Abstract
Introduction
Medical students may encounter patient death during clinical training, yet formal education on processing these experiences remains limited. Witnessing patient death can evoke a range of emotional responses and concerns, requiring effective coping strategies during an already demanding period of training. The extent to which clinical clerkships alone prepare students to navigate patient death remains unclear. We analyzed pre- and post-clerkship survey data to assess changes in medical students' confidence, emotional responses, coping strategies, and concerns related to patient death.
Methods
We conducted pre- and post-clerkship surveys of MD2027 students at Eastern Virginia Medical School at Old Dominion University. Anonymous REDCap surveys administered at the beginning and end of the clerkship year assessed expectations and experiences regarding patient death. Outcomes included confidence in managing patient death, emotional responses, coping strategies, and related concerns.
Paired and aggregate responses were compared using paired analyses and chi-square tests. Free-text responses were independently reviewed and categorized into themes within three domains: emotions, concerns, and coping strategies. Responses could be assigned to multiple categories. Cohen's κ was used to assess inter-rater reliability.
Results
Twenty-one students completed the pre-clerkship survey, and 13 completed the post-clerkship survey, yielding 13 paired responses. Ten respondents (76.9%) experienced the death of a patient during clerkship.
Confidence was measured using a 5-point Likert scale. Five students gained confidence (38.5%), six lost confidence (46.2%), and two reported no change (15.4%). No students reported complete confidence before clerkship, whereas four did afterward. Students experiencing their first patient death gained a median of 1 point in confidence, while those with prior exposure lost a median of 0.5 points.
Emotional themes included grief/sadness, guilt/empathy, anger/distress, and shock/emotional detachment. Grief/sadness was the most common anticipated and experienced emotion. Shock/emotional detachment remained uncommon (3 pre-clerkship vs. 2 post-clerkship responses). Inter-rater agreement was nearly perfect (κ=0.98).
Coping themes included physical self-care, mindfulness/reflection, social support, and avoidance/suppression. Social support was anticipated more often than utilized, while mindfulness/reflection was the most frequently reported coping strategy. Inter-rater reliability was nearly perfect (κ=0.98).
Concerns centered on family communication, emotional impact, desensitization, and effects on patient care. Reported concerns decreased across all categories after clerkship. Inter-rater reliability was substantial (κ=0.80).
CONCLUSIONS: Clinical exposure to patient death had a variable impact on students' confidence. While some students gained confidence, others lost confidence, suggesting that clinical experience alone may not adequately prepare students for the emotional, practical, and professional challenges of patient death. Despite limited statistical power, findings suggest increased variability in confidence following clinical exposure, differences between anticipated and experienced emotions, stable coping patterns, and fewer concerns related to patient death. These results indicate that formal education may be needed to complement clinical experience. We developed a targeted educational intervention addressing grief normalization, emotional responses, coping strategies, healthcare team roles, postmortem care, family communication, and interdisciplinary support. Future evaluation will assess its impact on student confidence, preparedness, and ability to process patient death.