Acceptability and Impact of a Required Palliative Care Rotation with Prerotation and Postrotation Observed Simulated Clinical Experience during Internal Medicine Residency Training on Primary Palliative Communication Skills

Abstract

Background:

Improving communication training for primary palliative care using a required palliative care rotation for internal medicine (IM) residents has not been assessed.

Objective:

To assess skills acquisition and acceptability for IM residents not selecting an elective.

Design:

A consecutive, single-arm cohort underwent preobjective structured clinical examination (OSCE) with learner-centric feedback, two weeks of clinical experience, and finally a post-OSCE to crystallize learner-centric take home points.

Setting/Subjects:

IM second year residents from Dartmouth-Hitchcock were exposed to a required experiential palliative care rotation.

Measurements:

Pre- and post-OSCE using a standardized score card for behavioral skills, including patient-centered interviewing, discussing goals of care/code status, and responding to emotion, as well as a confidential mixed qualitative and quantitative evaluation of the experience.

Results:

Twelve residents were included in the educational program (two were excluded because of shortened experiences) and showed statistically significant improvements in overall communication and more specifically in discussing code status and responding to emotions. General patient-centered interviewing skills were not significantly improved, but prerotation scores reflected pre-existing competency in this domain. Residents viewed the observed simulated clinical experience (OSCE) and required rotation as positive experiences, but wished for more opportunities to practice communication skills in real clinical encounters.

Conclusions:

A required palliative care experiential rotation flanked by OSCEs at our institution improved the acquisition of primary palliative care communication skills similarly to other nonclinical educational platforms, but may better meet the needs of the resident and faculty as well as address all required ACGME milestones.

Background

Communication skills are critical to high-quality patient care,^1–6 particularly in those patients with serious illness including a risk of shortened survival or significant morbidity.^7–10 Unfortunately, these communication skills are lacking in trainees,^11–17 but are becoming a priority in the graduate medical education curriculum.^18,19

Primary palliative care training, particularly in communication, is considered critical for internal medicine (IM) residents.¹⁹ Studies have shown improvement in communication skills with structured communication training,^17,20–22 but it has been reported that IM residents themselves value more clinical experience with bedside learning to increase their confidence in delivering competent end-of-life care.²³ In addition, IM residents have improved palliative care knowledge and attitudes with clinical experience compared with didactic curricular components.²⁴ Only one study has reported on the effects of a required palliative care rotation during IM residency, but its focus was on evaluation with a written examination on core palliative care topics and its results were prone to selection bias.²⁵

Objective

We aimed to assess the acquisition of primary palliative care communication skills as well as acceptability in IM residents who were required to rotate on a palliative care inpatient service.

Design

At our institution, second year IM residents have been required to spend a two-week block with the inpatient palliative care consulting service at Dartmouth-Hitchcock Medical Center with a focus on communication and pain/symptom management (Table 1). This report was on a consecutive, single-arm cohort participating during October 21, 2014, through January 22, 2016. The IM palliative care rotation curriculum was created with specific activities that address a broad array of reporting submilestones, particularly those pertaining to system-based practice, professionalism, and interpersonal and communication skills (Table 2).

Table 1.

Components of the Internal Medicine Resident Two-Week Required Rotation with the Inpatient Palliative Care Consulting Service at Dartmouth-Hitchcock Medical Center

Component	Description
Pre-OSCE	Goals of care discussion including code status in a patient with stage D congestive heart failure with standardized score card. Helps identify resident learning needs/objectives for the rotation. Done in simulation laboratory with a trained standardized patient.
Experiential patient encounters	Resident is matched with an attending faculty member for direct patient care to both observe and practice communication skills and symptom histories/treatment strategies.
Prerecorded faculty video didactics	Five 20-minute online videos designed to address core primary palliative care content, including introduction to palliative care, nausea/vomiting evaluation and management, pain management, including opioid toxicity and opioid rotation, imminent death syndrome, hospice, and appropriate use and ethics of artificial hydration and nutrition at the end of life.
Post-OSCE	Same as pre-OSCE, but focus is on reflecting on how resident-identified learning needs/objectives were met and other unexpected changes to communication skills.

OSCE, observed simulated clinical experience.

Table 2.

