Grief and Coping Education in US Preclinical Medical Curricula: Findings from an Exploratory Survey

Abstract

Background

Physicians frequently experience emotional distress and grief in response to patient suffering and death. Collective professional experience suggests that while these emotions may be burdensome, the skills needed to cope with these emotional realities develop gradually, through repeated exposure and structured reflection. Although many US medical schools now include end-of-life (EOL) teaching in their preclinical curricula, much less attention is paid to how medical trainees learn to develop healthy coping strategies to address these emotions.

Purpose

This exploratory survey examined how US medical schools address physician grief and coping during the preclinical years, defined as the educational phase before supervised clinical settings or clerkships.

Methods

A 30-item questionnaire was sent to a course director, academic dean, or other curricular leader at 192 Liaison Committee on Medical Education (LCME) accredited M.D. and Commission on Osteopathic College Accreditation (COCA) accredited D.O. schools in the US between November and December 2024. Survey items addressed the prevalence, format and depth of grief and coping-related instruction, as well as a broader EOL education. Responses were summarized using descriptive statistics.

Results

Ten institutions provided completed responses (response rate 5.2%). Among the responding institutions, 70% reported integrating EOL content into required courses, however instruction on physician grief and coping was limited. In total, 60% of respondents provided fewer than five hours devoted to coping, and most lacked a structured curriculum on the topic. Opportunities for reflection and faculty-led discussions about student well-being varied. Only one institution reported a curriculum committee on physician grief and coping.

Conclusions

Among responding institutions, structured grief and coping education in the preclinical years appears limited relative to the broader inclusion of EOL education. Our findings highlight variability in how US medical schools address the emotional dimensions of medicine and suggest opportunities for further investigation and curricular development. Integrating grief and coping education into preclinical curricula may ultimately support both professional identity formation and physician wellbeing.

Keywords

Medical education student well-being end-of-life care physician grief coping strategies professional identity formation

Introduction

Since 2000, research has increasingly shown that physicians experience significant stress, depression, and burnout, all of which can affect patient care.^1–3 Dealing with patient loss, and delivering difficult news to patients with significant suffering, are particularly challenging, and often cause considerable mental distress, including depression, anxiety, and irritability.^4–5 Recognizing the impact of these challenges on both physicians and patients, the Liaison Committee on Medical Education (LCME) suggested a new standard in 1998 to better address physician competence around end-of-life (EOL) care and palliative care.⁶ In response, medical schools have since widely incorporated EOL and palliative care content through lectures, modules, Objective Structured Clinical Examinations (OSCEs), workshops, and simulated patient encounters, all aimed at developing humanistic communication skills.^7–9

These educational efforts are crucial in early training as medical students begin to form their professional identities and develop coping strategies that they will use for the rest of their careers. It is important to recognize that coping strategies leading to emotional resilience take time to develop, and broad anecdotal evidence also reinforces the value of providing structured opportunities for students to cultivate these skills early in their training.¹⁰ Traditional US medical education includes two preclinical years focused on didactic learning and two clinical years emphasizing clerkships. Curricular content and timing vary, and some newer models include problem-based learning and earlier clinical exposure.¹¹ As mentioned before, medical training not only delivers clinical skills and knowledge but also shapes professional identity. Professional identity formation (PIF) is the process through which medical students internalize the values, behaviors, and norms of the medical profession.¹² In this context, structured emotional coping and grief education is necessary so students may develop healthy processing strategies, potentially influencing how they integrate emotion and empathy into their developing professional identities.

Although there is some data on EOL and palliative education,¹³ studies examining formal instruction on physician grief and coping are limited. Moreover, our review highlights a notable gap in the literature on this topic since 2020. There is some evidence, largely anecdotal, that suggests that students often learn these coping skills informally, influenced by attending physicians, peers, and postevent debriefings. In residency programs, debriefings are offered inconsistently,¹⁴ which may reflect similar gaps in medical school. Introducing coping skills during preclinical years could help students manage the emotional challenges of clinical training.¹⁵ This survey aimed to assess curricular patterns regarding grief and coping education during preclinical years, defined as educational years where medical students are not in supervised clinical settings or clerkships, in Liaison Committee on Medical Education (LCME) accredited M.D. and Commission on Osteopathic College Accreditation (COCA) accredited D.O. medical schools.

