [6]. Particularly, palliative care education and training needs to support students in developing appropriate attitudes towards caring for terminally ill patients [3]. Consequently, German universities have chosen various approaches to provide students with practical experience in the field of palliative care. Since 2005, medical students at RWTH Aachen University have had the opportunity of participating in the course “The Patient as Teacher”, offering a one-to-one exchange over several weeks with a patient receiving palliative care. Following the model of experiential learning, the course aims to help students understand experiences of terminally ill patients through personal exchange. Taking part is voluntary for both patients and students, and students from all years may apply to attend the course. While the individual patient largely determines the course of the exchange, the student has no specific task or assignment. Therefore, students may temporarily distance themselves from their role as future health professionals and meet the patients on a purely personal level. This is to enable the students to gain a more holistic view on the consequences of terminal illness on the individual. The course is based on a teaching concept from Harvard Medical School, Center of Palliative Care [7]. In particular, the course consists of three components: accompaniment of a terminally ill patient, supervision in small groups under psychological guidance, and writing of a reflective essay. The accompaniment of the patient comprises a total of 20 hours over a period of four to six weeks, with the actual frequency and duration of the meetings being determined individually between the patient and the student. Typically, the course extends over 10 to 25 encounters. While the first meeting takes place on the hospital ward, subsequent meetings might also take place at a hospice or at the patient's home after the patient’s discharge. Supervision usually takes place at four meetings spread over the course of the course. Here, students receive impulses for personal reflection and help with potential problems in interaction with their patients. At the same time, the meetings offer an exchange of experiences with other students taking part in the course. At the end of the course, students are requested to hand in a twenty-pages reflexive essay on their experiences. Students have the full freedom regarding the form and content of their essay, which it is seen as an invitation for reflection and evaluation. Ultimately, students do not receive a formal grade for their participation. The course “The Patient as Teacher” had run for a period of sixteen years before it was paused at the beginning of the Covid-19 pandemic. Over this period, the students’ interest in participating constantly exceeded the availability of placements, which led to long waiting lists. In 2009, the course "The Patient as Teacher" won the Palliative Medicine Promotion Award of the German Society for Palliative Medicine. To our knowledge, no comparable palliative care course has been described in the literature to date. There is a broad consensus that medical students benefit from experiential learning and reflective writing in the palliative care learning process. Particularly, one-to-one encounters with patients reveal the social, psychological and spiritual dimensions of illness to the students [8-11]. Simultaneously, authors underline that reflective training supports medical students in forming their professional identity [8,9,12]. In particular, comprehensive palliative care provision requires competencies of respectful and empathetic communication as well as professional behaviour with regards to one’s personal and professional values [2,13]. Likewise, experiential learning offers the chance to positively influence students’ attitudes towards palliative care by paying attention to the hidden curriculum (implicit changes in students’ attitudes, beliefs, and values due to extracurricular experiences and observations) [14,15]. While it is understood that first encounters with terminally ill patients can be distressful, it is important to provide a safe learning environment in which students can experience positive relationships, guidance and self-efficacy [11,12]. Reflective essays as written text are arguably helpful in restructuring consciousness [16]. However, the responsive orientation of written self-expression makes it particularly debatable whether the writing for a course contains merely personal values and experiences or whether they represent socially desirable responses. In this paper, we argue that the truths and views that become represented as individual interpretations in such written accounts represent the discourse influenced by language (ideologies) and culture framed by the institutional arrangement of a particular society [17]. Analysing students’ experiences within the course “The Patient as Teacher may provide valuable implications for experiential learning in palliative care. Simultaneously, it is unknown whether changes in the curriculum had an impact on students' motivation and experience with the course over the years. Therefore, this study aims to investigate students’ motivation and experiences within the course “The Patient as Teacher” by analysing students’ reflective essays from 2005-2020. In this respect, particular attention shall be paid to potential changes in students’ perceptions over the years. Methods In the period 2005-2020, a total of 114 medical students participated in the course (95 female and 19 male students). Of these, a total of 78 students submitted a reflexive essay (65 female and 13 male students). For this study, a sample of 24 essays was taken from all essays using stratified randomisation weighted by the number of essays submitted per year, eight essays each from the years 2005-2009, 2010-2014 and 2015-2020, subsequently referred to as group A, group B, and group C. Ultimately, the essays of 21 female and 3 male students were included for analysis. The average length of essays was 7361.50 words (SD = 1655.25). An assessment by the Medical Ethics Committee of RWTH Aachen was obtained for this study. All students were provided with sufficient information on the nature and content of the study including potential risks to assure the informed consent. At the same time, students could refuse to participate at any point without any negative consequences or the need for justification. In addition, anonymity of participants and protection of identity was warranted. All essays were kept anonymous and confidential, and participants were assigned a random identification number (e.g. C5). Those numbers were included with the quotes from the individual essay to illustrate the breadth of data. The thematic analysis of the reflexive essays was carried out by a female medical student with a background in health science and nursing (corresponding author), who had not been involved in the course otherwise, using MaxQDA (version 2022.2.0). The thematic analysis was chosen to gain an understanding of the students' motivations, perceptions, and experiences. The data analysis was guided by Braun and Clarke's (2022) “Reflexive Thematic Analysis approach” [18,19]. After familiarization with the data (step 1), initial codes were generated, and all relevant data collated to each code (step 2). Then, corresponding codes were gathered into potential themes (step 3). Next, the themes were reviewed whether they matched the initial codes as well as the dataset. The themes were refined and specified creating the final thematic ‘map’ of the analysis (step 4). Subsequently, the naming of themes was reviewed to unfold the overall story of analysis (step 5). Ultimately, illustrative quotes were selected, and the report was written while relating the analysis back to the research question and literature (step 6). The analysis was carried out in German language and only the final themes and corresponding text passages were translated into English under the guidance of a native speaker. Results The analysis revealed four main themes concerning students’ experiences within the course, namely motivation , the patient’s story , the interaction with the patient, and self-reflection . In particular, motivation concerned students’ expectations of the course and reasons for participating. The patient’s story referred to the personal and medical history of the patient as well as his or her individual constraints, needs, and wishes. Interaction mainly concerned aspects of communication and relationship-building. Lastly, self-reflection involved revisiting personal feelings and boundaries, felt notions of responsibility, and consequences of experiences within the course for the students’ professional self-image as prospective doctors (table 1). Finally, some students gave feedback on the course in their essays, which will be summarised at the end. Table 1: Main themes and associated key points as identified by analysis of students’ essays Main theme Key points Motivation Spending more time with a patient Exploring new learning concept Encountering patients outside their role as medical students Filling gaps of regular curriculum Reducing insecurities in dealing with terminally ill patients Improving communication skills Taking on new challenge Patient’s story Personal biography Medical history Dimensions of living with a life-limiting illness (physical, psychological, social and spiritual) Dreams and wishes Concept of quality of life Interaction Communication (conversation style, sharing feelings etc.) Relationship-building Closeness and distance Defining their own role Overcoming obstacles Saying goodbye Self-reflection Upcoming feelings (happiness, sadness, insecurity etc.) Personal boundaries Own life and personal values Professional self-image as future doctors Motivation Concerning their motivation to participate in the course, students most frequently reported taking the opportunity to spend more time with a patient than possible in their future working life. Specifically, students felt that the course offered them the opportunity to experience a more in-depth exchange with a patient, as one student reported: “ I know that I cannot and will not get involved with every one of my future patients in the way I was able to do with [patient’s name] in this course. Yes, it was a privilege for me to be able to accompany a person in such a special way and so intensively in terms of time ” (C3, female). Simultaneously, students appreciated the concept of experiential