Self-Assessment of Skills and Competencies among Residents Participating in a Pediatric Hospice and Palliative Medicine Elective Rotation

Abstract

Objective:

To describe our institutional experience with a four-week pediatric HPM elective rotation and its impact on residents' self-rated competencies.

Background:

In the spirit of bolstering primary hospice and palliative medicine (HPM) skills of all pediatricians, it is unclear how best to teach pediatric HPM. An elective rotation during residency may serve this need.

Methods:

An anonymous online survey was distributed to pediatric and internal medicine/pediatrics residents at a single, tertiary academic children's hospital. Respondents were asked to rate education, experience, and comfort with five aspects of communication with families of children with terminal illnesses and six domains of managing the symptoms of terminal illnesses. Self-ratings were recorded on a 1–5 scale: none, minimal, moderate, good, or excellent. Demographic data, including details of training and prior HPM training, were collected. Respondents completed a set of six questions gauging their attitude toward palliative care in general and at the study institution specifically.

Results:

All respondents desire more HPM training. Those residents who self-selected to complete a pediatric HPM elective rotation had significantly higher self-ratings in 10 of 11 competency/skill domains. Free-text comments expressed concern about reliance on the specialty HPM team.

Discussion:

A pediatric HPM elective can significantly increase residents' self-rated competency. Such rotations are an under-realized opportunity in developing the primary HPM skills of pediatricians, but wider adoption is restricted by the limited availability of pediatric HPM rotations and limited elective time during training.

Introduction

Despite the presence of pediatric hospice and palliative medicine (HPM) teams at 69% of United States children's hospitals,¹ the current workforce is inadequate² to meet the needs of the estimated 8600 American children who live each day with a serious illness.³ Thus, there is a need to develop the primary HPM skills of all pediatricians.^4,5

There is a persistent gap between high need and low access to training in HPM^6–15 and it is unclear how best to teach HPM to pediatricians.^15–24 Systematic reviews^25,26 suggest a curriculum of at least two weeks' duration. Shaw et al.²⁵ conclude that, “some intentional focus on individual competencies will be necessary,” and such competencies have since been described for pediatric HPM.²⁷ An HPM rotation during residency may serve this educational need,^{24,28,29–32} but no evidence regarding the impact of HPM residency rotations in pediatrics has been published. As postulated by Dickens,³³ a clinical rotation offers a focus on HPM not otherwise realized. It may allow the trainee to progress from passive recipient of HPM knowledge^{9,21,24,30,34} to empowered, active participant. An educational climate of supported autonomy might transform teachable moments¹⁶ into learnable moments.

In this study, we evaluated trainees' experience with an elective, four-week pediatric HPM rotation at our institution. We describe self-reported competencies in HPM and attitudes toward pediatric HPM among pediatric and internal medicine/pediatrics residents according to participation in this elective.

Methods

Review of the study was waived by the Institutional Review Board at Nationwide Children's Hospital (NCH; IRB16-00798), a 468-bed tertiary academic children's hospital in Columbus, Ohio. In 2015, NCH reported 18,361 inpatient discharges and 1,203,605 total patient visits for patients from all 50 United States and 41 foreign countries.³⁵ The advanced illness management (AIM) team, in place since 2009, provides HPM services and receives ∼450 consultations annually. A four-week elective rotation has been offered to residents since January 2014. The curriculum (outline in Supplementary Data; Supplementary Data are available online at www.liebertpub.com/jpm) combines an interdisciplinary approach to teaching core tenets of pediatric HPM with application in varied clinical settings.

In September 2016, current residents were invited to participate in an anonymous, online Qualtrics survey through e-mail with a single reminder sent 11 days later. The survey, adapted from a previously published study,⁹ asked respondents to rate their education, experience, and comfort with five aspects of communication with families of children with terminal illnesses, and six domains of managing the symptoms of terminal illnesses (full questionnaire in Supplementary Data). Responses were recorded on a 1–5 scale: none, minimal, moderate, good, or excellent. Data were collected on respondents' demographic characteristics, palliative care training before residency, experience with caring for patients with a terminal illness and patients who died, participation in a pediatric HPM elective during residency, and attitudes toward both palliative care in general and the AIM team at NCH specifically. Additional comments were solicited in a free-response field.