Methods

This cross-sectional survey targeted preclinical curriculum leadership at US-based allopathic and osteopathic medical schools. Eligible schools were identified based on accreditation by the LCME or the COCA as of July 1, 2024, resulting in 192 eligible institutions. One individual per institution, identified as a course director, academic dean, or other curricular leader, was invited to participate. Participants were identified using publicly available institutional websites and directories. Institutions outside the United States, including Caribbean medical schools, as well as residency programs, were excluded.

Given the lack of existing instruments focused specifically on preclinical physician grief and coping education, a novel instrument was necessary. Similarly, our survey instrument was not adapted from previously validated questionnaires. To ensure relevance to contemporary preclinical curricula, survey items were developed by the authors, with one author involved with teaching responsibilities at a US medical school, and the other author a third-year medical student at the time of survey instrument creation. Draft survey items underwent internal review and refinement by the authors prior to distribution to improve clarity and content validity. The survey was not pilot-tested prior to administration, which is consistent with its exploratory design. No formal sample size or power calculation was performed, as the study was designed as an exploratory survey intended to generate preliminary data about grief and coping education in US medical schools. This study is not intended to provide evidence for interventions at this time.

The final survey instrument consisted of 30 items, and included multiple-choice, yes/no, one Likert scale item, and 5 optional open-ended questions. The survey length was intentionally selected to balance the breadth of curricular information collected with the need to minimize respondent burden and promote participation. The primary outcome variable was the presence of dedicated curricular content specifically addressing physician grief and coping in the preclinical curriculum, defined as structured, instructional time explicitly focused on physician experiences of grief, patient loss, or coping strategies. Secondary variables included format of instruction, duration of curricular content, integration within broader EOL education, teaching methods, and cultural competence education.

The survey was administered electronically using Research Electronic Data Capture (REDCap), and all 192 eligible institutions were contacted by email. To reduce potential nonresponse bias, a reminder email was sent four weeks after the initial invitation. Data collection occurred between November and December 2024, and data were analyzed in the beginning of January 2025. This study did not assess faculty or student impressions. Participation was voluntary and completing the survey implied consent. Because only one respondent per institution was surveyed, responses may reflect individual interpretation of curricular content. No independent verification of reported curricula was performed. The reporting of this study conforms to The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guidelines for cross-sectional studies, and a checklist is available in Supplemental Files S1. The study was reviewed and deemed exempt by the institutional review board of New York Institute of Technology (NYIT IRB-2025-171).

Statistical Analysis

Data were exported from REDCap and analyzed using Microsoft Excel. Descriptive statistics were used to summarize survey responses; only frequencies and percentages were calculated for categorical variables. No inferential statistical analyses were performed, consistent with the exploratory nature of the study and the small sample size. Likert scale responses were not analyzed or included in data interpretation due to low response rate. Open-ended responses were reviewed descriptively and were not subjected to formal qualitative analysis. Data from incomplete or partially completed surveys were excluded from analysis. A survey was considered incomplete if the survey was only partially completed, even if the primary outcome item was answered.

Results

Seventeen institutions either provided complete or incomplete responses. Seven incomplete surveys were excluded from analysis, resulting in ten completed responses, yielding an adjusted response rate of 5.2%. Both M.D. and D.O. programs were represented equally, with five schools of each type. Most schools (60%) reported a preclinical curriculum of 12 to 18 months, while the remaining 40% had 18 to 24 months. All schools used lectures to teach cultural competence, and most also included lab sessions (90%), small discussion groups (90%), and OSCEs (90%). Other methods, such as problem-based learning (70%) and supervised preceptorships (60%), were used less consistently (Table 1).

