Downpours, Death, Degrees, Etc.

Pictures will simply never do the green of the English countryside justice.

Before I begin this post, I must add the disclaimer that education in the US – and the many ways it falls short – is one of my long-time roommates, Sage’s, favorite topics to tackle. In fact, I think we’ve rarely had a heated conversation concerning some issue in the US that doesn’t lead back to the education system. It’s almost become a running joke at this point; she’ll say don’t get me started and then proceed to verbally dismantle the entire system in one breath. As I sat ruminating over some of the ideas I will include here, I couldn’t help but laugh at her influence.

Yesterday, I had the privilege of attending the celebration of the official partnership between the university I am currently working with as a visiting researcher and a hospice in the community. Upon receiving the invitation to attend, I didn’t give too much thought to what the event would entail but I was very interested to see a local hospice and hear from some of the members of the staff.

Like many of my days recently, yesterday was filled with rain. However, as a professor and I drove towards the hospice, I was yet again stunned by the Northern English countryside. This is a type of green I’ve never seen before, and it just about makes up for the cold Autumn rain. I’ve had many of these moments recently as I walk around the area I am living where I realize the beauty of things that are often labeled ugly. For some, summer being ushered into immediate cold and wet weather is cause for frustration. But personally, as a visitor, I have found the routine of gray to be moody and poetic and my rain jacket to be a newfound comfort item. The gray, the rain, and the seasonal depression all make for a better backdrop against the intense green of the rolling hills and fields.

Similarly, as I arrived at the hospice, I was struck by the beauty of the physical space itself despite the connotations it begets. Between the garden room with large windows peering into a volunteer-kept traditional English garden, a chapel complete with commissioned paintings by community artists, several quiet family rooms, a puzzling area, a massage theater, and even a large game room for children, there was more life in the halls of this building than most places. Once again, I am struck by the way that physical spaces have the power to shift narratives and influence new thinking. Everything in the hospice felt so purposeful, down to the way the pull-out beds faced the patient beds or the newly commissioned “cuddle bed” was made large enough for last moments shared between partners.

When it was time for the ceremony, I wasn’t sure what to expect. Almost immediately though, my notebook was out and I was furiously jotting down ideas. In total, the event included speakers from both the University and the hospice. Each highlighted the importance of collaboration between centers for academic excellence and community health centers. This hospice particularly functioned as a pillar of the community; hospices in the UK are often funded through charity and this was no exception except that the community it’s located in is one of the poorest in the entire county. Despite this, the hospice is one of the best-funded and largest in the area.

Being away from home, I’ve spent a lot of time thinking about what makes a community, and in conversations with my host family, Char, and Rach, we’ve discussed how communities and being “neighborly” seem to be in decline. Even so, there seems to be much more sense of community in areas of England than back home in America. I once explained to Char that I have lived on my street for 23 years and have seen or spoken to my neighbors only a handful of times. She was shocked and I can understand why – almost every morning on my walk to catch the bus, I get hellos and waves and “you alright?” from almost everyone I pass. Char, Rach, and I have spent time discussing how community seems to disappear the more money is poured into a place; in other words, money makes people isolationist, more inclined to their private lives than those around them or the greater good of their community. Thus, it tracks that a hospice that depends on the support and donation of the community – both in time and money – would flourish in spite of being in the most under-resourced area of the county.

Anyway, I digress. As I was listening to the speakers talk, I was surprised to hear about the history of collaboration between the university and the hospice despite this celebration making the partnership “official.” With hospices being a disjointed piece of the medical system in the US, they aren’t connected to medical school clinical sites in the same manner that outpatient clinics or inpatient hospitals are. In fact, when trying to find examples of such partnerships in the US, the only thing that turned up was a 2002 journal from the Joan C. Edwards School of Medicine in West Virginia proposing a possible collaboration model. While one of the doctors from the hospice was speaking, she had two medical students who were there on rotation from the University stand. She referenced how the partnership affords early exposure to proper palliative and end-of-life care to medical students as well as emphasizes the importance of medical spaces created for and by the community it serves.

And here is where my Sage-inspired diatribe begins:

81.9% of nursing students in the US, in a study done in a 2021 report, said that their education surrounding end-of-life is insufficient. Another 2024 study with medical students found that the majority leave school unprepared to deal with people who have palliative and end-of-life care needs. And yet, despite this, the Association of American Medical Colleges (AAMC) only has a single mandate about end-of-life care and none regarding palliative care.  The single mandate is broad leading to “varied and uneven approaches, ranging from 2 hours in the classroom on EoL to weeks of palliative care training or hospice-based clinical rotations” (Horowitz et al). To further hammer this point home, the article that references this mandate is over 10 years old, published in 2014, meaning that the lack of formal curricula as mandated by the AAMC has been rather uninvestigated and unacknowledged since. Even with clinical health students demonstrating a need for a more comprehensive and unified end-of-life and palliative care education, there does not seem to be an overwhelming response or movement towards one by the institutions that provide the education themselves.

I question why end-of-life and palliative education is not more of a priority if there is a demonstrated desire by students and a demonstrated need for better care from patients and their families. I am not here, however, to say this is the fault of individual medical schools. The amount that has to be taught within four years to produce clinical healthcare workers is overwhelming. But sitting at this hospice-university celebration, I couldn’t help but wonder why more schools wouldn’t partner with hospice facilities in their communities. Hearing from the teaching doctors at the hospice and witnessing the students in this hospice space made me see the effect that teaching within a hospice can have on improving confidence and reducing fear when it comes to end-of-life care. If, as I have discussed in other posts, one of the major barriers to improving palliative and end-of-life care in the US is the cultural fear and avoidance of death then early exposure in a controlled setting could improve this drastically. An entire year or more of medical school is devoted to clinical rotations through different medical services and often in various clinical settings. So why couldn’t a hospice be one of these settings? Not only would this perhaps help clinical students feel more prepared for inevitable encounters with dying during their careers, but it also would show medicine outside the in-patient hospital setting. It could even have the potential to improve the “continuity” piece that I referred to in my last post; perhaps, if some training occurred in hospices and these university-hospice partnerships grew, the referral process to hospice would become more commonplace, comfortable, and less shrouded in mystery and fear. If I have said it once during my prep and journey this year so far, it starts with education. We can’t possibly hope for the system of medicine to change if we are not changing the way we teach it at all levels. If students in the US are asking for this type of education, perhaps this is one way to give it to them.

And, of course, it goes both ways because it is not only the students, I saw yesterday that are benefitting, but both the hospice and the university through reciprocally important research endeavors. By partnering with each other, the university can continue to conduct research with the hospice as a primary research site. Not only will this inevitably advance our academic understanding of the strengths and pitfalls of palliative and end-of-life care currently, but it will also help clarify to the hospice what is working for their patients and staff and where there can be improvement. As a member of the Observatory was presenting research that she has already conducted at the hospice, so many of the hospice staff present commented on the clarity it provided. The quantitative research explained a lot of what the staff felt they were experiencing but couldn’t put statistics to. In real-time, I could see the magic of academia when its powers are harnessed properly; this research showcased empirical evidence that helped clinical staff validate and understand their own experiences.

So maybe this was less of a pure rant and more of a rant about a hopeful way forward. I know it’s incredibly early in my Watson journey to already be considering ways to continue this research when I go home, but I can’t help but feel a pull towards education. I felt it before this week and even more so now after getting to participate in such a celebratory day. It was certainly one of many moments I’ve had thus far where I feel filled with gratitude for all that I have learned and witnessed; a day where the grass felt extra green.