An Innovative Application of Online Learning for Hospice Education in Medicine Trainees

Abstract

Objective:

To improve residents' knowledge, self-perceived skills, and attitudes about hospice.

Methods:

An online case-based curriculum in a flipped classroom design was provided to postgraduate year-one (PGY-1) residents. Residents completed a pre- and postassessment. Postgraduate year-two (PGY-2) residents served as a historical control.

Results:

Fifty-one PGY-1 residents received the curriculum. Postcurriculum knowledge scores increased significantly and were not statistically different from PGY-2 controls (n = 55). Postcurriculum confidence scores increased significantly and were statistically different from controls in subdomains of talking about hospice, facilitating the clinic to hospice transition, and seeking help with hospice dilemmas. Satisfaction with training in hospice was significantly higher after receiving the curriculum.

Conclusion:

A flipped classroom curriculum increased knowledge, confidence in skills, and satisfaction with residency training in hospice care. This design offers curriculum solutions that address competing demands in the new era of social distancing and remote learning.

Introduction

The ability to provide high-quality transitions of care at pivotal moments in patients' lives is a skill required of all physicians.¹ Medical training must assure competence in end-of-life (EOL) care and transitions of care.^2–7 Yet, problems arise in the hospital to hospice transition,⁸ including misunderstandings about hospice⁹ and discomfort at EOL.¹⁰

A successful transition requires anticipatory guidance regarding caregiving, equipment, medications, symptom management, and contingency planning. Physicians feel underprepared citing lack of knowledge about hospice eligibility, prognostication,¹¹ and lack of comfort with EOL conversations.^12,13 In academic medical institutions, this transition is provided by residents who are not trained to provide high-quality transitions to hospice,¹⁴ often rendering them* unable to provide essential anticipatory guidance at this pivotal transition.¹⁵

We aimed to address this by creating a foundational curriculum about hospice for postgraduate year-one (PGY-1) trainees. We addressed the time constraints of vying clinical and academic demands through curricular design. We used an online case-based format with blended asynchronous, synchronous, and just-in-time learning. We postulated that PGY-1 residents with dedicated training would have increased knowledge, self-perceived skills, and attitudes about hospice than their historical control peers.

Methods

Internal medicine (IM) and family medicine (FM) interns were recruited at The University of Pittsburgh Medical Center (UPMC). Mid-year PGY-2 residents, without dedicated hospice training, served as a historical control. The University of Pittsburgh Institutional Review Board reviewed the curriculum and approved it as exempt.

Three hospice and palliative medicine (HPM) faculty (B.K., R.M.A., and J.W.C.) created learning objectives (Table 1) and the CoMPhoRT mnemonic highlighting five key themes: criteria, model, pharmacy interventions, referral to palliative care, and triage (Table 2). Expert HPM faculty reviewed this for face and content validity.

Table 1.

Curriculum Learning Objectives

By the end of the intervention, internal medicine and family medicine interns will be able to:

• define hospice to a patient and family

• describe the general tenets of hospice care at home

• recognize increased needs prompting palliative care consultation

• counsel patients and families on what to expect with the transition to home hospice

• incorporate anticipatory guidance into discharge and after-visit summary materials

• perform medication and intervention review to eliminate noncomfort-focused items

• appreciate their role as a generalist in end-of-life care

• appreciate their role in transitions of care for the seriously ill.

Table 2.

The CoMPhoRT Mnemonic for Hospice Enrollment

Criteria	<6-month life expectancy
Model	Comfort focus
	Multidisciplinary team
	Home based model
	Family and friends as primary caregivers
	Medicare and most private insurance
	No coverage for caregivers or facility room and board
Pharmacy interventions	Anticipate symptoms with sublingual and oral options
Pharmacy interventions	Only continue meds to prevent distress
Referral to palliative	When home isn't an option
Referral to palliative	Uncontrolled symptoms despite best efforts
Triage	Hospice is the new 911: available 24-7

University of Pittsburgh Medical Center Section of Palliative Care and Medical Ethics.