Respondents who reported whether they had participated in the palliative care elective were included in the analysis, and were classified according to participation in the palliative care elective. Continuous data were summarized as medians with interquartile ranges, and compared using Wilcoxon rank-sum tests. Categorical data were summarized as counts with percentages and compared using Fisher's exact test. For each rating of education, experience, or comfort, a 95% confidence interval of the difference in medians between elective participants and nonparticipants was calculated using the Hodges–Lehmann method. Data analysis was performed using Stata/IC 13.1 (StataCorp, LP, College Station, TX). A two-tailed p < 0.05 was considered statistically significant, and hypothesis tests were not adjusted for multiple comparisons.

Results

The survey was circulated to 147 residents and 93 (63%) completed all or part of the survey. Analysis was limited to 78 respondents who reported whether they had participated in the palliative care elective (7 participants and 71 nonparticipants). Demographic characteristics of the analytic sample are summarized in Table 1. Six of seven elective participants were in their third or fourth postgraduate year (PGY), compared with 43/71 nonparticipants. Most elective participants were internal medicine/pediatrics residents, whereas most nonparticipants were in a categorical program. There was no difference between the two groups in preresidency training in palliative care (57% of participants vs. 54% of nonparticipants).

Table 1.

Characteristics of Pediatric Residents, According to Participation in a Palliative Care Elective (N = 78)

Variable	Palliative care elective (n = 7)	No palliative care elective (n = 71)	p^a
Variable	N (%) or Median (IQR)	N (%) or Median (IQR)	p^a
Sex			0.666
Male	1 (14%)	21 (30%)
Female	6 (86%)	50 (70%)
Age	29 (28, 30)	28 (26, 29)	0.012
Postgraduate year			0.001
1	0	27 (38%)
2	1 (14%)	21 (30%)
3	3 (43%)	21 (30%)
4	3 (43%)	2 (3%)
Graduated from United States medical school	7 (100%)	70 (99%)	>0.999
Received palliative and hospice care training before residency	4 (57%)	38 (54%)	>0.999
Program			0.070
Categorical	2 (29%)	48 (68%)
Dual	1 (14%)	5 (7%)
Internal medicine/pediatrics	4 (57%)	18 (25%)
Estimated number of patients cared for during residency
Patients with a terminal illness	50 (40, 150)	15 (5, 40)	0.003
Patients who died	10 (10, 25)	4 (0, 10)	0.015

Fisher's exact test for categorical data and Wilcoxon rank-sum test for continuous data.

IQR, interquartile range.

In the primary analysis, self-rated education, experience, and comfort with 11 aspects of pediatric HPM were compared between elective participants and nonparticipants (Table 2). Among participants, median ratings were “moderate” (3) or “good” (4) on all but one item. Nonparticipants' median ratings of education, experience, and comfort were 1–2 points lower than the participant group on 29 of the 33 questions. In each aspect of palliative care, apart from discussing spiritual and religious needs, self-ratings of education, experience, or comfort were statistically significantly higher among participants compared with nonparticipants. Due to potential confounding by PGY, this analysis was repeated for the subsample of 29 residents in PGY three or four (6 participants, 23 nonparticipants) in Table 3. Consistent with the results for the entire sample, participants in the elective were more experienced and comfortable with communication skills and providing adequate pain control; although differences between the groups in specific symptom management skills were attenuated in this subanalysis.

Table 2.