learning and, in particular, being in contact with patients without a specific teaching assignment and outside of their role as doctors. In this context, one student noted: “ I have certainly heard the medical facts in a lecture before and I can research them relatively easily; however, the personal account and experience of the disease with all its aspects (i.e. also psychological, mental and spiritual) is something that cannot be taught so easily in conventional academic courses ” (C8, female). For many students, the course represented their first one-to-one encounter with a terminally ill person. Many students lamented that insufficient attention was paid to palliative care in their regular course work. Likewise, they felt that the regular curriculum did not sufficiently prepare them for working with terminally ill patients. The students hoped that their participation in the course would help to improve their communication skills and reduce their insecurities when dealing with seriously ill patients and death. Generally, the students perceived their participation as a challenge as they were not familiar with the teaching concept and, simultaneously, did not have a clear idea of what they would be encountering. Accordingly, many of the students expressed concerns and fears about what to expect from the course and whether they were up to the challenge: “As soon as I had the acceptance, my thoughts began to circle: Can I do it at all? What did I sign up for here?” (B6, male). Ultimately, many students took part out of curiosity or on the recommendation of other students. Patient story The course enabled students to gain insight into their patients’ personal biography as well as their medical history. Due to the personal character of the meetings, the students got to know the patient’s social environment and often encountered the patient's relatives as well. In this context, many students reflected on the social dimension of disease and the importance of social support for the patient. Moreover, students could discover their patients’ distinct needs and develop an understanding for their patients’ experiences of living with a life-limiting illness: “ I was allowed to get to know a person in a very unbiased way, to get to know a part of his inner being without much ado, to share happy and bitter moments, to meet family and friends, to experience conversations, memories, cohesion, quarrels, hope and suffering. ” (C7, female). Particularly, students reported that they got to know their patients’ dreams and wishes and learned what quality of life could mean for a terminally ill person: “It always warmed my heart to hear her talk about strawberry ice cream cups with shining eyes. In those moments I really forgot that she was sick - that is how much she could enjoy the little things” (A7, female). Some students have also learned about the spiritual needs of the patient. At the same time, students witnessed the patients’ aggravating physical limitations as well as the emotional burden linked to the progression of disease: “Illness puts the sufferer in a state of physical and mental inconstancy: the sufferer has to constantly redefine himself and explore which abilities and things can still be carried out in everyday life. Phases of hope alternate with phases in which hope seems to be exhausted” (B2, male). While some students paid a last visit to their patient after his or her death, none of the students were present when their patient died. Interaction According to the students, interacting with their patients required skills in communication and relationship-building. In order to gain their patients’ trust, finding the most appropriate conversation style was crucial. Jointly, students could practise exchanging views, sharing personal feelings, expressing empathy, and setting boundaries. Some students aimed to make regular appointments and create shared rituals (e.g. going for a walk or sharing a cup of coffee in the patient’s kitchen) to build up a relationship towards their patient. Generally, students aimed to find common interests with their patients. Many students reported they were surprised at how quickly they formed a trustful bond with their patient: “ You meet a [...] person in a closed room, with limited time, and despite this, or precisely because of this, a climate of trust builds up relatively quickly [...] I have the feeling that you don't achieve this closeness so easily and quickly with people you will see again or with whom you have connections ” (B6, male). At the same time, some students found it difficult to connect with their patient: “ It took a lot of strength and commitment to establish and maintain contact with her. During the whole time, I tried to recognise her fears and needs and to help her cope. Initially, this seemed almost impossible due to the patient's resistance. In the course of the conversations, however, an increasingly trusting relationship developed between [patient’s name] and me. ” (A4, female). In this context, students reflected on the appropriate degree of closeness and distance towards their patient: “ It helped me a lot to be aware of my motivation and the goal of a meeting beforehand. Because these two points only became fully apparent to me in the course of the course, due to [the course’s] concept and my personal characteristics, I saw a challenge in sensing and finding this boundary. ” (B5, female). Whereas many students initially feared to burden the patient with their presence, they later described the mutual benefit of the encounter: “ In the beginning I felt out of place. I thought I was disturbing the family, who surely had so many things to discuss. This feeling disappeared very quickly after I realised how much my patient and his wife looked forward to my visits. ” (A3, female). Some students thought that their patients valued sharing their thoughts with an unbiased person. Others reported they could provide emotional support when their patient was in distress: “ I knew that I could not relieve him of the burden of dying, but that perhaps through my visits I could carry a little more diversion and entertainment into his enviro nment and lessen the loneliness and isolation to which he was subjected in that room. ” (A2, female). At the same time, students repeatedly mentioned being unsure of their own role in interaction with the patient: “What am I doing here anyway? Where is this supposed to lead? [...] What is the justification for my presence? ” (A8, female). “ What is my goal? My purpose in our conversations? The purpose of my visits to her? ” (C1, female). In this context, students frequently reported that their role and purpose was implicitly defined by the patient and his or her needs: “ Overall, the course gave me the opportunity to search for and question my role through my patients [...] Thus, from my perspective throughout the course, I was in varying proportions a learner, an independent, a confidant and a listener, who was also asked for assessment or advice at times ” (B5). In addition, the students reported on some obstacles in interacting with their patients. Occasionally, they experienced difficulties in scheduling meetings with their patient. Simultaneously, several patients were limited in their ability to communicate due to their illness. In some cases, only non-verbal communication was possible at times. Moreover, some students did not know how to react to the patient's statements: “And again the sentence: "My days are numbered". These words sound like something out of a drama, so unrealistic and useless for daily use. Is that why it makes me feel uneasy? There is an end in sight, negative associations. Why did she tell me that? Was it an accepting ‘ok’ or a desperate ‘why’? What did she expect me to answer?” (B8, female). Similarly, some students faced issues of miscommunication and conflict they had to solve. For instance, when the expectations of patients and students diverged. In this context, many students indicated that they found the input from the supervision sessions very helpful. Ultimately, the concerned students found ways to solve the tension between the different parties: “ I have learned how important it is to address problems directly with those involved. In this way, misunderstandings can be quickly resolved and people can deal with each other in a completely different way ” (B4, female). For the majority of students, saying goodbye to their patient formed the most challenging part of the course: “ I would have liked to be with her until the end. Perhaps it was right to distance myself beforehand and to consciously end the accompaniment. Sometimes it feels wrong to have the opportunity to choose when to say goodbye, while others have no choice. ” (C7, female). “This farewell could likely be the final one. This woman came very close to me, or rather I let her come very close to me, and it is not easy for me to say goodbye today. It is a gentle regret mixed with the knowledge that this is the course of life.” (B1, female). In some cases, the patient died before the actual end of the course. Depending on how established the relationship between student and patient was at that point, this experience could be very distressing for the concerned student: “ How could this happen so quickly? I felt terrible because I had always put off saying goodbye [...]