Original Article
Adapting Existing Resources for Serious Illness Communication Skills Training for Internal Medicine Residents
Abstract
Objectives: Goals of care discussions are a vital component of patient care, but Internal Medicine residents receive limited training in these skills. Existing curricula often require simulated patients or faculty development, limiting implementation in many residency programs. Thus, we developed and implemented a curriculum leveraging existing educational resources with the goal of improving resident attitudes and confidence in conducting goals of care discussions in training settings.Methods: We developed cases and a detailed faculty guide for small-group discussion with three exercises to standardize the learner experience and minimize the need for faculty development. Exercises introduced established communication skill frameworks including SPIKES (setting, perception, invitation, knowledge, empathy, summary) and REMAP (reframe, emotion, map, align, propose a plan) for how to break bad news, respond to strong emotions, and conduct a goals of care discussion. Participants were 163 Internal Medicine postgraduate year 1, -2, and -3 residents at a large urban academic institution, where residency-wide curriculum is delivered in weekly half-day didactic sessions during the course of 5 weeks. Primary outcomes were resident self-reported confidence with goals of care communication skills.
Results: A total of 109 (response rate 67%) of residents reported improvement in overall confidence in goals of care discussion skills (3.6 ± 0.9 vs 4.1 ± 0.6, P < 0.001), responding to emotions (3.5 ± 0.9 vs 3.9 ± 0.6, P = 0.004), making care recommendations (3.5 ± 1.0 vs 3.9 ± 0.7, P < 0.001), and quickly conducting a code status discussion (3.6 ± 1.0 vs 4.0 ± 0.7, P < 0.001). Residents also expressed an increased desire for supervision and feedback to further develop these skills.
Conclusions: This goals of care communication curriculum improves resident confidence and requires minimal resources. It may be ideal for programs that have limited access to simulated patients and/or faculty trained in communication skill simulation, but desire enhanced education on this important aspect of patient–doctor communication and high-quality patient care. Future studies measuring clinical outcomes and changes in learner behavior as a result of this intervention are needed. Ongoing observation and feedback on these skills will be important to solidify learning and sustain impact.
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References
1. Carayon P, Weinger MB, Brown R, et al. How do residents spend their time in the intensive care unit? Am J Med Sci 2015;350:403–408.
2. Miller DC, McSparron JI, Clardy PF, et al. Improving resident communication in the intensive care unit. The proceduralization of physician communication with patients and their surrogates. Ann Am Thorac Soc 2016;13:1624–1628.
3. Sharma R, Jain N, Peswani N, et al. Unpacking resident-led code status discussions: results from a mixed methods study. J Gen Intern Med 2014;29:750–757.
4. Loertscher L, Beckman T, Cha S, et al. Code status discussions: agreement between internal medicine residents and hospitalized patients. Teach Learn Med 2010;22:251–256.
5. Billings ME, Curtis JR, Engelberg RA. Medicine residents’ self-perceived competence in end-of-life care. Acad Med 2009;84:1533–1539.
6. Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med 2007;167:453–460.
7. Levy D, Strand J, McMahon G. Evaluating residents' readiness to elicit advance care plans. J Grad Med Educ 2015;7:364–368.
8. Tulsky JA, ChesneyMA, Lo B. See one, do one, teach one? House staff experience discussing do-not-resuscitate orders. Arch Intern Med 1996;156:1285–1289.
9. Chung H-O, Oczkowski SJW, Hanvey L, et al. Educational interventions to train healthcare professionals in end-of-life communication: a systematic review and meta-analysis. BMC Med Educ 2016;16:131.
10. Siddiqui MF, Holley JL. Residents' practices and perceptions about do not resuscitate orders and pronouncing death: an opportunity for clinical training. Am J Hosp Palliat Med 2011;28:94–97.
11. Einstein D, Einstein K, Mathew P. Dying for advice: code status discussions between resident physicians and patients with advanced cancer—a national survey. J Palliat Med 2015;18:535–541.
12. Buss MK, Alexander GC, Switzer GE, et al. Assessing competence of residents to discuss end-of-life issues. J Palliat Med 2005;8:363–371.
13. Smith L, O'Sullivan P, Lo B, et al. An educational intervention to improve resident comfort with communication at the end of life. J Palliat Med 2013;16:54–59.
14. Sullivan AM, Rock LK, Gadmer NM, et al. The impact of resident training on communication with families in the intensive care unit. Resident and family outcomes. Ann Am Thorac Soc 2016;13:512–521.
15. Hope AA, Hsieh SJ, Howes JM, et al. Let's talk critical. Development and evaluation of a communication skills training program for critical care fellows. Ann Am Thorac Soc 2015;12:505–511.
16. Szmuilowicz E, el-Jawahri A, Chiappetta L, et al. Improving residents’ end-of-life communication skills with a short retreat: a randomized controlled trial. J Palliat Med 2010;13:439–452.
17. Allenbaugh J, Corbelli J, Rack L, et al. A brief communication curriculum improves resident and nurse communication skills and patient satisfaction. J Gen Intern Med 2019;34:1167–1173.
18. Berns SH, Camargo M, Meier DE, et al. Goals of care ambulatory resident education: training residents in advance care planning conversations in the outpatient setting. J Palliat Med 2017;20:1345–1351.
19. Elder A, Chi J, Ozdalga E, et al. A piece of my mind. The road back to the bedside. JAMA 2013;310:799–800.
20. Baile WF, Buckman R, Lenzi R, et al. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5:302–311.
21. Childers JW, Back AL, Tulsky JA, et al. REMAP: a framework for goals of care conversations. J Oncol Pract 2017;13:e844–e850.
22. Back AL, Arnold RM, Baile WF, et al. Faculty development to change the paradigm of communication skills teaching in oncology. J Clin Oncol 2009;27:1137–1141.
23. Spagnoletti CL, Merriam S, Milberg L, et al. Teaching medical educators how to teach communication skills: more than a decade of experience. South Med J 2018;111:246–253.
24. Wayne DB, Moazed F, Cohen ER, et al. Code status discussion skill retention in internal medicine residents: one-year follow-up. J Palliat Med 2012;15:1325–1328.
25. Bays AM, Engelberg RA, Back AL, et al. Interprofessional communication skills training for serious illness: evaluation of a small-group, simulated patient intervention. J Palliat Med 2014;17:159–166.
26. Torke AM, Quest TE, Kinlaw K, et al. A workshop to teach medical students communication skills and clinical knowledge about end-of-life care. J Gen Intern Med 2004;19(5 Pt 2):540–544.
27. Back A, Arnold R, Tulsky J. Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope. New York: Cambridge University Press; 2009.
28. Selph RB, Shiang J, Engelberg R, et al. Empathy and life support decisions in intensive care units. J Gen Intern Med 2008;23:1311–1317.
29. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Internal Medicine. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/140_InternalMedicine_2020.pdf. Published July 1, 2020. Accessed March 10, 2021.
30. Nicolaides M, Cardillo L, Theodoulou I, et al. Developing a novel framework for non-technical skills learning strategies for undergraduates: a systematic review. Ann Med Surg 2018;36:29–40.
31. Koponen J, Pyorala E, Isotalus P. Comparing three experiential learning methods and their effect on medical students' attitudes to learning communication skills. Med Teach 2012;34:e198–207.
32. Kaufman DM, Laidlaw TA, Macleod H. Communication skills in medical school: exposure, confidence, and performance. Acad Med 2000;75(10 suppl):S90–S92.