Milestones and Submilestones for Internal Medicine Residency That Are Addressed with a Palliative Care Rotation with Included Specific Activities That Address Each Submilestone

Milestones	Submilestones	Activities
Patient care	PC-1	Primary palliative care history taking and differentials (physical and emotional)
	PC-2	Development of targeted symptom plan for each patient
	PC-5	Demonstrates understanding of primary palliative care versus specialty/consultative palliative care
Medical knowledge	MK-1	Demonstrates ability to incorporate scientific, socioeconomic, and behavioral factors into clinical care of a patient
	MK-2	Utilizes testing to help aid in patient comfort or to achieve patient–family-centered goals
System-based practice	SBP-1	Actively participates in interdisciplinary team meetings and care for patients
	SBP-2	Demonstrates understandings of hospice care shortcomings and learns to advocate for patient–family values and goals
	SBP-3	Demonstrates ability to choose most cost-effective medications/interventions because of hospice reimbursement system
	SBP-4	Experiences transitions between healthcare settings for palliative care patients (outpatient, inpatient, home hospice, end-of-life care in facilities)
Problem-based learning and improvement	PBLI-1	Actively engages in self-reflection before and after patient encounters
	PBLI-2/PBLI-3	Demonstrates ability to incorporate feedback into communication skills with prerotation and postrotation OSCE
	PBLI-4	Demonstrates ability to improve point-of-care self-evaluation skills after patient encounters with debriefing.
Professionalism	PROF-1	Engages in interdisciplinary team discussion during daily team rounds
	PROF-2	Demonstrates ability to take responsibility for the palliative care needs of patients
	PROF-3	Actively utilizes patient–family values and goals to create tailored symptom and communication plans
	PROF-4	Demonstrates ability to understand ethics of withholding or withdrawing life-sustaining therapies
Interpersonal and communication skills	ICS-1	Demonstrates ability to communicate effectively with patient and families in real time and during OSCE
	ICS-2	Communicates effectively with interdisciplinary team members during daily meeting and throughout rotation
	ICS-3	Demonstrates ability to efficiently and accurately document a goals-of-care discussion with a palliative care patient

Regarding the prerotation and postrotation observed simulated clinical experience (OSCEs), simulated patient (SP) training was performed by a palliative care faculty member using developed training materials (Supplementary Data; Supplementary Data are available online at www.liebertpub.com/jpm). Table 3 includes the prompt given to the residents just before both the pre- and post-OSCEs. The scenario was identical in pre- and post-OSCEs. Use of the simulation laboratory is offered at no cost to faculty members when used for educational purposes. Pre-OSCE learner-centric take home points were incorporated into the experiential part of the rotation.

Table 3.

Observed Simulated Clinical Experience Resident-Facing Clinical Situation Used for Both Pre- and Postpalliative Care Inpatient Rotation Evaluation of Communication Skills Acquisition for Second Year Internal Medicine Residents

The situation:

You are the inpatient resident caring for a 76-year-old patient named Tracy who you met this morning on rounds. Tracy was diagnosed with CHF five years ago after suffering an MI leading to systolic heart failure with an EF around 30%. Tracy has been pretty compensated for the last number of years, but did have some symptomatic VT (syncope), requiring placement of an AICD about two years ago. This likely has saved Tracy's life in the past year as it has fired twice during that time appropriately. Preceding this admission, Tracy called the cardiologist because of repeated firing of the AICD and Tracy was found to be in NSVT that was refractory to the AICD shocks. Tracy was admitted to the hospital to see whether loading with antiarrhythmic drugs can help break the VT. In general, the cardiologist's notes indicate that Tracy's QOL has deteriorated over the past six months with CHF refractory to diuretics and other medication optimization as well as worsening cardiorenal syndrome (Cre 2.5). Tracy's cardiologist, Dr. Smith, is worried that even if the sustained VT is broken with antiarrhythmics, this all likely represents the beginning of the end for Tracy. Dr. Smith feels it is time to discuss Tracy's preferences for life-sustaining therapies at this point, including potentially turning off his AICD and shares these concerns with you, the resident. Dr. Smith is tied up in clinic all day and asks you as the responsible house staff to have this discussion with Tracy. You know Tracy has a significant other who has her own health problems at home and two adult children who live out of state.

Your task:

Please meet with Tracy to discuss Tracy's preferences for life-sustaining therapies (CPR in the event of a cardiac arrest and mechanical ventilation; consider AICD continuation if there is time) at this point in the disease process. You have ∼15–20 minutes total to complete this task, but you do not need to use the whole time if you do not need it.

AICD, automatic implantable cardioverter defibrillator; CHF, congestive heart failure; NSVT, non-sustained ventricular tachycardia; QOL, quality of life; VT, ventricular tachycardia.

This study received exempt status from the institutional review board.