. A conscious farewell to [patient’s name] at the end of the internship would have been enriching for both of us. ” (A7, female). “ I was particularly affected by the death at that time, more than I would have expected. I had met [patient name] as a palliative care patient, so I knew that he could die at any time. But somehow I just didn't expect it at the time. ” (C2, female). Self-reflection Students’ participation raised many feelings among them, which they reflected on in their essays: “ Not only during the course, but also while I was writing this text, I experienced a rollercoaster of emotions. I was happy, joyful, sad, despairing, angry and stunned and much more than could be put into words easily ” (B7, female). At the beginning of the course, many students felt insecure as they had no clear picture of what was expected from them or unsure how to approach a terminally ill patient. Occasionally, students were uncomfortable with the thought of taking up the patient's time: “ I suddenly felt a very bad conscience to be there at all and to let such a sick person gift me with time. ” (B5, female). However, those feelings generally diminished in the course of the course once they got to know their patients better and built up a relationship towards them. Being met with openness and kindness, many students developed a sense of responsibility towards their patients. The more the students built up closeness and trust with their patient, however, the more worried they became about the thought of parting and the possible death of their patient: “ At some point I was afraid that his wife would pick up the phone and tell me that her husband had died. I didn't want to stumble into such a situation. ” (A6, female). At the same time, some students felt rejected and disappointed as they faced difficulties in connecting with their patient, as mentioned above. Generally, interacting with their patient required many students to become aware of their personal boundaries. Students reported that they allowed themselves to be more personally involved than they would be in their role as doctors: “ Our relationship takes on almost family-like structures. ” (B1, female). Simultaneously, those students stated they had been able to take away more from the encounter by putting off the ‘white coat’. As many students felt sad for leaving their patient at the end of the course, some were too afraid to say goodbye: “ Distancing and saying goodbye is one of the essential components of this course. I didn't succeed, but you learn more from mistakes in the end. ” (B8, female). Those students who witnessed the death of their patient needed some time to come to terms with what had happened: “ Sometimes my thoughts still wander to the people whose difficult time and sad loss I witnessed, and I wonder how they are doing now. However, these questions arise less and less in me as time goes by ” (A2, female). For many students, the exchange with their patient formed an occasion to reflect on their own lives and personal values: “ Where would I be in 60 years? Will I be able to look back on my life happily? What losses will shape my life? ” (C5, female). “It is banal, but it is known that there is a fine difference between knowing things and comprehending things. I knew that death makes the time we have in our lives valuable. It was only in the course of my encounter with [patient name]. that I came to comprehend it.” (C6, female). Within the course of the course, many of the students rethought their professional self-image as future doctors. On the one hand, students witnessed how their patients felt concerning their caretakers’ behaviour towards them, including potential shortcomings. As future doctors, the students formed the wish to take time for their patients and to listen closely to them, despite all adversities of clinical routine: “ By now, I find it more and more unbelievable how the simplest rules of interpersonal interaction can so often be lost in the clinical routine. [...] I have noticed how difficult and important it is to communicate properly with patients in order to build up a relationship of trust ” (A7, female). “ I believe that a doctor who is very brilliant professionally but not very empathetic or caring as a human being can achieve little cooperation with a patient” (B3, female). On the other hand, students drew conclusions based on the needs and emotional experience of their patient that they may have assessed differently beforehand: “ When I listened to [patient name], I was surprised that he himself said that he did not know exactly what cancer meant. He also expressed his frustration that he did not understand the doctors' letters [...]. He felt overlooked, even though it was about HIS disease ” (C3, female). Moreover, the students learned to respect the patient’s autonomy: “ It is not always easy to understand the patient's will, and it is difficult for a doctor to respect the patient's autonomy without [...] getting into a conflict of conscience of his own. [...] So part of the doctor's task is to find a balance between the patient's will and what is right from a medical point of view. ” (A1, male). Generally, the students recognised the value of palliative care: “ For me, the medical profession took on a new dimension during the course. [...] I learned the difference between ‘nothing more can be done’ and ‘it can no longer be cured’” (B7, female). The students’ verdict Overall, the students perceived their participation as a valuable experience which was enriching on both a personal and professional level. Moreover, students commented on the value of supervision when facing difficulties in interaction with their patient. Likewise, students perceived the reflective essay as a valuable tool to process their experiences. At the same time, a few students also expressed criticism of the course. First, some students lamented a lack of structure and plannability as their participation caused a time conflict with their classes and exams. Second, some students struggled with the open character of the course and would have preferred to receive a more predefined assignment. Third, a few students mentioned difficulties in writing the reflective essay as they were not familiar with the concept: “ Writing the report proved to be a great challenge for me. It took me quite a few attempts to write the report. This made me realise that I seem to have problems with such a task. I have never written so many pages on one topic. ” (B8, female). Overall, the students drew a positive conclusion from their participation: “ I am convinced that the experience I gained will be invaluable for me later on, regardless of the field I will work in one day. ” (A1, male) . “ For me, this course was a great preparation. Preparation for what? For life, I would say. For becoming a doctor and staying human ” (A8, female). Discussion Motivated by a lack of expertise in dealing with terminally ill patients, students considered their participation a valuable and inspiring experience both on a professional and personal level. Although the students were not familiar with the course format, they approached the patient encounter with an open mind and adapted quickly. Overall, the course offered students a more holistic picture of the existential impact of terminal illness on the individual including social, psychological, and spiritual factors of disease. Likewise, the course positively influenced students’ vision on end-of-life care. Offering a self-led learning experience, medical students could reduce insecurities and train their interpersonal skills which is expected to benefit their overall performance in palliative care [20,21]. While the open character of the course is essential to facilitate the self-led exchange with patients, some students expressed criticism regarding the limited capacity for planning within the course. Likewise, some students missed having a defined assignment, which made them feel uncertain about their own role within the course. As students’ experiences within the course have shown, German medical students value reflective writing as a tool in experiential learning. Although widely applied in other countries such as the United Kingdom, reflective writing is not standard at German universities [22]. While many students in this study appeared to be naturally self-reflective, others mentioned difficulties in the writing process, which could also be seen in the rather descriptive character of those essays. It might therefore be useful to provide medical students with guidelines for reflective writing to facilitate the process and deepen students’ learning experience. Additionally, reflective skills will enhance students’ capacity for professional development [12]. The analysis revealed that students' motivations to participate have remained unchanged over the years. On one hand, the course content's relevance has not diminished. On the other hand, students' insecurities in caring for palliative patients have remained despite continuous adjustments in the core curriculum. Studies in other European countries have yielded comparable findings [21,23]. One reason might be that young adults are generally less likely to have experienced losses at this stage of their life. While the variety of palliative care teaching formats has increased over the last years (beside-teaching, e-learning, simulated patients etc.), many German universities do not offer elective courses on palliative care at all [22]. Our findings underline the importance of experiential training as a tool to build up confidence for palliative care provision among medical students, which they should be offered to train besides their timely-limited curriculum [24]. Limitations There are certain limitations to this study that need to be considered. Due to the descriptive nature of some of the reports, the overall depth of the analysis was variable. While the key themes arose in all analysed essays, the data needed to allow for a more in-depth analysis of the grounded theory approach (to identify underlying motives of observed patterns). Although participation was completely voluntary and no formal mark was given, it is not clear how truthful students were concerning their experiences and reflections as they might have intended to meet certain expectations. Yet, Ong (2002) suggests that any finished written text becomes removed from its author. This creates an independent discourse, and the text thus becomes a source for an independent analysis [X]. Lastly, not all students who took part in the course handed in their reflective essay. While their reasons remain uncertain, it might be related to students’ intensive curriculum. Conclusion “The Patient as Teacher” represents a highly valued palliative care learning tool among German medical students demonstrating the added value of experiential learning in palliative care education. It offers students a more holistic picture of the existential impact of terminal illness on the individual including social, psychological, and spiritual factors of disease while positively impacting medical students’ vision on end-of-life care. Moreover, it supports the students in overcoming insecurities in dealing with terminally ill patients and helps them to further develop their professional identity. Overall, “The Patient as Teacher” is a valuable and inspiring experience for medical students both on a professional and personal level. Declarations Ethics approval and consent to participate An assessment by the Medical Ethics Committee of RWTH Aachen was obtained for this study. All participants gave verbal informed consent. Consent for publication Not applicable. Availability of data and materials No data or material can be made available due to privacy and ethical concerns. Those interested may contact the corresponding author for further information. Competing interests The authors declare that they have no competing interests. Funding No funding was received for conducting this study. Authors' contributions FE and SS were responsible for the study as well as the analysis and interpretation of findings. SB and PP were involved in drafting and revising the manuscript. All authors gave final approval to this manuscript. Acknowledgements The authors thank all participants of this study for their time and sharing of their experiences. References World Health Organisation [Internet]. Palliative Care. Key facts, 2020. https://www.who.int/news-room/fact-sheets/detail/palliative-care. Accessed 13 May 2023. Gamondi C, Larkin L, Payne P. Core competencies in palliative care: an EAPC White Paper on palliative care education – part 2. Europ J Palliat Care. 2013;20(3). Ilse B, Alt-Epping B, Kiesewetter I, Elsner E, Hildebrandt J, Laske A, et al. Undergraduate education in palliative medicine in Germany: a longitudinal perspective on curricular and infrastructural development. BMC Med Educ. 2015; doi:10.1186/s12909-015-0439-6. Elsner F, Ohlmeier L, Neukirchen M, Scherg A. Palliative care in medical education as QB13 and beyond-a teaching survey. [Palliativmedizin in der Ärztlichen Ausbildung als QB13 und darüber hinaus–eine Lehrumfrage]. Z Palliativmed. 