The CoMPhoRT mnemonic outlines the key aspects of hospice care to discuss during the transition from hospital or clinic to hospice care. These aspects include: the criteria for hospice enrollment, the model of hospice care, the pharmacy interventions typically utilized in hospice care, when a palliative care referral is appropriate during this transition, and who to call for assistance with triage once enrolled in hospice.

The curriculum consisted of two cases: an ambulatory patient with advanced pulmonary disease and a hospitalized patient with metastatic cancer. Each case mapped key learning points to the CoMPhoRT mnemonic and learning objectives. The cases were presented in vpSim, an online case-based learning software at The University of Pittsburgh. The clinical cases were interspersed with multiple choice questions and free response text. The tasks were gated requiring completion to progress. The correct answer and rationale were provided.

The intervention consisted of three parts in a flipped classroom model: (1) case-based online modules, (2) a face-to-face debrief, and (3) just in time cognitive aids. The intervention ran from September 2019 to June 2020. Participants received access to the online modules in vpSim to complete at their own pace over the course of a week. The modules took 30 minutes.

A HPM physician facilitated the debrief. A facilitator's guide focused the conversation on what was learned, what questions remained, and the application to clinical situations (Supplementary Data S1). This ran 15–30 minutes. In March 2020, these sessions transitioned from in-person to the Zoom videoconferencing platform due to social distancing requirements with the COVID-19 pandemic.

Interns received just-in-time and reference materials including the CoMPhoRT mnemonic, a checklist for hospice enrollment, and a link to a Fast Facts and Concepts article.

A multiple choice test and survey assessed change in knowledge, self-perceived skills, and attitudes immediately before the intervention, approximately one month after, and at the end of the PGY-1 academic year (June 2020). This was electronically distributed using Survey Monkey, an online survey software. Learners created a unique identifier to link their assessments. The PGY-2 historical control assessment occurred between November 2019 and January 2020.

The multiple choice test assessed knowledge with nine case-based questions in pre- and post-test versions. Each question mapped to a theme within the CoMPhoRT mnemonic and predetermined learning objectives (Supplementary Table S1). The survey assessed self-perceived skills and attitudes on a 5-point Likert scale.

Paired t-test and independent two-sample t-tests compared differences between the PGY-1 and the PGY-2 cohorts. The paired t-test used the participants' unique identifiers to link the assessments. Unpatched identifiers were excluded from the paired analysis.

Results

Fifty-one PGY-1 residents received the intervention (IM n = 41, FM n = 10) from September 2019 to June 2020. Thirty-one (61%) PGY-1 residents completed the end-of-the-year postassessment with 21 (42%) matched pairs. Fifty-five PGY-2 residents received the assessment. Thirty (58%) completed the full assessment and three only completed the knowledge test.

The paired PGY-1 data (n = 21) (Table 3) showed a statistically significant increase in knowledge scores on a 100-point scale (66.7 vs. 78.3; p < 0.05) and statistically significant improvements in confidence scores on a 5-point Likert scale (average confidence 3.2 vs. 3.9; p < 0.05). Statistically significant (p < 0.05) increases were seen in confidence subdomains: identifying those eligible for hospice (3.7 vs. 4.2), talking about hospice with patients and families (3.5 vs. 4.2), facilitating the transition from hospital to hospice (3.3 vs. 4.0), facilitating the transition from clinic to hospice (2.0 vs. 3.2), and knowing where to seek help with a hospice dilemma (2.8 vs. 4.1).

Table 3.

Postgraduate Year One Paired Assessments

Mean ± SD	Pre (n = 21)	EoY post (n = 21)	p-value ≤0.05^a
Total test score^b	66.7 ± 16.5	78.3 ± 12.9	^*
Average confidence^c	3.2 ± 0.5	3.9 ± 0.6	^*
Identifying	3.7 ± 0.8	4.2 ± 0.9	^*
Talking	3.5 ± 1.0	4.2 ± 0.9	^*
Medications	3.7 ± 1.0	3.9 ± 1.1	—
Hospital	3.3 ± 0.9	4.0 ± 0.7	^*
Clinic	2.0 ± 0.73	0.2 ± 1.0	^*
Help	2.8 ± 1.0	4.1 ± 0.9	^*
Average importance^c	5.0 ± 0.2	4.6 ± 1.1	—
Generalist	5.0 ± 0.2	4.6 ± 1.1	—
Themselves	5.0 ± 0.2	4.6 ± 1.1	—
Satisfaction^c
Residency training	3.6 ± 0.8	4.3 ± 0.7	^*

Postgraduate year-one paired scores from pre-intervention compared to end-of-year post-intervention total knowledge test scores and survey assessments.