Table 1.

Preclinical Curriculum and Teaching Methods (n = 10).

Category	Subcategory	Number (%) of Schools
Length of preclinical curriculum	12-18 months	6 (60%)
	18-24 months	4 (40%)
Delivery methods in medical education	Lectures	10 (100%)
	Lab sessions	9 (90%)
	Small discussion groups	9 (90%)
	Objective structured clinical examinations (OSCEs)	9 (90%)
	Problem-based learning	7 (70%)
	Supervised preceptorships	6 (60%)
	Other	2 (20%)

70% of respondents include EOL care in core courses, while 30% addressed it through occasional lectures or workshops. Most institutions integrated death and dying topics into existing courses (70%), with a smaller portion using standalone modules (20%) or being unsure (10%). Sixty percent of schools reported dedicated communication training for EOL care, while 20% offered interspersed training and 20% offered none. Clinical exposure to palliative and hospice care was limited: Only 20% of schools offered specific experiences, 30% had limited opportunities, and 50% provided none. Only 20% of institutions emphasized cultural competence in EOL training, while 70% acknowledged limited focus, and 10% were unsure (Table 2).

Table 2.

End-of-Life (EOL) Care Education (n = 10).

Category	Subcategory	Number (%) of Schools
Where EOL care topics are explored	Part of core curriculum	7 (70%)
	Occasional lectures/workshops	3 (30%)
	Integrated into existing courses	7 (70%)
	Standalone modules	2 (20%)
	Unsure	1 (10%)
Communication training in EOL care	Dedicated/standalone training	6 (60%)
	Interspersed training	2 (20%)
	No specific training	2 (20%)
Clinical exposure to EOL care	Specific experiences	2 (20%)
	Limited opportunities	3 (30%)
	No experiences	5 (50%)
Cultural competence in EOL care	Emphasized	2 (20%)
	Limited focus	7 (70%)
	Unsure	1 (10%)

Instruction on coping with grief and stress was minimal, with 60% of schools offering fewer than five hours. Most schools (60%) did not include physician grieving or coping in the formal curriculum. Faculty engagement on self-care and student mental health was inconsistent, with only 30% reporting frequent discussions. Elective courses on grief and resilience were available in 20% of schools. Opportunities for reflective practice on patient loss were present in 40% of schools, limited in another 40%, absent in 10%, and unknown in 10%. Forty-percent of schools reported curriculum changes in response to burnout and the need for coping education. Only one school had a curriculum advisory committee focused on physician grief, while 30% had considered such a committee and 50% had not considered it (Table 3). Responses to optional open-ended questions regarding barriers, coping, and EOL education are summarized in Table 4. Open-ended responses were not subject to statistical analysis. The survey included one Likert-scale item designed to explore perceptions regarding curricular emphasis and future changes. However, given the limited number of responses and the descriptive aims of the study, these data are not reported or analyzed.

Table 3.

Grief, Stress, Coping and Resilience Education (n = 10).

Category	Subcategory	Number (%) of Schools
Duration of education on coping with grief/stress	<5 h	6 (60%)
	5-10 h	1 (10%)
	Unsure	3 (30%)
Inclusion of physician grieving/coping in curriculum	Included	4 (40%)
	Not included	6 (60%)
Faculty engagement in self-care/mental health	Frequent	3 (30%)
	Occasional	2 (20%)
	Rare	2 (20%)
	Unsure	3 (30%)
Elective courses on grief/resilience	Available	2 (20%)
	Unavailable	8 (80%)
Opportunities for reflective practices on patient loss	Present	4 (40%)
	Limited	4 (40%)
	Absent	1 (10%)
	Unknown	1 (10%)
Curriculum changes for coping education	Made changes	4 (40%)
	No changes	6 (60%)
Curriculum committees on physician grief education	Established	1 (10%)
	Considered but no committee	3 (30%)
	Not considered	5 (50%)

Table 4.