2018; doi:10.1055/s-0038-1669266. Elsner F. The new curriculum for students of the society for palliative medicine. [Das neue DGP-Curriculum für Studierende]. Z Palliativmed. 2009; 182. Boland JW, Barclay S, Gibbins J. Twelve tips for developing palliative care teaching in an undergraduate curriculum for medical students. Med Teach. 2019; doi:10.1080/0142159X.2018.1533243. Block SD, Billings JA. Learning from the dying. N Engl J Med. 2005;353(13):1313. Braun UK, Gill AC, Teal CR, Morrison LJ. 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BMJ Support Palliat Care. 2016; doi:10.1136/bmjspcare-2016-001110. Pieters J, Dolmans DHJM, Van den Beuken-van Everdingen, MHJ, Warmenhoven FC, Westen JH, Verstegen DML. A National Palliative Care Competency Framework for Undergraduate Medical Curricula. Int J Environ Res Publ Health. 2020; doi:10.3390/ijerph17072396. Billings ME, Engelberg R, Curtis JR, Block S, Sullivan AM. Determinants of Medical Students' Perceived Preparation To Perform End-of-Life Care, Quality of End-of-Life Care Education, and Attitudes Toward End-of-Life Care. J Palliat Med. 2010; doi:10.1089/jpm.2009.0293. Gaufberg EH, Batalden M, Sands R, Bell SK. The Hidden Curriculum: What Can We Learn From Third-Year Medical Student Narrative Reflections? Acad Med. 2010; doi:10.1097/ACM.0b013e3181f57899. Ong WJ: Orality and Literacy. 2nd ed. London: Routledge; 2002. Paal P. Written cancer narratives [dissertation]. Helsinki (FI): University of Helsinki; 2011. Braun V, Clarke V. Using thematic analysis in psychology. Qual research in psych. 2006; doi:10.1191/1478088706qp063oa. Braun V, Clarke, V. Supporting best practice in reflexive thematic analysis reporting in Palliative Medicine: A review of published research and introduction to the Reflexive Thematic Analysis Reporting Guidelines (RTARG). Palliat Med. 2024; doi: https://doi.org/10.1177/02692163241234800. Weber M, Braun J, Schildmann J. Effects of a Ninety-Minute Teaching Module for Fourth-Year Medical Students on a Palliative Care Ward with Student–Patient Encounter. J Palliat Med. 2011; doi:10.1089/jpm.2011.0025. Wells G, Youssef E, Winter R, Wright J, Llewellyn C. Medical student confidence in care of the dying and their family: a systematic review. BMJ Support Palliat Care. 2020; doi:10.1136/bmjspcare-2019-001977. Ohlmeier L, Scherg A, Ilse B, Elsner, F. Status of palliative care education in Germany: a survey of medical faculties in 2018. Schmerz. 2021; doi: https://doi.org/10.1007/s00482-021-00536-7. Pieters J, Dolmans DHJM, Verstegen DML, Warmehoven FC, Courtens AM, Van den Beuken-van Everdingen MHJ. Palliative care education in the undergraduate medical curricula: students’ views on the importance of, their confidence in, and knowledge of palliative care. BMC Palliat Care. 2019; doi:10.1186/s12904-019-0458-x. Boland JW, Brown MEL, Duenas A, Finn GM, Gibbins J. How effective is undergraduate palliative care teaching for medical students? A systematic literature review. BMJ Open. 2020; doi:10.1136/bmjopen-2019-036458. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Oct, 2024 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 16 Aug, 2024 Reviews received at journal 14 Aug, 2024 Reviews received at journal 14 Aug, 2024 Reviews received at journal 09 Aug, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviewers agreed at journal 01 Aug, 2024 Reviewers agreed at journal 29 Jul, 2024 Reviewers invited by journal 25 Jul, 2024 Editor invited by journal 24 Jul, 2024 Editor assigned by journal 22 Jul, 2024 Submission checks completed at journal 22 Jul, 2024 First submitted to journal 21 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4777087","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":340820274,"identity":"be0042be-3bae-4fe8-a6ca-b35ad01b61c1","order_by":0,"name":"Stephanie Stocklassa","email":"data:image/png;base64,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","orcid":"","institution":"RWTH Aachen University, Uniklinik RWTH Aachen","correspondingAuthor":true,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Stocklassa","suffix":""},{"id":340820276,"identity":"ea92a37a-214e-457f-81a1-6b4730e09172","order_by":1,"name":"Susan Block","email":"","orcid":"","institution":"Harvard Medical School","correspondingAuthor":false,"prefix":"","firstName":"Susan","middleName":"","lastName":"Block","suffix":""},{"id":340820277,"identity":"be6e2c9b-0ae5-4e51-bf18-c262468747e5","order_by":2,"name":"Piret Paal","email":"","orcid":"","institution":"Paracelsus Medical University","correspondingAuthor":false,"prefix":"","firstName":"Piret","middleName":"","lastName":"Paal","suffix":""},{"id":340820279,"identity":"21b9e3ef-b686-4045-a294-a0b4a6580387","order_by":3,"name":"Frank Elsner","email":"","orcid":"","institution":"RWTH Aachen University, Uniklinik RWTH Aachen","correspondingAuthor":false,"prefix":"","firstName":"Frank","middleName":"","lastName":"Elsner","suffix":""}],"badges":[],"createdAt":"2024-07-21 14:10:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4777087/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4777087/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-024-01570-9","type":"published","date":"2024-10-09T15:56:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66597039,"identity":"29662a18-69dc-4994-bb74-3e63600e62b5","added_by":"auto","created_at":"2024-10-14 16:05:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":342760,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4777087/v1/301c4f83-ee43-4c96-b959-edb22ff1df3c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“The Patient as Teacher” - thematic analysis of undergraduate medical students’ experiences with an experiential learning project in Palliative Care","fulltext":[{"header":"Background","content":"\u003cp\u003eGiven global demographic change and the rising rate of non-communicable diseases, the demand for comprehensive palliative care will continue to rise [1]. Therefore, the European Association for Palliative Care has argued that all medical professionals should be capable of providing appropriate palliative care as they will encounter patients in need of palliative Care from primary care to tertiary hospitals [2]. Consequently, increased demands are placed on the education and training of medical professionals today. In this context, undergraduate medical students\u0026rsquo; access to palliative care education has been significantly expanded at German universities over the past few decades [3,4]. Since 2009, it has been a legal requirement that all medical students in Germany are trained in the provision of palliative care (\u0026Auml;ApprO as of 03.07.2002, last amended in 31.07.2009, \u0026sect;27 and supplement 15 to \u0026sect;29 sect. 3 sentence 2)\u0026nbsp;[5]. Simultaneously, it has been acknowledged that practical training and clinical exposure are essential for teaching students how to interact adequately with terminally ill patients and their families [6]. Particularly, palliative care education and training needs to support students in developing appropriate attitudes towards caring for terminally ill patients [3]. Consequently, German universities have chosen various approaches to provide students with practical experience in the field of palliative care.\u003c/p\u003e\n\u003cp\u003eSince 2005, medical students at RWTH Aachen University have had the opportunity of participating in the course\u0026nbsp;\u0026ldquo;The Patient as Teacher\u0026rdquo;, offering a one-to-one exchange over several weeks with a patient receiving palliative care. Following the model of experiential learning, the course aims to help students understand experiences of terminally ill patients through personal exchange. Taking part is voluntary for both patients and students, and students from all years may apply to attend the course. While the individual patient largely determines the course of the exchange, the student has no specific task or assignment. Therefore, students may temporarily distance themselves from their role as future health professionals and meet the patients on a purely personal level. This is to enable the students to gain a more holistic view on the consequences of terminal illness on the individual. The course is based on a teaching concept from Harvard Medical School, Center of Palliative Care [7].