Paired t-test.

Quiz score is 100 point scale number. For example, 8 out of 9 is 100 × 8/9 = 88.9.

Reversed code: “Very confident,” “Very important,” and “Very satisfied” have score of 5.

represents statistically significant results.

EoY, end-of-year; SD, standard deviation.

The end-of-the-year PGY-1 residents (n = 33 for knowledge test, n = 30 for survey) compared with PGY-2 historical controls (n = 31) (Table 4) had similar increases in knowledge scores (80.6 vs. 75.1) and statistically significant improvement in average confidence (4.0 vs. 3.4; p < 0.05), including the subdomains of talking about hospice (4.2 vs. 3.6; p < 0.05), facilitating the transition from clinic to hospice (3.1 vs. 2.3; p < 0.05), and knowing where to seek help with a hospice dilemma (4.2 vs. 3.3; p < 0.05). Although not statistically significant (p-value = 0.059), there was a trend toward increased confidence in facilitating the transition from hospital to hospice (4.1 vs. 3.7). The PGY-1 intervention group rated their overall satisfaction with their residency training in hospice and end-of-life care as significantly higher (4.4 vs. 3.5; p < 0.05).

Table 4.

Postgraduate Year Two versus End of Year Postgraduate Year One Assessments

Mean ± SD	PGY-2 (n = ^b)	PGY-1	p-value ≤0.05^a
Mean ± SD	PGY-2 (n = ^b)	EoY post (n = 31)	p-value ≤0.05^a
Total test score^c	75.1 ± 17.8	80.6 ± 12.2	—
Average confidence^d	3.4 ± 0.6	4.0 ± 0.6	^*
Identifying	3.9 ± 0.7	4.2 ± 0.9	—
Talking	3.6 ± 0.9	4.2 ± 0.9	^*
Medications	3.6 ± ± 1.1	4.0 ± 0.9	—
Hospital	3.7 ± 0.8	4.1 ± 0.8	—
Clinic	2.3 ± 0.7	3.1 ± 1.0	^*
Help	3.3 ± 1.1	4.2 ± 0.9	^*
Average importance^d	4.7 ± 0.6	4.7 ± 0.9	—
Generalist	4.8 ± 0.6	4.7 ± 0.9	—
Themselves	4.6 ± 0.7	4.7 ± 0.9	—
Satisfaction^d
Residency training	3.5 ± 1.1	4.4 ± 0.7	^*

Postgraduate year-two versus end-of-year postgraduate year-one comparison of total knowledge test scores and survey assessments.

Independent two-sample t-test.

PGY-2 sample size for quiz n = 33 and for survey n = 30.

Quiz score is 100 point scale number. For example, 8 out of 9 is 100 × 8/9 = 88.9.

Reversed code: “Very confident,” “Very Important,” and “Very satisfied” have score of 5.

represents statistically significant results.

PGY-1, postgraduate year-one; PGY-2, postgraduate year-two.

When learners were asked about their preference for prework before a flipped classroom session (Table 5), the majority agreed that they preferred online-based curriculum compared with reading articles or book chapters. The PGY-1 postintervention group strongly agreed at a (p < 0.05) greater frequency than their historical control peers.

Table 5.

Online Curriculum Preferences

n (%)	PGY-2 (n = 30)	PGY-1	p-value ≤0.05^a
n (%)	PGY-2 (n = 30)	EoY post (n = 31)	p-value ≤0.05^a
Prefer online curriculum (mean ± SD)	3.9 ± 0.9	4.4 ± 0.8	^*
Strongly agree (5)	8 (27%)	17 (55%)	^*
Somewhat agree (4)	13 (43%)	12 (39%)	—
Neutral (3)	7 (23%)	1 (3%)	—
Somewhat disagree (2)	2 (7%)	0 (0%)	—
Strongly disagree (1)	0 (0%)	1 (3%)	—

Postgraduate year-two versus end-of-year postgraduate year-one preference for online curriculum as pre-work before a flipped classroom session.

