Two-Dimensional Deaths? A Discourse Analysis of Patient Death in Preclinical Tutorial Cases at a Canadian Medical School.

Abstract

Introduction: The prospect of death is everywhere, but seldom directly addressed, in undergraduate medical education (UGME). Despite calls for UGME curricula to address the complex social and emotional aspects of death and dying, most curricula focus on biomedical, legal, and logistical aspects, or concentrate these topics within palliative care content and/or in simulations with simulated patients and manikins. We aimed to add to death education scholarship by exploring the complexities of death and dying within two dimensional simulations-i.e., in the text-based cases used in Case-Informed-Learning (CIL). Method: We conducted a critical discourse analysis exploring how death and dying were discursively constructed in the formal, planned curriculum at one medical school. We used two methods: (1) Document Analysis: We developed a template to analyze 127 cases regarding their discursive constructions of death and dying; (2) Longitudinal Interviewing: We conducted semi-structured interviews with a cohort of 12 medical students, twice annually throughout their medical program (total 92 interviews). We collectively analyzed data, attuning to how the format, content, and purpose of each case discursively constructed death and dying. Results: There were 127 tutorial cases included in the undergraduate, pre-clerkship case-informed curriculum. In the five (4%) cases featuring a patient who dies, death and dying were discursively constructed as: (1) predictable; (2) a plot device; (3) a cautionary tale; (4) an epilogue; (5) deliberate and careful; and (6) an absence. Very few cases highlighted death and dying in their titles, learning objectives, or questions, and where it did feature, it was framed a biomedical fact or outcome. Only one case allowed for a nuanced, in-depth and open-ended discussion of patient death and dying, but it was scheduled at a time that prevented meaningful engagement. This glossing over the complexities of death was identified as a missed opportunity by students, who, as their clinical placements loomed, were eager to broach this topic in detail with tutors and other teaching faculty. Discussion: Death was often a conspicuous absence in this CIL curriculum. In the few cases that featured the death of the main patient character, multiple discourses were mobilized that worked together to construct death as something that happens elsewhere, outside the parameters of core curriculum. In other words, death happens-predictably, slowly, as a means to an end and the result of moral failures, in the case or somewhere in the future-but was not the primary concern. To deepen engagement with these subjects in CIL, we encourage medical educators to attend to representations of patient death by considering the format, content, purpose, and timing of these cases. Conclusion: Carefully rendered cases thoughtfully embedded in the curriculum offer tremendous potential. We suggest nuanced cases featuring patient death, with plenty of space and time for discussion, reflection, and storytelling may help address gaps in formal UGME preclinical curricula addressing death and dying.