\u003c/p\u003e\n\u003cp\u003eIn particular, the course consists of three components: accompaniment of a terminally ill patient, supervision in small groups under psychological guidance, and writing of a reflective essay. The accompaniment of the patient comprises a total of 20 hours over a period of four to six weeks, with the actual frequency and duration of the meetings being determined individually between the patient and the student. Typically, the course extends over 10 to 25 encounters. While the first meeting takes place on the hospital ward, subsequent meetings might also take place at a hospice or at the patient\u0026apos;s home after the patient\u0026rsquo;s discharge. Supervision usually takes place at four meetings spread over the course of the course. Here, students receive impulses for personal reflection and help with potential problems in interaction with their patients. At the same time, the meetings offer an exchange of experiences with other students taking part in the course. At the end of the course, students are requested to hand in a twenty-pages reflexive essay on their experiences. Students have the full freedom regarding the form and content of their essay, which it is seen as an invitation for reflection and evaluation. Ultimately, students do not receive a formal grade for their participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe course \u0026ldquo;The Patient as Teacher\u0026rdquo; had run for a period of sixteen years before it was paused at the beginning of the Covid-19 pandemic. Over this period, the students\u0026rsquo; interest in participating constantly exceeded the availability of placements, which led to long waiting lists. In 2009, the course \u0026quot;The Patient as Teacher\u0026quot; won the Palliative Medicine Promotion Award of the German Society for Palliative Medicine. To our knowledge, no comparable palliative care course has been described in the literature to date.\u003c/p\u003e\n\u003cp\u003eThere is a broad consensus that medical students benefit from experiential learning and reflective writing in the palliative care learning process. Particularly,\u0026nbsp;one-to-one encounters with patients reveal the social, psychological and spiritual dimensions of illness to the students [8-11]. Simultaneously, authors underline that reflective training supports medical students in forming their professional identity [8,9,12]. In particular, comprehensive palliative care provision requires competencies of respectful and empathetic communication as well as professional behaviour with regards to one\u0026rsquo;s personal and professional values [2,13]. Likewise, experiential learning offers the chance to positively influence students\u0026rsquo; attitudes towards palliative care by paying attention to the hidden curriculum (implicit changes in students\u0026rsquo; attitudes, beliefs, and values due to extracurricular experiences and observations) [14,15]. While it is understood that first encounters with terminally ill patients can be distressful, it is important to provide a safe learning environment in which students can experience positive relationships, guidance and self-efficacy [11,12].\u0026nbsp;Reflective essays as written text are arguably helpful in restructuring consciousness [16]. However, the responsive orientation of written self-expression makes it particularly debatable whether the writing for a course contains merely personal values and experiences or whether they represent socially desirable responses. In this paper, we argue that the truths and views that become represented as individual interpretations in such written accounts represent the discourse influenced by language (ideologies) and culture framed by the institutional arrangement of a particular society [17].\u003c/p\u003e\n\u003cp\u003eAnalysing students\u0026rsquo; experiences within the course \u0026ldquo;The Patient as Teacher may provide valuable implications for experiential learning in palliative care. Simultaneously, it is unknown whether changes in the curriculum had an impact on students\u0026apos; motivation and experience with the course over the years. Therefore, this study aims to investigate students\u0026rsquo; motivation and experiences within the course \u0026ldquo;The Patient as Teacher\u0026rdquo; by analysing students\u0026rsquo; reflective essays from 2005-2020. In this respect, particular attention shall be paid to potential changes in students\u0026rsquo; perceptions over the years. \u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIn the period 2005-2020, a total of 114 medical students participated in the course (95 female and 19 male students). Of these, a total of 78 students submitted a reflexive essay (65 female and 13 male students). For this study, a sample of 24 essays was taken from all essays using stratified randomisation weighted by the number of essays submitted per year, eight essays each from the years 2005-2009, 2010-2014 and 2015-2020, subsequently referred to as group A, group B, and group C. Ultimately, the essays of\u0026nbsp;21 female and 3 male students\u0026nbsp;were included for analysis.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe average length of essays was 7361.50 words (SD = 1655.25).\u003c/p\u003e\n\u003cp\u003eAn assessment by the Medical Ethics Committee of RWTH Aachen was obtained for this study. All students were provided with sufficient information on the nature and content of the study including potential risks to assure the informed consent. At the same time, students could refuse to participate at any point without any negative consequences or the need for justification. In addition, anonymity of participants and protection of identity was warranted. All essays were kept anonymous and confidential, and participants were assigned a random identification number (e.g. C5). Those numbers were included with the quotes from the individual essay to illustrate the breadth of data.\u003c/p\u003e\n\u003cp\u003eThe thematic analysis of the reflexive essays was carried out by a female medical student with a background in health science and nursing (corresponding author), who had not been involved in the course otherwise, using MaxQDA (version 2022.2.0). The thematic analysis was chosen to gain an understanding of the students\u0026apos; motivations, perceptions, and experiences. The data analysis was guided by Braun and Clarke\u0026apos;s (2022) \u0026ldquo;Reflexive Thematic Analysis approach\u0026rdquo; [18,19]. After familiarization with the data (step 1), initial codes were generated, and all relevant data collated to each code (step 2). Then, corresponding codes were gathered into potential themes (step 3). Next, the themes were reviewed whether they matched the initial codes as well as the dataset. The themes were refined and specified creating the final thematic \u0026lsquo;map\u0026rsquo; of the analysis (step 4). Subsequently, the naming of themes was reviewed to unfold the overall story of analysis (step 5). Ultimately, illustrative quotes were selected, and the report was written while relating the analysis back to the research question and literature (step 6). The analysis was carried out in German language and only the final themes and corresponding text passages were translated into English under the guidance of a native speaker.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe analysis revealed four main themes concerning students\u0026rsquo; experiences within the course, namely \u003cem\u003emotivation\u003c/em\u003e, the\u003cem\u003e\u0026nbsp;patient\u0026rsquo;s story\u003c/em\u003e, the \u003cem\u003einteraction\u003c/em\u003e with the patient, and \u003cem\u003eself-reflection\u003c/em\u003e. \u0026nbsp;In particular, \u003cem\u003emotivation\u003c/em\u003e concerned students\u0026rsquo; expectations of the course and reasons for participating. The \u003cem\u003epatient\u0026rsquo;s story\u003c/em\u003e referred to the personal and medical history of the patient as well as his or her individual constraints, needs, and wishes. \u003cem\u003eInteraction\u003c/em\u003e mainly concerned aspects of communication and relationship-building. Lastly, \u003cem\u003eself-reflection\u003c/em\u003e involved revisiting personal feelings and boundaries, felt notions of responsibility, and consequences of experiences within the course for the students\u0026rsquo; professional self-image as prospective doctors (table 1). Finally, some students gave feedback on the course in their essays, which will be summarised at the end. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Main themes and associated key points as identified by analysis of students\u0026rsquo; essays\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.23217247097844%\" valign=\"top\"\u003e\n \u003cp\u003eMain theme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.76782752902156%\" valign=\"top\"\u003e\n \u003cp\u003eKey points\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.23217247097844%\" valign=\"top\"\u003e\n \u003cp\u003eMotivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.76782752902156%\" valign=\"top\"\u003e\n \u003cp\u003eSpending more time with a patient\u003c/p\u003e\n \u003cp\u003eExploring new learning concept\u003c/p\u003e\n \u003cp\u003eEncountering patients outside their role as medical students\u003c/p\u003e\n \u003cp\u003eFilling gaps of regular curriculum\u003c/p\u003e\n \u003cp\u003eReducing insecurities in dealing with terminally ill patients\u003c/p\u003e\n \u003cp\u003eImproving communication skills\u003c/p\u003e\n \u003cp\u003eTaking on new challenge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.23217247097844%\" valign=\"top\"\u003e\n \u003cp\u003ePatient\u0026rsquo;s story\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.76782752902156%\" valign=\"top\"\u003e\n \u003cp\u003ePersonal biography\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMedical history\u003c/p\u003e\n \u003cp\u003eDimensions of living with a life-limiting illness (physical, psychological, social and spiritual)\u003c/p\u003e\n \u003cp\u003eDreams and wishes\u003c/p\u003e\n \u003cp\u003eConcept of quality of life\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.23217247097844%\" valign=\"top\"\u003e\n \u003cp\u003eInteraction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.76782752902156%\" valign=\"top\"\u003e\n \u003cp\u003eCommunication (conversation style, sharing feelings etc.)\u003c/p\u003e\n \u003cp\u003eRelationship-building\u003c/p\u003e\n \u003cp\u003eCloseness and distance\u003c/p\u003e\n \u003cp\u003eDefining their own role\u003c/p\u003e\n \u003cp\u003eOvercoming obstacles\u003c/p\u003e\n \u003cp\u003eSaying goodbye\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.23217247097844%\" valign=\"top\"\u003e\n \u003cp\u003eSelf-reflection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.76782752902156%\" valign=\"top\"\u003e\n \u003cp\u003eUpcoming feelings (happiness, sadness, insecurity etc.)