Self-Rated Education, Experience, and Comfort with Skills or Competencies in Palliative Care among Pediatric Residents, According to Participation in a Palliative Care Elective (N = 78)

Skill or competency (Rated on the scale, 1 = none; 2 = minimal; 3 = moderate; 4 = good; 5 = exceptional)	Palliative care elective (n = 7)	No palliative care elective (n = 71)	p	95% CI ^a
	Median (IQR)	Median (IQR)	p	95% CI ^a
Conducting family conference to discuss newly diagnosed life-threatening illness
Education	4 (4, 4)	3 (2, 4)	0.037	(0, 2)
Experience	4 (4, 5)	2 (2, 3)	0.002	(1, 2)
Comfort	4 (3, 4)	2 (2, 3)	0.004	(1, 2)
Discussing transition to comfort-based approach
Education	3 (3, 5)	3 (2, 3)	0.063	(0, 2)
Experience	4 (3, 5)	2 (2, 3)	0.005	(1, 2)
Comfort	4 (3, 5)	2 (2, 3)	<0.001	(1, 2)
Discussing code status
Education	4 (4, 5)	3 (2, 4)	0.002	(1, 2)
Experience	4 (4, 5)	3 (2, 4)	<0.001	(1, 2)
Comfort	4 (4, 5)	3 (2, 4)	0.002	(1, 2)
Discussing spiritual and religious needs
Education	3 (2, 4)	2 (2, 3)	0.194	(0, 2)
Experience	3 (2, 4)	2 (2, 3)	0.115	(0, 1)
Comfort	3 (2, 4)	3 (2, 4)	0.331	(0, 1)
Discussing the dying process
Education	3 (2, 5)	2 (2, 3)	0.048	(0, 2)
Experience	3 (3, 5)	2 (1, 2)	0.001	(1, 3)
Comfort	4 (3, 5)	2 (1, 3)	0.002	(1, 2)
Providing adequate pain control
Education	4 (3, 5)	3 (2, 4)	0.005	(0, 2)
Experience	4 (4, 5)	3 (2, 3)	<0.001	(1, 2)
Comfort	4 (4, 5)	3 (2, 3)	<0.001	(1, 2)
Providing adequate nausea control
Education	4 (3, 5)	3 (3, 4)	0.145	(0, 1)
Experience	4 (4, 5)	3 (3, 4)	0.013	(0, 1)
Comfort	4 (3, 5)	3 (3, 4)	0.044	(0, 1)
Providing care for malignant bowel obstruction
Education	4 (2, 5)	2 (1, 3)	0.003	(0, 3)
Experience	3 (3, 5)	2 (1, 2)	<0.001	(1, 3)
Comfort	3 (3, 5)	2 (1, 2)	<0.001	(1, 3)
Providing care for patients with severe fatigue
Education	3 (2, 3)	2 (1, 2)	0.012	(0, 1)
Experience	3 (2, 4)	2 (1, 2)	0.006	(0, 2)
Comfort	2 (2, 4)	2 (1, 2)	0.023	(0, 2)
Recognizing signs of impending death
Education	3 (3, 5)	3 (3, 2)	0.008	(0, 2)
Experience	3 (3, 5)	2 (2, 3)	0.002	(1, 2)
Comfort	3 (3, 5)	2 (2, 3)	0.001	(1, 2)
Providing care for breathlessness
Education	3 (2, 5)	2 (2, 3)	0.100	(0, 2)
Experience	3 (2, 4)	2 (2, 3)	0.045	(0, 2)
Comfort	3 (2, 4)	2 (2, 3)	0.037	(0, 2)

Hodges–Lehmann CI for difference between medians.

CI, confidence interval.

Table 3.

Self-Rated Education, Experience, and Comfort with Skills or Competencies in Palliative Care among Pediatric Residents in Postgraduate Year 3 or 4, According to Participation in a Palliative Care Elective (N = 29)