Summary of Optional Open-Ended Survey Responses: Barriers, Changes, and Initiatives in Preclinical Physician Coping and End-of-Life (EOL) Education.

Theme/Question	Key Findings	Representative Quotes
Barriers to preclinical physician grieving and coping education	Respondents indicated that EOL content is more appropriate for clinical years due to limited patient exposure during preclinical years; some noted basic discussion exists preclinically	“This topic is most likely to be covered in the clinical years, and in a transition to residency course.”“We discuss grief/coping now—anything further would be better situated in the clinical curriculum.”
Recent changes to preclinical coping and emotional well-being education	Increased reflective writing and small group exercises; structured palliative care experiences including shadowing, peer/small group debriefing, reflection, and elective sessions; some respondents indicated complete changes to curriculum.	“We have more reflective writing and deliberate small group process that directly addresses how different elements of medicine make the students feel.”“As part of the new 4-year curriculum in palliative care, all students shadow in a palliative care clinical environment. They then debrief with a peer, write a reflection and then debrief again in a small group setting… The palliative care specialty interest group also runs an elective yearly session on grief and bereavement.”“Our entire curriculum was renewed beginning in 2020.”
Recent initiatives in EOL and palliative care education	Some respondents indicated the integration of EOL content into new or existing palliative care curriculum; some schools reported minimal or no changes.	“We recently updated and integrated this with some palliative care as well as adding integrated panels.”“We have designed our longitudinal palliative care curriculum to begin to address coping strategies with second-year medical students … with more opportunities during the clinical years.”“Curriculum generally only changes minimally year to year, unless there are bigger changes warranted.”

Discussion

Despite growing attention to physician burnout and student wellbeing, how medical education prepares trainees to navigate emotionally distressing events and grief remains underexamined. Medical schools have increasingly emphasized end-of-life and palliative care education, yet far less attention is paid to how students process the emotional toll of this work, or how they cope with loss. While EOL education often emphasizes patient-centered communication and clinical decision-making, it does not inherently address the physician's internal emotional response to loss or grief. Without intentional preparation which equips students with skills to recognize and process these emotions, early unstructured experiences with patient loss may shape professional identity in ways that support emotional detachment over resilience. This pilot survey was developed to examine how medical schools address grief and coping education specifically during preclinical years, and allows us to frame this issue as an educational concern, but also as a matter of long-term physician wellbeing and comprehensive patient care. Our findings suggest that while most of the responding institutions include EOL content into preclinical curricula, substantially fewer provide instruction on physician grief, emotional resilience, and offer opportunities for reflective practices, despite growing evidence that these skills are essential for supporting mental health and preventing burnout.¹⁶

Prior research suggests that experiential learning through real patient encounters, simulations, or structured debriefings helps students develop empathy, strengthen communication, and manage their emotions when faced with dying patients.^17–19 Among the institutions that responded to our survey, 70% reported integrating EOL care into preclinical courses, but only 20% offered dedicated clinical experiences during those preclinical years that allow students to develop the know-how to work with this patient population in emotionally healthy ways (Table 2). This finding highlights the gap between classroom preparation and real-world practice. This is interesting considering programs such as the End-of-Life Nursing Education Consortium (ELNEC), originally designed for nursing schools, have already demonstrated how longitudinal, structured experiential training can improve competencies for nurses, and could inform similar approaches in medical education.²⁰