\u003c/p\u003e\n \u003cp\u003ePersonal boundaries\u003c/p\u003e\n \u003cp\u003eOwn life and personal values\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProfessional self-image as future doctors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eMotivation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConcerning their motivation to participate in the course, students most frequently reported taking the opportunity to spend more time with a patient than possible in their future working life. Specifically, students felt that the course offered them the opportunity to experience a more in-depth exchange with a patient, as one student reported: \u0026ldquo;\u003cem\u003eI know that I cannot and will not get involved with every one of my future patients in the way I was able to do with [patient\u0026rsquo;s name] in this course. Yes, it was a privilege for me to be able to accompany a person in such a special way and so intensively in terms of time\u003c/em\u003e\u0026rdquo; (C3, female). Simultaneously, students appreciated the concept of experiential learning and, in particular, being in contact with patients without a specific teaching assignment and outside of their role as doctors. In this context, one student noted: \u0026ldquo;\u003cem\u003eI have certainly heard the medical facts in a lecture before and I can research them relatively easily; however, the personal account and experience of the disease with all its aspects (i.e. also psychological, mental and spiritual) is something that cannot be taught so easily in conventional academic courses\u003c/em\u003e\u0026rdquo; (C8, female). For many students, the course represented their first one-to-one encounter with a terminally ill person. Many students lamented that insufficient attention was paid to palliative care in their regular course work. Likewise, they felt that the regular curriculum did not sufficiently prepare them for working with terminally ill patients. The students hoped that their participation in the course would help to improve their communication skills and reduce their insecurities when dealing with seriously ill patients and death. Generally, the students perceived their participation as a challenge as they were not familiar with the teaching concept and, simultaneously, did not have a clear idea of what they would be encountering. Accordingly, many of the students expressed concerns and fears about what to expect from the course and whether they were up to the challenge: \u003cem\u003e\u0026ldquo;As soon as I had the acceptance, my thoughts began to circle: Can I do it at all? What did I sign up for here?\u0026rdquo;\u0026nbsp;\u003c/em\u003e(B6, male). Ultimately, many students took part out of curiosity or on the recommendation of other students. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient story\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe course enabled students to gain insight into their patients\u0026rsquo; personal biography as well as their medical history. Due to the personal character of the meetings, the students got to know the patient\u0026rsquo;s social environment and often encountered the patient\u0026apos;s relatives as well. In this context, many students reflected on the social dimension of disease and the importance of social support for the patient. Moreover, students could discover their patients\u0026rsquo; distinct needs and develop an understanding for their patients\u0026rsquo; experiences of living with a life-limiting illness: \u0026ldquo;\u003cem\u003eI was allowed to get to know a person in a very unbiased way, to get to know a part of his inner being without much ado, to share happy and bitter moments, to meet family and friends, to experience conversations, memories, cohesion, quarrels, hope and suffering.\u003c/em\u003e\u0026rdquo; (C7, female). Particularly, students reported that they got to know their patients\u0026rsquo; dreams and wishes and learned what quality of life could mean for a terminally ill person: \u003cem\u003e\u0026ldquo;It always warmed my heart to hear her talk about strawberry ice cream cups with shining eyes. In those moments I really forgot that she was sick - that is how much she could enjoy the little things\u0026rdquo;\u0026nbsp;\u003c/em\u003e(A7, female). Some students have also learned about the spiritual needs of the patient. At the same time, students witnessed the patients\u0026rsquo; aggravating physical limitations as well as the emotional burden linked to the progression of disease: \u003cem\u003e\u0026ldquo;Illness puts the sufferer in a state of physical and mental inconstancy: the sufferer has to constantly redefine himself and explore which abilities and things can still be carried out in everyday life. Phases of hope alternate with phases in which hope seems to be exhausted\u0026rdquo;\u003c/em\u003e (B2, male). While some students paid a last visit to their patient after his or her death, none of the students were present when their patient died.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInteraction\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the students, interacting with their patients required skills in communication and relationship-building. In order to gain their patients\u0026rsquo; trust, finding the most appropriate conversation style was crucial. Jointly, students could practise exchanging views, sharing personal feelings, expressing empathy, and setting boundaries. Some students aimed to make regular appointments and create shared rituals (e.g. going for a walk or sharing a cup of coffee in the patient\u0026rsquo;s kitchen) to build up a relationship towards their patient. Generally, students aimed to find common interests with their patients. Many students reported they were surprised at how quickly they formed a trustful bond with their patient: \u0026ldquo;\u003cem\u003eYou meet a [...] person in a closed room, with limited time, and despite this, or precisely because of this, a climate of trust builds up relatively quickly [...] I have the feeling that you don\u0026apos;t achieve this closeness so easily and quickly with people you will see again or with whom you have connections\u003c/em\u003e\u0026rdquo; (B6, male). At the same time, some students found it difficult to connect with their patient: \u0026ldquo;\u003cem\u003eIt took a lot of strength and commitment to establish and maintain contact with her. During the whole time, I tried to recognise her fears and needs and to help her cope. Initially, this seemed almost impossible due to the patient\u0026apos;s resistance. In the course of the conversations, however, an increasingly trusting relationship developed between [patient\u0026rsquo;s name] and me.\u003c/em\u003e\u0026rdquo; (A4, female). In this context, students reflected on the appropriate degree of closeness and distance towards their patient: \u0026ldquo;\u003cem\u003eIt helped me a lot to be aware of my motivation and the goal of a meeting beforehand. Because these two points only became fully apparent to me in the course of the course, due to [the course\u0026rsquo;s] concept and my personal characteristics, I saw a challenge in sensing and finding this boundary.\u003c/em\u003e\u0026rdquo; (B5, female). Whereas many students initially feared to burden the patient with their presence, they later described the mutual benefit of the encounter: \u0026ldquo;\u003cem\u003eIn the beginning I felt out of place. I thought I was disturbing the family, who surely had so many things to discuss. This feeling disappeared very quickly after I realised how much my patient and his wife looked forward to my visits.\u003c/em\u003e\u0026rdquo; (A3, female). Some students thought that their patients valued sharing their thoughts with an unbiased person. Others reported they could provide emotional support when their patient was in distress: \u0026ldquo;\u003cem\u003eI knew that I could not relieve him of the burden of dying, but that perhaps through my visits I could carry a little more diversion and entertainment into his enviro\u003c/em\u003e\u003cem\u003enment and lessen the loneliness and isolation to which he was subjected in that room.\u003c/em\u003e\u0026rdquo;\u003cem\u003e\u0026nbsp;\u003c/em\u003e(A2, female).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the same time, students repeatedly mentioned being unsure of their own role in interaction with the patient: \u003cem\u003e\u0026ldquo;What am I doing here anyway? Where is this supposed to lead? [...] What is the justification for my presence?\u003c/em\u003e\u0026rdquo; (A8, female). \u0026ldquo;\u003cem\u003eWhat is my goal? My purpose in our conversations? The purpose of my visits to her?\u003c/em\u003e\u0026rdquo; (C1, female). In this context, students frequently reported that their role and purpose was implicitly defined by the patient and his or her needs: \u0026ldquo;\u003cem\u003eOverall, the course gave me the opportunity to search for and question my role through my patients [...] Thus, from my perspective throughout the course, I was in varying proportions a learner, an independent, a confidant and a listener, who was also asked for assessment or advice at times\u003c/em\u003e\u0026rdquo; (B5). In addition, the students reported on some obstacles in interacting with their patients. Occasionally, they experienced difficulties in scheduling meetings with their patient. Simultaneously, several patients were limited in their ability to communicate due to their illness. In some cases, only non-verbal communication was possible at times. Moreover, some students did not know how to react to the patient\u0026apos;s statements: \u003cem\u003e\u0026ldquo;And again the sentence: \u0026quot;My days are numbered\u0026quot;. These words sound like something out of a drama, so unrealistic and useless for daily use. Is that why it makes me feel uneasy? There is an end in sight, negative associations. Why did she tell me that? Was it an accepting \u0026lsquo;ok\u0026rsquo; or a desperate \u0026lsquo;why\u0026rsquo;? What did she expect me to answer?\u0026rdquo;\u003c/em\u003e (B8, female). Similarly, some students faced issues of miscommunication and conflict they had to solve. For instance, when the expectations of patients and students diverged. In this context, many students indicated that they found the input from the supervision sessions very helpful. Ultimately, the concerned students found ways to solve the tension between the different parties: \u0026ldquo;\u003cem\u003eI have learned how important it is to address problems directly with those involved. In this way, misunderstandings can be quickly resolved and people can deal with each other in a completely different way\u003c/em\u003e\u0026rdquo; (B4, female).\u003c/p\u003e\n\u003cp\u003eFor the majority of students, saying goodbye to their patient formed the most challenging part of the course: \u0026ldquo;\u003cem\u003eI would have liked to be with her until the end. Perhaps it was right to distance myself beforehand and to consciously end the accompaniment. Sometimes it feels wrong to have the opportunity to choose when to say goodbye, while others have no choice.