Skill or competency (Rated on the scale, 1 = none; 2 = minimal; 3 = moderate; 4 = good; 5 = exceptional)	Palliative care elective (n = 6)	No palliative care elective (n = 23)	p	95% CI ^a
	Median (IQR)	Median (IQR)	p	95% CI ^a
Conducting family conference to discuss newly diagnosed life-threatening illness
Education	4 (3, 4)	3 (2, 3)	0.153	(0, 2)
Experience	4 (4, 4)	3 (2, 4)	0.049	(0, 2)
Comfort	4 (3, 4)	2 (2, 4)	0.045	(0, 2)
Discussing transition to comfort-based approach
Education	3 (3, 5)	3 (3, 4)	0.431	(−1, 2)
Experience	4 (3, 5)	3 (2, 3)	0.130	(0, 2)
Comfort	5 (3, 5)	3 (2, 4)	0.012	(1, 2)
Discussing code status
Education	4 (4, 5)	3 (3, 4)	0.028	(0, 2)
Experience	4 (4, 5)	3 (2, 4)	0.023	(1, 2)
Comfort	4 (4, 5)	3 (3, 4)	0.030	(0, 2)
Discussing spiritual and religious needs
Education	3 (2, 4)	3 (2, 4)	0.613	(−1, 1)
Experience	3 (2, 3)	3 (2, 4)	0.802	(−1, 1)
Comfort	3 (2, 3)	3 (2, 4)	0.888	(−1, 1)
Discussing the dying process
Education	3 (2, 5)	3 (2, 4)	0.401	(−1, 2)
Experience	4 (3, 5)	2 (2, 4)	0.058	(0, 2)
Comfort	4 (3, 5)	2 (2, 3)	0.040	(0, 2)
Providing adequate pain control
Education	4 (3, 4)	3 (3, 4)	0.094	(0, 1)
Experience	4 (4, 4)	3 (3, 4)	0.032	(0, 1)
Comfort	4 (4, 4)	3 (3, 4)	0.022	(0, 1)
Providing adequate nausea control
Education	4 (3, 4)	3 (3, 4)	0.882	(−1, 1)
Experience	4 (4, 4)	3 (3, 4)	0.169	(0, 1)
Comfort	4 (3, 4)	4 (3, 4)	0.511	(0, 1)
Providing care for malignant bowel obstruction
Education	4 (2, 4)	2 (2, 3)	0.111	(0, 2)
Experience	3 (3, 4)	2 (2, 3)	0.046	(0, 2)
Comfort	3 (3, 4)	2 (2, 3)	0.061	(0, 2)
Providing care for patients with severe fatigue
Education	3 (2, 3)	2 (2, 3)	0.288	(0, 1)
Experience	3 (2, 4)	2 (2, 3)	0.174	(0, 2)
Comfort	3 (2, 4)	2 (2, 3)	0.174	(0, 2)
Recognizing signs of impending death
Education	3 (3, 4)	3 (2, 3)	0.124	(0, 1)
Experience	3 (3, 4)	3 (2, 3)	0.150	(0, 1)
Comfort	3 (3, 4)	3 (2, 3)	0.124	(0, 1)
Providing care for breathlessness
Education	3 (3, 5)	3 (2, 3)	0.170	(0, 2)
Experience	3 (3, 4)	3 (2, 4)	0.284	(0, 1)
Comfort	3 (3, 4)	3 (2, 4)	0.235	(0, 1)

Hodges–Lehmann confidence interval for difference between medians.

Respondents' attitudes toward HPM are summarized in Table 4. Participants and nonparticipants equally agreed that “palliative care is an important competence for general pediatrics,” whereas all participants and 42 of 71 nonparticipants strongly agreed with the statement, “I desire more palliative care training during residency.” Of the 12 additional comments submitted in the free-response field, six (five participants, one nonparticipant) expressed some type of concern about HPM (Table 5); four nonparticipants expressed a desire for more training or experience in HPM; and two nonparticipants offered other general comments.

Table 4.

Attitudes of Pediatric Residents Toward Palliative Care, According to Participation in a Palliative Care Elective (N = 78)

Question prompt ^a	Palliative care elective (n = 7)	No palliative care elective (n = 71)	P
Question prompt ^a	Median (IQR)	Median (IQR)	P
Palliative care is an important competence for general pediatrics	5 (5, 5)	5 (4, 5)	0.455
Palliative care conversations signal that you are giving up on a patient	1 (1, 1)	1 (1, 1)	0.333
Palliative care should be left to oncologists, critical care, and palliative care providers	1 (1, 4)	1 (1, 2)	0.362
I desire more palliative care training during residency	5 (5, 5)	5 (4, 5)	0.036
The AIM team at NCH contributes positively to patient care	5 (5, 5)	5 (5, 5)	0.242
The AIM team at NCH contributes positively to resident education	5 (5, 5)	4 (3, 5)	0.004

Responses were given on the scale, 1 = strongly disagree; 2 = disagree a little; 3 = neither agree nor disagree; 4 = agree a little; 5 = strongly agree.