Setting/Subjects

IM second year residents from Dartmouth-Hitchcock exposed to a required experiential palliative care rotation were included in this cohort. The IM residency program contains ∼19 second year residents, 9 of whom are nonprimary care track IM residents. Primary care track IM residents did not participate in the requirement for a palliative care rotation for logistical reasons, and, therefore, could not be included.

Measurements

The primary measure of acquired communication skills was obtained by comparison of the pre-OSCE and post-OSCE resident experience using a standardized OSCE score card (Table 4), which was modified with permission from other work done by Szmuilowicz et al.²² Although the pre- and post-OSCE scenario was identical, the SP differed so that the resident experience was unique at each encounter.

Table 4.

Observed Simulated Clinical Experience Score Card Used in the Prerotation and Postrotation Structured Clinical Examination Experience to Inform Acquisition of Pertinent Skills Used Only to Help Facilitate Learner Feedback and to Understand Impact of the Curriculum

Communication skill	Rating
A. General patient-centered interviewing skills	No (0 point)	Yes (1 point)
1. Establishes rapport promptly (within first 30 seconds of encounter)
2. Describes the purpose of the encounter during the first third of the interview (i.e., discussing general/future care)
3. Uses summary statements to ensure understanding of patient's statements (“It sounds like…”)
4. Explicitly elicits additional questions and/or concerns
5. Makes explicit statement of “partnership building” and/or “nonabandonment”
6. Uses nontechnical language
	Subtotal_________
B. Discussing code status	No (0 point)	Yes (1 point)
1. Asks patient about prior experiences with EOL decision making (e.g., prior discussions)
2. Inquires about assignment of healthcare proxy or power of attorney for healthcare; identifies specific proxy if not already done
3. Assesses patient's understanding of his/her current condition
4. Explores patient's understanding of the prognosis
5. Explicitly asks about patient's concerns about the future
6. Explores and clarifies the patient's general values and goals
7. Discusses outcomes of attempted resuscitation (not just specific interventions)
8. Proposes a care plan that respects patient's goals, values, and concerns (i.e., makes a recommendation regarding code status)
9. Frames recommendation by focusing on “active” treatments first, rather than just on “withheld” treatments
	Subtotal_________
C. Responding to emotion	No (0 point)	Yes (1 point)
1. Names, validates, or expresses understanding of the patient's emotional reaction
2. Explores patient's emotional reaction(s) in greater detail
3. Uses silence appropriately after providing information or asking a difficult question (at least three seconds)
	Subtotal_________
Overall total _____________

Faculty scored each item as 0 (competency not demonstrated), 0.5 (competency partially demonstrated), or 1 (competency demonstrated). These score cards were not shared with the IM resident. The score cards were solely used for the purpose of trying to capture skills acquisition during the two-week rotation for quality improvement. The total scores were used as our primary outcome of efficacy and secondary outcomes included improvement in subscores (Table 4). A student's t test analysis was used to analyze statistical differences between preassessment and postassessment made of residents for mean total score and subscores.

To assess residents' perspectives on the required rotation, we were provided with confidential resident evaluations that were administered and managed within the IM residency program. These included quantitative data with regard to the numerical rating the resident gave our rotation overall on a 0–5 Likert scale. In addition, nonrequired comments made by residents about the rotation were also included. The categories were strengths, weaknesses, and suggestions for improvement. A narrative descriptive approach was used in reporting these data.

Results

We collected pre- and post-OSCE scoring on 12 out of 14 residents (86%). Two residents were excluded because they had very shortened palliative care rotation experiences, defined by spending <50% of the time expected on the rotation.

Total scores showed a statistically significant improvement from a mean of 8.2 (standard deviation [SD] 3.6; 95% confidence interval [CI] 5.9–10.5) for the pre-OSCE to a mean of 11.6 (SD 3.6; 95% CI 9.3–13.9) for the post-OSCE (p = 0.02) on an 18-point scale. The general patient-centered interviewing skills subscore showed a nonstatistically significant improvement from a mean of 4.1 (SD 1.3; 95% CI 0.5–2.1) for the pre-OSCE to 4.9 (SD 1.2; 95% CI 0.4–2) for the post-OSCE (p = 0.07) on a six-point scale. The discussing code status subscore showed a statistically significant improvement from a mean of 3.1 (SD 2; 95% CI 1.8–4.4) for the pre-OSCE to 4.8 (SD 2.1; 95% CI 3.4–6.2) for the post-OSCE (p = 0.03) on a nine-point scale. The responding to emotion subscore showed a statistically significant improvement from a mean of 1.1 (SD 0.8; 95% CI 0.6–1.6) for the pre-OSCE to 1.8 (SD 1; 95% CI 1.1–2.5) for the post-OSCE (p = 0.04) on a three-point scale. A summary of these results can be found in Table 5.