\u003c/em\u003e\u0026rdquo; (C7, female). \u003cem\u003e\u0026ldquo;This farewell could likely be the final one. This woman came very close to me, or rather I let her come very close to me, and it is not easy for me to say goodbye today. It is a gentle regret mixed with the knowledge that this is the course of life.\u0026rdquo;\u003c/em\u003e (B1, female). In some cases, the patient died before the actual end of the course. Depending on how established the relationship between student and patient was at that point, this experience could be very distressing for the concerned student: \u0026ldquo;\u003cem\u003eHow could this happen so quickly? I felt terrible because I had always put off saying goodbye [...]. A conscious farewell to [patient\u0026rsquo;s name] at the end of the internship would have been enriching for both of us.\u003c/em\u003e\u0026rdquo; (A7, female). \u0026ldquo;\u003cem\u003eI was particularly affected by the death at that time, more than I would have expected. I had met [patient name] as a palliative care patient, so I knew that he could die at any time. But somehow I just didn\u0026apos;t expect it at the time.\u003c/em\u003e\u0026rdquo; (C2, female). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSelf-reflection\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents\u0026rsquo; participation raised many feelings among them, which they reflected on in their essays: \u0026ldquo;\u003cem\u003eNot only during the course, but also while I was writing this text, I experienced a rollercoaster of emotions. I was happy, joyful, sad, despairing, angry and stunned and much more than could be put into words easily\u003c/em\u003e\u0026rdquo; (B7, female). At the beginning of the course, many students felt insecure as they had no clear picture of what was expected from them or unsure how to approach a terminally ill patient. Occasionally, students were uncomfortable with the thought of taking up the patient\u0026apos;s time: \u0026ldquo;\u003cem\u003eI suddenly felt a very bad conscience to be there at all and to let such a sick person gift me with time.\u003c/em\u003e\u0026rdquo; (B5, female). However, those feelings generally diminished in the course of the course once they got to know their patients better and built up a relationship towards them. Being met with openness and kindness, many students developed a sense of responsibility towards their patients. The more the students built up closeness and trust with their patient, however, the more worried they became about the thought of parting and the possible death of their patient: \u0026ldquo;\u003cem\u003eAt some point I was afraid that his wife would pick up the phone and tell me that her husband had died. I didn\u0026apos;t want to stumble into such a situation.\u003c/em\u003e\u0026rdquo; (A6, female). At the same time, some students felt rejected and disappointed as they faced difficulties in connecting with their patient, as mentioned above. Generally, interacting with their patient required many students to become aware of their\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003epersonal boundaries. Students reported that they allowed themselves to be more personally involved than they would be in their role as doctors: \u0026ldquo;\u003cem\u003eOur relationship takes on almost family-like structures.\u003c/em\u003e\u0026rdquo; (B1, female). Simultaneously, those students stated they had been able to take away more from the encounter by putting off the \u0026lsquo;white coat\u0026rsquo;. As many students felt sad for leaving their patient at the end of the course, some were too afraid to say goodbye: \u0026ldquo;\u003cem\u003eDistancing and saying goodbye is one of the essential components of this course. I didn\u0026apos;t succeed, but you learn more from mistakes in the end.\u003c/em\u003e\u0026rdquo; (B8, female). Those students who witnessed the death of their patient needed some time to come to terms with what had happened: \u0026ldquo;\u003cem\u003eSometimes my thoughts still wander to the people whose difficult time and sad loss I witnessed, and I wonder how they are doing now. However, these questions arise less and less in me as time goes by\u003c/em\u003e\u0026rdquo; (A2, female). For many students, the exchange with their patient formed an occasion to reflect on their own lives and personal values: \u0026ldquo;\u003cem\u003eWhere would I be in 60 years? Will I be able to look back on my life happily? What losses will shape my life?\u003c/em\u003e\u0026rdquo; (C5, female). \u003cem\u003e\u0026ldquo;It is banal, but it is known that there is a fine difference between knowing things and comprehending things. I knew that death makes the time we have in our lives valuable. It was only in the course of my encounter with [patient name]. that I came to comprehend it.\u0026rdquo;\u003c/em\u003e (C6, female).\u003c/p\u003e\n\u003cp\u003eWithin the course of the course, many of the students rethought their professional self-image as future doctors. On the one hand, students witnessed how their patients felt concerning their caretakers\u0026rsquo; behaviour towards them, including potential shortcomings. As future doctors, the students formed the wish to take time for their patients and to listen closely to them, despite all adversities of clinical routine: \u0026ldquo;\u003cem\u003eBy now, I find it more and more unbelievable how the simplest rules of interpersonal interaction can so often be lost in the clinical routine. [...] I have noticed how difficult and important it is to communicate properly with patients in order to build up a relationship of trust\u003c/em\u003e\u0026rdquo; (A7, female). \u0026ldquo;\u003cem\u003eI believe that a doctor who is very brilliant professionally but not very empathetic or caring as a human being can achieve little cooperation with a patient\u0026rdquo;\u0026nbsp;\u003c/em\u003e(B3, female). On the other hand, students drew conclusions based on the needs and emotional experience of their patient that they may have assessed differently beforehand: \u0026ldquo;\u003cem\u003eWhen I listened to [patient name], I was surprised that he himself said that he did not know exactly what cancer meant. He also expressed his frustration that he did not understand the doctors\u0026apos; letters [...]. He felt overlooked, even though it was about HIS disease\u003c/em\u003e\u0026rdquo; (C3, female).\u003cem\u003e\u0026nbsp;\u003c/em\u003eMoreover, the students learned to respect the patient\u0026rsquo;s autonomy: \u0026ldquo;\u003cem\u003eIt is not always easy to understand the patient\u0026apos;s will, and it is difficult for a doctor to respect the patient\u0026apos;s autonomy without [...] getting into a conflict of conscience of his own. [...] So part of the doctor\u0026apos;s task is to find a balance between the patient\u0026apos;s will and what is right from a medical point of view.\u003c/em\u003e\u0026rdquo; (A1, male). Generally, the students recognised the value of palliative care: \u0026ldquo;\u003cem\u003eFor me, the medical profession took on a new dimension during the course. [...] I learned the difference between \u0026lsquo;nothing more can be done\u0026rsquo; and \u0026lsquo;it can no longer be cured\u0026rsquo;\u0026rdquo;\u003c/em\u003e (B7, female).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe students\u0026rsquo; verdict\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOverall, the students perceived their participation as a valuable experience which was enriching on both a personal and professional level. Moreover, students commented on the value of supervision when facing difficulties in interaction with their patient. Likewise, students perceived the reflective essay as a valuable tool to process their experiences. At the same time, a few students also expressed criticism of the course. First, some students lamented a lack of structure and plannability as their participation caused a time conflict with their classes and exams. Second, some students struggled with the open character of the course and would have preferred to receive a more predefined assignment. Third, a few students mentioned difficulties in writing the reflective essay as they were not familiar with the concept: \u0026ldquo;\u003cem\u003eWriting the report proved to be a great challenge for me. It took me quite a few attempts to write the report. This made me realise that I seem to have problems with such a task. I have never written so many pages on one topic.\u003c/em\u003e\u0026rdquo; (B8, female). Overall, the students drew a positive conclusion from their participation: \u0026ldquo;\u003cem\u003eI am convinced that the experience I gained will be invaluable for me later on, regardless of the field I will work in one day.\u003c/em\u003e\u0026rdquo; (A1, male)\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u0026ldquo;\u003cem\u003eFor me, this course was a great preparation. Preparation for what? For life, I would say. For becoming a doctor and staying human\u003c/em\u003e\u0026rdquo; (A8, female).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMotivated by a lack of expertise in dealing with terminally ill patients, students considered their participation a valuable and inspiring experience both on a professional and personal level. Although the students were not familiar with the course format, they approached the patient encounter with an open mind and adapted quickly. Overall, the course offered students a more holistic picture of the existential impact of terminal illness on the individual including social, psychological, and spiritual factors of disease. Likewise, the course positively influenced students\u0026rsquo; vision on end-of-life care. Offering a self-led learning experience, medical students could reduce insecurities and train their interpersonal skills which is expected to benefit their overall performance in palliative care [20,21]. \u0026nbsp;While the open character of the course is essential to facilitate the self-led exchange with patients, some students expressed criticism regarding the limited capacity for planning within the course. Likewise, some students missed having a defined assignment, which made them feel uncertain about their own role within the course.