AIM, advanced illness management; NCH, Nationwide Children's Hospital.

Table 5.

Selected Free-Response Comments Expressing Concern Regarding Hospice and Palliative Medicine

# I do hope that I will always have specialists available…I would feel unqualified to handle much of the conversations and medical management that palliative care is trained in.

# I am comfortable initiating conversations about palliative care and code status but am discouraged from doing so by my attendings, who would rather just enter a consult to avoid difficult conversations.

# I've never been invited into [the pediatric HPM team's] conversations with my patients and do feel this would have helped my understanding of end-of-life care.

# I do feel that because [the pediatric HPM team] exists, we rely on them heavily for pain management, and it takes away from active learning.

# I don't think we get enough of [HPM] in pediatrics and we should.

# Need more autonomy to have code status discussion.

HPM, hospice and palliative medicine.

Discussion

Our results offer novel insight into the impact of a pediatric HPM elective rotation during residency. In all but one domain, elective participants' self-ratings were significantly better than nonparticipants and may be due to increased exposure to HPM. Having cared for greater numbers of patients who were terminally ill or who died, participants had additional clinical encounters in which to hone skills and apply the elective's curriculum. Nonparticipants' self-ratings in HPM competencies were comparable to those obtained in similar studies.^9,12

The only skill not rated significantly higher among elective participants was discussing spiritual and religious needs. This may be due to the curriculum not offering structured communication skills practice. It may also reflect the differences in spirituality and religious beliefs among patients, families, and providers previously described.^36–38 The need for better care persists^8,39 despite available guidelines⁴⁰ for addressing spirituality and religion in pediatric HPM and the importance of spiritual needs to patients and families.^37,41–43

Regardless of elective participation, all residents strongly agreed with desiring more HPM training. Potential explanations include the low amount of hands-on experience available to residents and acquiescence bias to this question.

Furthermore, most elective participants (57%) were internal medicine/pediatrics residents, compared with 25% of nonparticipants. Exposure to HPM at another institution may confound our findings, but also illustrates an opportunity for individualized education based on a resident's previous experience.

The six comments expressing concern around the idea of reliance on the HPM team present opportunity for improvement at our institution and may be generalizable to other pediatric hospitals with HPM teams. These comments also underscore the unmet need for primary pediatric HPM.

Our current curriculum addresses the need for pediatric HPM education one resident at a time. The primacy of individualized, sensitive care inherent in HPM does not lend itself to multiple trainees participating in a single encounter. It will take interdisciplinary teaching by an interdisciplinary team to create new opportunities for more learners.

Limitations

Our study has inherent limitations as a retrospective study with a small number of participants that utilized self-assessment⁴⁴ without pre- and post-participation data. The single-center design limits the generalizability of our results although conducting the study at a single center may reduce confounding due to between-center variability in the presence and role of HPM teams.²⁰ While self-selection into the palliative care elective is a potential confounding factor, we have demonstrated that elective participants were similar to nonparticipants in previous palliative care training (Table 1) and in agreement with the importance of palliative care in pediatrics (Table 4).

Conclusion

Improving the care for all children with HPM needs will require bolstering primary HPM skills for pediatricians. We report higher self-rated competency in communication skills (other than spiritual/religious needs) and symptom management for pediatric and internal medicine/pediatrics residents who completed our elective rotation. Challenges remain to meet the educational demand for primary HPM in pediatrics; an elective rotation during residency, such as the rotation evaluated in this study, presents an under-realized opportunity.

Footnotes

Acknowledgments

The authors wish to thank the residents who devoted limited elective time to HPM and to those who participated in their survey. They also appreciate the members of the HPM care team at their institution—across disciplines—and their commitment to education.

Author Disclosure Statement

ZMR—No competing financial interests exist; DT—No competing financial interests exist; LMH—Spouse, Prashant S. Malhotra, MD, FAAP—who practices otolaryngology, was a one-time consultant for MED-EL, a cochlear implant manufacturing company.

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