Table 5.

Summary of Results for Prerotation and Postrotation Observed Simulated Clinical Experience for Internal Medicine Residents Required to Rotate with the Palliative Care Consult Service

	Prerotation OSCE score, mean (SD)	Postrotation OSCE score, mean (SD)	p
Total OSCE score	8.2 (3.6)	11.6 (3.6)	0.02
General patient-centered interviewing skills	4.1 (1.3)	4.9 (1.2)	0.07
Discussing code status	3.1 (2)	4.8 (2.1)	0.03
Responding to emotion	1.1 (0.8)	1.8 (1)	0.04

SD, standard deviation.

With regard to acceptability of the experience for the IM residents, the average confidential rating of this rotation by residents for 2014 and 2015 was 4.43 and 4.5 out of 5 possible points, respectively. Strengths (42%; n = 5) commented on the value of practice and direct observation by expert faculty during the OSCE, the opportunity to self-identify areas for improvement through the OSCE, the breadth of family meetings experienced during the clinical rotation, helpful online training modules, good team environment, the emphasis on communication skills training, and finally interacting with SPs. Weaknesses (27%; n = 3) commented on feeling the OSCE were a surprise, OSCE was the only major chance to practice communication skills during the rotation, and a desire to lead more clinical encounters during the rotation. Lastly, suggestions for improvements (27%; n = 3) commented on adding observed clinical encounters to the OSCEs and wishing the online video lectures were available after completion of the rotation.

Conclusions

This is the first study to our knowledge that has demonstrated that a required palliative care rotation during IM residency improves core communication skills, specifically skills for discussion of code status and responding to patient emotion, and is acceptable to the residents as a required curriculum. This minimizes selection bias because the residents were not self-selected by electing to rotate with the inpatient palliative care team. We did not find a change in patient-centered communication skills, but high baseline scores on this subscore may have contributed (4.1 out of 6 possible points). Other studies, using nonclinical educational methods, have also not found changes in general communication skills for IM residents, including a three-hour program focused on the SPIKES model,²⁰ a controlled study of a two-day retreat with five hours of dedicated communication training,²¹ and a day-long retreat.²² The effect of a longer elective palliative care rotation demonstrated improved communication and interviewing skills as well as the time spent with hospice and palliative care attending physicians who served as role models.²⁵

The educational value of the attending physician as a role model was well described by Dr. Kenny et al.,²⁶ and our clinical educational experience encompasses many of the concepts they identify. Observational learning (i.e., clinical experience) and reflective practice (i.e., OSCE practice), including use of the OSCEs not as evaluative tools for grading purposes but rather diagnostic tools to identify a resident's specific learning goals as well as a tool for reinforcing practice change when repeated at the end of the rotation, were critical parts of our curriculum. These experiences are unique to the clinical setting and may represent an advantage of a clinical rotation over a didactic experience for improving communication skills in this group of learners.

Advantages to our model as compared with classroom-based or didactic methods include incorporating residents in the daily work of palliative care (to allow more robust teaching time by the attending), although the investment of faculty time in the OSCE experience may be a significant barrier with residency programs larger than ours.

Important limitations exist. Since this was only performed in IM residents at one institution, used only a heart failure case, and lacked inclusion of primary care track IM residents generalizability is in question. There is a natural trend of improved skills over the course of an academic year for an IM resident, but we found this to be non-significant (p = 0.20) when comparing beginning and end of the second year IM residents. Use of identical pre- and post-OSCE scenarios for evaluating our intervention make improvements from repetition of scenarios possible, particularly with the lack of a control group. Lastly, we lacked assessment of actual patient encounters or patient satisfaction although others have found structured communication training to have underwhelming results when patient evaluations were assessed,²⁷ calling into question the training method or the optimal assessment method for meaningful acquisition of these skills.

Footnotes

Acknowledgment

The authors thank Dr. Harley Friedman for his support in valuing this type of educational experience for his IM residents.

Author Disclosure Statement

No competing financial interests exist.

References

Ong

, de Haes

, Hoos

, Lammes

: Doctor-patient communication: A review of the literature. Soc Sci Med, 1995; 40:903–918.

Swenson

, Buell

, Zettler

, et al.: Patient-centered communication: Do patients really prefer it?. J Gen Intern Med, 2004; 19:1069–1079.

