Abstract
C
In this controlled pilot study, pediatric subspecialty fellows at one institution participated in three PPC simulation scenarios of increasing complexity tailored to fellows' disciplinary training (i.e., cardiology, neonatology, critical care, or hematology/oncology), whereas fellows at a second institution received didactic PPC educational materials. Importantly, on baseline assessments, participants reported greatest discomfort with leading discussions when families disagreed with the medical team's recommendations. Of 21 queried PPC topics, only 2 others—guiding a family through a physician order for life-sustaining treatment form and explaining the physiologic processes during death—were similarly discomfiting. The third simulation scenario asked participants to engage with a parent who requests escalation of disease-directed interventions, although the treating medical team has recommended against such measures. 7 At the three-month mark, intervention fellows reported significantly improved comfort with discussions in the setting of disagreement relative to comparison fellows (change between groups +0.9 favoring intervention group, p = 0.03; supplementary table S2). Thus, this pilot study supplies evidence that simulation-based education may enhance pediatric subspecialty trainees' comfort with discussions across disagreement in the setting of childhood serious illness.
Although the primary outcome upon which the study was powered was self-efficacy (comfort), Brock et al. also assessed communication behaviors during simulations and palliative care referral patterns. Gains were observed in several key communication behaviors, including relationship building, opening the discussion, and gathering information, consistent with published studies of communication skills programs geared to adult oncologists.8,9 However, these gains were not sustained at three months. Durable behavioral change may require additional “doses.” For example, interventions to improve informed consent conferences for randomized trials of childhood leukemia treatment showed a benefit of booster training. 10 Increased referrals to dedicated PPC specialists from participating academic units may suggest a mindset shift among participants. Crucially, investment in longitudinal, comparative educational research is needed to answer questions about how to ensure adequate, lasting PPC skills among pediatric subspecialists.
Also in this issue, Rossfeld's Letter to the Editor reminds us that simulating discussions across disagreement forms a basis for legislative advocacy. There is great hope that bipartisan support and sustained advocacy for the Palliative Care and Hospice Education and Training Act will lead to the bill's passage, expanding access to PPC now and in years to come. To meet the goal of expanded access to PPC, we must bolster the supply of skilled PPC “generalists” as well as train more interdisciplinary specialist PPC providers. Currently, many pediatric subspecialty fellows undergo educational programs that lack sufficient PPC exposure and training. 11 Brock et al. suggest that targeted simulation-based PPC education can enhance pediatric subspecialty trainees' comfort with discussions across disagreement. Given that physicians' discomfort with difficult communication may contribute to poor communication outcomes, 12 this finding is compelling. Through a combination of legislative action, research, education, and training, we can and will move closer to ensuring that family-provider disagreements can be more easily resolved, if not prevented.