Perhaps the clearest gap lies in formal education on physician grief and coping. Sixty percent of responding institutions reported fewer than five hours devoted to this topic, and most offered no structured curriculum at all (Table 3). This finding is concerning given the evidence that physicians frequently experience “professional bereavement” after patient deaths, which may include guilt, helplessness, and withdrawal, all of which contribute to burnout.²¹ Responses to optional open-ended questions indicate that preclinical exposure to physician grieving, coping, and end-of-life care is limited in part because many respondents perceive these topics as more appropriate for clinical years (Table 4). While this rationale is understandable, it nonetheless raises an important concern: Without explicit instruction on grieving and coping before clinical years, trainees during their clinical years may often rely on a “hidden curriculum,” referring to the informal lessons, values, and behaviors that trainees learn indirectly through observation and workplace culture rather than through formal instruction. Because emotional literacy develops gradually over time, delaying structured education on emotional responses until clinical years, or failing to formally deliver this education entirely, may mean that some trainees never receive this training at all. Introducing it later, during busy, high-stakes clinical rotations or residency, can be even more challenging and further limit opportunities to develop healthy coping strategies before exposure to emotionally demanding situations. In fact, literature examining how residents process distressing events further suggests that structured experiences to process grief may continue to be limited in busy clinical settings, where significant emotional challenges are more likely, and may normalize emotional detachment as the default coping strategy.¹⁴ Taken together, without structured grief and coping education provided earlier in training, perhaps some medical students are left to navigate their emotional responses to difficult scenarios without much guidance, potentially contributing to emotional burnout, and hindering PIF.

Our data also suggest that cultural competence training is widely taught in medical education, but its application to EOL education remains limited. Only 20% of responding institutions emphasized this aspect, despite evidence that culturally sensitive communication is crucial for supporting patients and families during bereavement.²² Because studying cultural competence education was not the primary focus of our survey, our preliminary findings about cultural competence education should be interpreted cautiously, and further investigation is necessary to understand how cultural considerations are integrated into education on EOL, grief, and coping. Nonetheless, innovative approaches such as peer-led workshops, narrative medicine, and reflective writing have been shown to improve cultural competence in EOL care while also fostering emotional resilience.²²

These findings we report should be interpreted with caution in light of several important limitations. First, the survey instrument was novel, not formally validated and not pilot-tested prior to administration, which is consistent with the instrument's exploratory nature. This could have influenced how participants interpreted items and may have affected the depth and focus of the open-ended responses. Second, of the 17 total survey responses we received, 7 were excluded due to incompletion, resulting in a small sample size with a response rate of 5.2%. This limits the generalizability of our findings, and raises the possibility of response bias, as participating institutions may have had particular interests in EOL and or wellness education. Furthermore, because all survey responses were fully anonymous and did not include institutional identifiers, it was not possible to compare respondent and nonrespondent schools or assess differences in curricular characteristics between these groups. Third, the survey's length of 30 questions and its distribution during November and December, when many academic leaders are managing end-of-term responsibilities, may have further limited engagement. Therefore, our findings should be viewed as preliminary and idea-generating rather than descriptive of US medical education more broadly.

Still, even with these limitations, the survey highlights patterns that deserve attention. In fact, the low participation itself may reflect how coping and grief education remains at the periphery within many medical school curricula. While national data suggest that most US medical schools include some instruction on death and dying, the depth, structure and scope of these efforts vary widely.¹⁵ Without coordinated frameworks, opportunities for reflective practice and structured emotional support remain inconsistent.^23,24

Several structural barriers may further limit the integration of grief coping education into preclinical curricula. Key challenges include time constraints within an already dense curriculum, competing educational priorities, and limited faculty expertise in teaching grief and coping skills (Table 4). Although no responding institution reported a comprehensive or standardized approach, some noted ongoing curricular efforts such as reflective writing, small group discussion, shadowing palliative care and elective sessions of grief, demonstrating efforts to introduce coping strategies early. Still, some respondents report minimal or no changes to their institution's curriculum (Table 4). These efforts suggest increasing awareness of the importance of preparing students to cope with the emotional tolls of the job.