Harmsen

JAM

, Bernsen

RMD

, Bruijnzeels

, Meeuwesen

: Patients' evaluation of quality of care in general practice: What are the cultural and linguistic barriers?. Patient Educ Couns, 2008; 72:155–162.

Roter

, Hall

: Doctors Talking with Patients/Patients Talking with Doctors: Improving Communication in Medical Visits, 2nd ed. Westport, CT: Praeger, 2006.

, Zhang

, Yum

Y-O

, et al.: Interruption and patient satisfaction in resident-patient consultations. Health Educ, 2008; 108:411–427.

Kelley

, Kraft-Todd

, Schapira

, et al.: The influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials. PLoS One, 2014; 9:e101191.

Zhang

, Wright

, Huskamp

, et al.: Health care costs in the last week of life: Associations with end-of-life conversations. Arch Intern Med, 2009; 169:480–488.

Heyland

, Allan

, Rocker

, et al.; Canadian Researchers at the End-of-Life Network (CARENET): Discussing prognosis with patients and their families near the end-of-life: Impact on satisfaction with end-of-life care. Open Med, 2009; 3:e101–e110.

Detering

, Hancock

, Reade

, Silvester

: The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. Br Med J, 2010; 340:c1345.

10.

Wright

, Zhang

, Ray

, et al.: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA, 2008; 300:1665–1673.

11.

Orlander

, Fincke

, Hermanns

, Johnson

: Medical residents' first clearly remembered experiences of giving bad news. J Gen Intern Med, 2002; 17:825–840.

12.

Smith

, Ries

, Zhang

, et al.: Resident approaches to advance care planning on the day of hospital admission. Arch Intern Med, 2006; 166:1597–1602.

13.

Stevens

, Cook

, Guyatt

, et al.: Education, ethics, and end-of-life decisions in the intensive care unit. Crit Care Med, 2002; 30:290–296.

14.

Tulsky

, Chesney

, Lo

: See one, do one, teach one?: House staff experience discussing do-not-rescusitate orders. Arch Intern Med, 1996; 156:1285–1289.

15.

Schroder

, Heyland

, Jiang

, et al.: Educating medical residents in end-of-life care: Insights from a multicenter study. J Palliat Med, 2009; 12:459–470.

16.

Billings

, Curtis

, Engelberg

: Medicine residents' self-perceived competence in end-of-life care. Acad Med, 2009; 84:1533–1539.

17.

Ahern

, Doyle

, Marquis

, et al.: Critically ill patients and end-of-life decision-making: The senior medical resident experience. Adv Health Sci Educ, 2012; 17:121–136.

18.

Des Ordons

, Ajjawi

, Macdonald

, et al.: Palliative and end of life care communication as emerging priorities in postgraduate medical education. Can Med Educ J, 2016; 7:e4–e21.

19.

Schaefer

, Chittenden

, Sullivan

, et al.: Raising the bar for the care of seriously ill patients: Results of a national survey to define essential palliative care competencies for medical students and residents. Acad Med, 2014; 89:1024–1031.

20.

Williams

, Fisicaro

, Veloski

, Berg

: Development and evaluation of a program to strengthen first year residents' proficiency in leading end-of-life discussions. Am J Hosp Palliat Med, 2011; 28:328–334.

21.

Alexander

, Keitz

, Sloane

, Tulsky

: A controlled trial of a short course to improve residents' communication with patients at the end of life. Acad Med, 2006; 81:1008–1012.

22.

Szmuilowicz

, el-Jawahri

, Chiappetta

, et al.: Improving residents' end-of-life communication skills with a short retreat: A randomized controlled trial. J Palliat Med, 2010; 13:439–452.

23.

Fischer

, Gozansky

, Kutner

, et al.: Palliative care education: An intervention to improve medical residents' knowledge and attitudes. J Palliat Med, 2003; 6:391–399.

24.

Olden

, Quill

, Bordley

, Ladwig

: Evaluation of a required palliative care rotation for internal medicine residents. J Palliat Med, 2009; 12:150–154.

25.

von Gunten

, Twaddle

, Preodor

, et al.: Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents. Am J Hosp Palliat Care, 2005; 22:195–203.

26.

Kenny

, Mann

, MacLeod

: Role modeling in physician's professional formation: Reconsidering an essential but untapped educational strategy. Acad Med, 2003; 78:1203–1210.

27.

Curtis

, Back

, Ford

, et al.: Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: A randomized trial. JAMA, 2013; 310:2271–2281.

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