Collaborative curriculum: Students develop clinical scenarios

Georgina De la Garza had only been a student at the Texas A&M Health Science Center (TAMHSC) College of Medicine for a year when she went home in summer 2012 to visit her family in Mexico, but the real world doesn’t always stagger challenges as predictably as licensing exams. She arrived home at a moment of familial crisis: Her grandmother was dying, and the medical director at her hospital was a firm believer in aggressive medical treatment, insisting on lifesaving measures even when they could significantly impair a patient’s quality of life.

“My grandma was suffering, and she told us she wanted to stop all of it, and go home and rest,” De la Garza said. “So we took her home.”

Mexico does not have widespread access to hospice care, and in the weeks that followed, the family turned to De la Garza as the expert who could help them navigate the complex and confusing decisions involved in palliative, or “end-of-life,” care, when goals shift from fighting off disease to maximizing the patient’s comfort in the last phase of life.

“I was the only one in my family with any medical background,” De la Garza said, but her family turned to her to assess each difficult decision. Should they give her IV fluids? A feeding tube? What about a blood transfusion, if her peptic ulcer started bleeding?

“I wanted my grandma to have a dignified death. I wanted her to be comfortable, and I didn’t want to prolong her suffering,” she said. “But I didn’t know what to do. Was withdrawing fluids and food the humane thing to do? Was a narcotic induced coma to relieve the pain ethical? It was all very hard.”

Second-year medical student Georgina De la Garza, left, consults with first-year student Jorge-Jayme Montes during a palliative care exercise. De la Garza assisted in developing scenarios for the new, experiential training.

Second-year medical student Georgina De la Garza, left, consults with first-year student Jorge-Jayme Montes during a palliative care exercise. De la Garza assisted in developing scenarios for the new, experiential training.

Despite a few lectures on palliative care in her first year of medical school, she admitted, “I really didn’t know anything about what to do in these cases. My grandma’s disease made me realize I needed to learn more…for my own sake and for the sake of my future patients.”

The next fall, De la Garza asked Dr. Craig Borchardt, an assistant professor in the medical school’s Department of Humanities in Medicine and the head of Hospice Brazos Valley, to mentor her as part of a second-year mentorship opportunity. Dr. Borchardt suggested she work with another student, Charis Santini, who had participated in a summer fellowship program on end-of-life care, to develop palliative care scenarios for students to experience in the TAMHSC’s Clinical Learning Resource Center in Bryan, a simulation lab where students were already using sophisticated equipment to simulate medical emergencies and doctor-patient interactions using mechanical and computer simulations and local actors.

Under Dr. Borchardt’s guidance, De la Garza and Santini spent time between anatomy labs, lectures and study sessions writing scenarios for a pair of exercises. First- and second-year students would have exercises appropriate for their level of training, and each exercise would require dozens of case studies—each a “character” with his or her own case presentation, complicating factors, and personal and family details to script.

The workload was, as Santini put it, “a bit of a challenge,” but also helped reinforce what she was learning in the rest of her classes. “It was a great experience to be able to incorporate everything we had learned in other blocks to develop the cases,” she said.

The first- and second-year students, or “M1s” and “M2s,” each face two distinct challenges in the new curriculum. For first-year students, one scenario involves visiting with and examining a patient and determining whether the patient is actively dying; in the other, they must have a difficult conversation with a patient to help them develop an advance directive.

Second-year students must assess patients’ appropriateness for hospice care, an important distinction for Medicare eligibility and coverage for hospice services. They also face perhaps the most unnerving challenge: Delivering the news to a patient that he or she is dying, or delivering news to a loved one that a patient has died.

Each group also has small-group discussions on separate occasions. For M1s, the focus is on practical topics like pain management, hydration and nutrition, and sedation. M2s discuss ethical issues in palliative and hospice care.

After months of research, writing, reviews by members of the Hospice Brazos Valley team of physicians and nurses, and copious revisions, the students were ready for the next phase of their curricular experiment: Piloting the scenarios with the Bryan-College Station campus’ first- and second-year classes.

“Georgina and Charis will leave a significant legacy in advancing our college’s mission to train students,” Dr. Borchardt said.

All that was left was see if it worked.

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To read Part 2 of this two-part story, click here.

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