At present, the field remains at an early, descriptive stage, and additional foundational work is needed before interventions can be meaningfully pursued. Future research should build on these preliminary findings through the development of a refined survey instrument and the incorporation of qualitative methods, such as interviews with curricular leaders, to more deeply explore institutional decision-making, perceived barriers, and educational priorities. Such approaches may provide richer contextual data and inform the development of evidence-based curricular interventions. Lastly, collaborations with national organizations like the American Association of Medical Colleges (AAMC) or the American Association of Colleges of Osteopathic Medicine (AACOM) could allow for more expansive data collection and subsequent guideline development. Adapting existing programs such as ELNEC and integrating grief education into competency frameworks like the Accreditation Council for Graduate Medical Education Milestones or AAMC Entrustable Professional Activities could help further standardize instruction.^20,25,26

Conclusion

Taken together, our results suggest that medical schools could do more to prepare students for the emotional realities of medicine. The most important contribution of this pilot study is its identification of a persistent gap between the expanding presence of end-of-life (EOL) education in medical curricula and the limited attention paid to how medical students are prepared to cope with grief and loss in a professional capacity. These findings highlight the need for more detailed and systematic information about the nature, scope, and drivers of grief-related education in undergraduate medical training. Although additional foundational work is needed to guide future intervention development, delaying attention to this issue risks prolonging a recognized educational gap.

As such, we suggest several feasible changes that can be incorporated into existing medical school curricular frameworks without major restructuring or additional clinical burden. First, small curricular changes, such as structured reflection sessions, facilitated debriefings, or resilience-focused workshops, may help normalize grief as part of professional identity formation (PIF) and provide students with healthier coping strategies. These approaches can foster emotional self-awareness, peer support, and adaptive coping skills that are foundational to long-term professional wellbeing. Beyond isolated sessions, integrating grief and coping education across multiple points in the curriculum can reinforce its importance and provide repeated opportunities for learning and reflection. For instance, briefly addressing the emotional impact of delivering difficult diagnoses within a pathology module can create space for open dialogue and normalize these challenging experiences as part of clinical training. This type of careful integration reinforces the idea that emotional processing is not separate from clinical competence, but rather central to it. In addition, collaboration between medical education leaders will be critical to ensure that physician grief and coping education is not left to chance but is embedded into core medical training for all students.

Ultimately, the skills needed to cope with grief are crucial to PIF. Thoughtful incorporation of structured reflection and experiential learning during the preclinical years may better equip students to navigate emotionally challenging clinical experiences while maintaining empathy and a strong commitment to patient care. One concrete step to help achieve this goal could be dedicating a week between preclinical and clinical years to help students practice navigating the emotional realities they are likely to face on the wards. Similarly, an additional week in the final year could ensure that this vital training is reinforced, this time after personal experience, before students enter residency. This graduated exposure acknowledges that emotional literacy, and grief and coping processing evolves with time and experience and warrants intentional revisiting. More broadly, the findings from this survey should serve as a call to more meaningfully integrate physician grief and coping education within the context of existing, patient-focused death and dying curricula. In doing so, medical schools have an opportunity to support student wellbeing and develop competent and emotionally sound physicians. These are the types of physicians who can sustain meaningful engagement with patients and families over an entire arc of patient presentations, illnesses, and loss.

Supplemental Material

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Supplemental material, sj-pdf-1-mde-10.1177_23821205261435459 for Grief and Coping Education in US Preclinical Medical Curricula: Findings from an Exploratory Survey by Vineet Vishwanath and Maria M Plummer in Journal of Medical Education and Curricular Development

Supplemental Material

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Supplemental material, sj-docx-2-mde-10.1177_23821205261435459 for Grief and Coping Education in US Preclinical Medical Curricula: Findings from an Exploratory Survey by Vineet Vishwanath and Maria M Plummer in Journal of Medical Education and Curricular Development

Footnotes

ORCID iDs

Vineet Vishwanath

Maria M. Plummer

Authors’ Contributions

Both authors contributed to the conceptualization of the manuscript. Mr Vishwanath conducted survey administration, data collection, data analysis, and drafting of the manuscript. The contents of this manuscript, and analyses and interpretations within were prepared solely by the authors, without the use of generative AI or other automated writing tools.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Departmental funding was procured to support publication fees.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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