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs students\u0026rsquo; experiences within the course have shown, German medical students value reflective writing as a tool in experiential learning. Although widely applied in other countries such as the United Kingdom, reflective writing is not standard at German universities [22]. While many students in this study appeared to be naturally self-reflective, others mentioned difficulties in the writing process, which could also be seen in the rather descriptive character of those essays.\u0026nbsp;It might therefore be useful to provide medical students with guidelines for reflective writing to facilitate the process and deepen students\u0026rsquo; learning experience. Additionally, reflective skills will enhance students\u0026rsquo; capacity for professional development [12].\u003c/p\u003e\n\u003cp\u003eThe analysis revealed that students\u0026apos; motivations to participate have remained unchanged over the years. On one hand, the course content\u0026apos;s relevance has not diminished. On the other hand, students\u0026apos; insecurities in caring for palliative patients have remained despite continuous adjustments in the core curriculum. Studies in other European countries have yielded comparable findings [21,23]. One reason might be that young adults are generally less likely to have experienced losses at this stage of their life. While the variety of palliative care teaching formats has increased over the last years (beside-teaching, e-learning, simulated patients etc.), many German universities do not offer elective courses on palliative care at all [22]. Our findings underline the importance of experiential training as a tool to build up confidence for palliative care provision among medical students, which they should be offered to train besides their timely-limited curriculum [24].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are certain limitations to this study that need to be considered. Due to the descriptive nature of some of the reports, the overall depth of the analysis was variable. While the key themes arose in all analysed essays, the data needed to allow for a more in-depth analysis of the grounded theory approach (to identify underlying motives of observed patterns). Although participation was completely voluntary and no formal mark was given, it is not clear how truthful students were concerning their experiences and reflections as they might have intended to meet certain expectations. Yet, Ong (2002) suggests that any finished written text becomes removed from its author. This creates an independent discourse, and the text thus becomes a source for an independent analysis [X]. \u0026nbsp;Lastly, not all students who took part in the course handed in their reflective essay. While their reasons remain uncertain, it might be related to students\u0026rsquo; intensive curriculum.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u0026ldquo;The Patient as Teacher\u0026rdquo; represents a highly valued palliative care learning tool among German medical students demonstrating the added value of experiential learning in palliative care education. It offers students a more holistic picture of the existential impact of terminal illness on the individual including social, psychological, and spiritual factors of disease while positively impacting medical students\u0026rsquo; vision on end-of-life care. Moreover, it supports the students in overcoming insecurities in dealing with terminally ill patients and helps them to further develop their professional identity.\u0026nbsp;Overall, \u0026ldquo;The Patient as Teacher\u0026rdquo; is a valuable and inspiring experience for medical students both on a professional and personal level.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn assessment by the Medical Ethics Committee of RWTH Aachen was obtained for this study. All participants gave verbal informed consent. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo data or material can be made available due to privacy and ethical concerns. Those interested may contact the corresponding author for further information. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFE and SS were responsible for the study as well as the analysis and interpretation of findings. SB and PP were involved in drafting and revising the manuscript. All authors gave final approval to this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all participants of this study for their time and sharing of their experiences.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organisation [Internet]. Palliative Care. Key facts, 2020. https://www.who.int/news-room/fact-sheets/detail/palliative-care. Accessed 13 May 2023.\u003c/li\u003e\n \u003cli\u003eGamondi C, Larkin L, Payne P. Core competencies in palliative care: an EAPC White Paper on palliative care education \u0026ndash; part 2. Europ J Palliat Care. 2013;20(3).\u003c/li\u003e\n \u003cli\u003eIlse B, Alt-Epping B, Kiesewetter I, Elsner E, Hildebrandt J, Laske A, et al. Undergraduate education in palliative medicine in Germany: a longitudinal perspective on curricular and infrastructural development. 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Effects of a Ninety-Minute Teaching Module for Fourth-Year Medical Students on a Palliative Care Ward with Student\u0026ndash;Patient Encounter. J Palliat Med. 2011; doi:10.1089/jpm.2011.0025.\u003c/li\u003e\n \u003cli\u003eWells G, Youssef E, Winter R, Wright J, Llewellyn C. Medical student confidence in care of the dying and their family: a systematic review. BMJ Support Palliat Care. 2020; doi:10.1136/bmjspcare-2019-001977.\u003c/li\u003e\n \u003cli\u003eOhlmeier L, Scherg A, Ilse B, Elsner, F. Status of palliative care education in Germany: a survey of medical faculties in 2018. Schmerz. 2021; doi: https://doi.org/10.1007/s00482-021-00536-7.\u003c/li\u003e\n \u003cli\u003ePieters J, Dolmans DHJM, Verstegen DML, Warmehoven FC, Courtens AM, Van den Beuken-van Everdingen MHJ. Palliative care education in the undergraduate medical curricula: students\u0026rsquo; views on the importance of, their confidence in, and knowledge of palliative care. BMC Palliat Care. 2019; doi:10.1186/s12904-019-0458-x.\u003c/li\u003e\n \u003cli\u003eBoland JW, Brown MEL, Duenas A, Finn GM, Gibbins J. How effective is undergraduate palliative care teaching for medical students? A systematic literature review. BMJ Open. 2020; doi:10.1136/bmjopen-2019-036458.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"palliative care, undergraduate medical students, teaching, experiential learning, reflective writing","lastPublishedDoi":"10.21203/rs.3.rs-4777087/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4777087/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Experiential learning holds high potential for medical students’ education in palliative care. At RWTH Aachen University in Germany, medical students can participate in the course “The Patient as Teacher” offering a one-to-one exchange with a terminally ill patient over a period of several weeks complemented with four supervision sessions and writing of a reflective essay. The course had run from 2005-2020 before it was paused due to the Covid-19 pandemic. This study aimed to assess the course's value as a palliative care teaching tool by investigating students’ motivation and experiences over the years 2005-2020.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A stratified sample of 24 essays was taken from all submitted essays (n = 78), eight essays from the years 2005-2009, 2010-2014, and 2015-2020. Subsequently, a thematic analysis of the selected essays was conducted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The students felt motivated by the opportunity to gain more experience in palliative care, to improve their communication skills and to decrease insecurities in interaction with terminally ill patients. They learned about the patient’s biography and medical history, and encountered physical, psychological, social, and spiritual dimensions of living with a life-limiting disease. Moreover, they experienced relationship building and communication with a terminally ill patient outside their role as future doctors. Ultimately, they considered their participation as a beneficial experience on both a personal and professional level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The course “The Patient as Teacher” presents a valuable tool for experiential learning in palliative care, which has elicited an unceasingly positive response among the students who participated over the years. It has facilitated medical students in overcoming insecurities in dealing with terminally ill patients and supported them in further developing their professional identity.\u003c/p\u003e","manuscriptTitle":"“The Patient as Teacher” - thematic analysis of undergraduate medical students’ experiences with an experiential learning project in Palliative Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-16 07:34:07","doi":"10.21203/rs.3.rs-4777087/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-16T09:40:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-14T15:30:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-14T06:53:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-09T09:57:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2077161054307756817294525047244919195","date":"2024-08-07T01:58:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"154559107485847094476648645225424448226","date":"2024-08-01T13:13:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119452258200038040222384657388648132093","date":"2024-07-29T04:48:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-25T21:14:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-24T04:52:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-22T15:42:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-22T15:41:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2024-07-21T14:09:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"79afd1f1-6525-49ba-8cfc-b0cc601b60a4","owner":[],"postedDate":"August 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-14T15:58:55+00:00","versionOfRecord":{"articleIdentity":"rs-4777087","link":"https://doi.org/10.1186/s12904-024-01570-9","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2024-10-09 15:56:57","publishedOnDateReadable":"October 9th, 2024"},"versionCreatedAt":"2024-08-16 07:34:07","video":"","vorDoi":"10.1186/s12904-024-01570-9","vorDoiUrl":"https://doi.org/10.1186/s12904-024-01570-9","workflowStages":[]},"version":"v1","identity":"rs-4777087","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4777087","identity":"rs-4777087","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}