Pearson's chi-square test or independent two-sample t-test.

Discussion

We found that a flipped classroom model using an online case-based hospice curriculum increased knowledge scores, confidence in skills, and overall satisfaction with residency training in hospice and EOL care. This increase in the PGY-1 residents was at least as good as the maturation effect of intern year in improving knowledge scores and confidence in hospice eligibility when compared with historical control PGY-2 residents. The curriculum showed significant improvements in confidence when talking about hospice care, facilitating the transition to hospice from clinic and knowing where to find help with a hospice dilemma.

The curriculum addressed the time constraints of medical education by using technology and leveraging adult learning theory. The flipped classroom approach allowed for a blended model with self-guided learning followed by an opportunity to engage with the material, their peers, and a facilitator.¹⁶ The preparatory work was done in a digital format. Online curricula and gamification strategies in a digital interface allow for increased engagement with the material.¹⁷

Cases are ideal for high-stakes low-frequency events, such as enrollment in home hospice, because they provide cognitive scaffolding to discuss situations that learners have yet to be exposed to in a clinical setting. Case-based formats have been positively reviewed by learners and facilitators alike.¹⁸ Implementation of a flipped classroom model with a digital case-based curriculum is an innovative way to provide both content and the opportunity for guided reflection while acknowledging competing demands and time constraints of the clinical and academic environments. These constraints are even more evident in the era of COVID-19 and distanced learning.

The strengths of this study include that it created a portable curriculum allowing for asynchronous learning that limited one-on-one facilitator time and allowed learners to have more flexibility. By providing just-in-time cognitive aides with check lists, pocket cards with a mnemonic, additional resources, and the ability to return to the modules, we provided support to learners when these high-stakes low-frequency events occur in real time.

There were notable limitations in this study that can be addressed through future iterations. The sample size was limited to a single academic institution with IM and FM interns only. The sample size was further limited by survey completion rates and small number of matched unique identifiers used to promote confidentiality. Next steps include upscaling to allow for increased utilization. The curriculum is more broadly available through the Wolff Center at UPMC's Wolff Learning Academy (online module available).

Also, the study design was limited to lower levels of Miller's pyramid with assessments of knowledge and change in confidence. We did not assess skills in practice or patient outcomes due to logistical challenges notably financial and time limitations with standardized patient encounters. Future directions include assessment of skill acquisition and improvement in skills through direct observation of patient encounters through a Mini-CEX or standardized patient experience.

A final limitation was the short follow-up time making it impossible to comment on the durability of the changes observed. The longevity of the knowledge and skill acquisition could be observed with a follow-up assessment in 6–12 months.

Conclusion

An online case-based module with a face-to-face debrief is an innovative way to improve knowledge and self-perceived skills in an environment that has competing demands and time constraints. Further studies to assess patient-centered outcomes and skill acquisition are still needed.

Ethical Approval

Ethical approval was granted as exempt by the institutional review board at the University of Pittsburgh on September 6, 2019 (STUDY19080230).

Footnotes

Funding Information

This project was supported by the University of Pittsburgh Medical Center, Department of General Internal Medicine's Fellow's Grant to provide statistical support through the University of Pittsburgh Data Center.

Author Disclosure Statement

No competing financial interests exist. Presented June 2020 at University of Pittsburgh Medical Center's MERMAID (Medical Educational Research Methods and Innovative Design) lecture series. Scheduled presentation February 2021 at The 2021 Virtual Annual Assembly of Hospice & Palliative Medicine.

Supplementary Material*

*Correction added on March 18, 2021 after first online publication of March 1, 2021: has been labeled correctly per the text. In Supplementary Table S1 the highlight of the word ‘tenets’ has been removed.

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Supplementary Material

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