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Advocating palliative care worldwide is difficult without having basic facts about the situation globally. If you do not know how many people
need palliative care, it is hard to say that there is an unmet need. If you do
not have a consensus on which diagnoses indicate a need for palliative
care, you cannot advocate for patients with those conditions. If you do not know what the barriers are to expanding palliative care, you
will have difficulty overcoming them.
For this reason, the idea of an advocacy document, which would attempt to answer these and other questions, was born. In 2012,
the Worldwide Palliative Care Alliance (WPCA) was entering into official relations with the WHO. A joint project that would demonstrate the value of this relationship was needed. This became the Global Atlas of
Palliative Care at the End of Life.1 The Global Atlas is an advocacy tool. It sets a baseline to help measure improvements in global palliative care development over time. It brings together a number of measurement
tools that are key to answering a larger set of questions: what is palliative care? Why is it a human rights issue? What are the main diseases requiring palliative care? What is the need for palliative care? What are
the barriers to palliative care? Where is palliative care currently available?
What are the models of palliative care worldwide? What resources are devoted to palliative care? What is the way forward?
Aim:
To explore resident and faculty perceptions of the feedback process, especially residents' feedback-seeking activities.
Methods:
We conducted focus groups of faculty and residents exploring experiences in giving and receiving feedback, feedback-seeking, and suggestions to support feedback-seeking. Using qualitative methods and an iterative process, all authors analyzed the transcribed audiotapes to identify and confirm themes.
Results:
Emerging themes fit a framework situating resident feedback-seeking as dependent on four central factors: (1) learning/workplace culture, (2) relationships, (3) purpose/quality of feedback, (4) emotional responses to feedback. Residents and faculty agreed on many supports and barriers to feedback-seeking. Strengthening the workplace/learning culture through longitudinal experiences, use of feedback forms and explicit expectations for residents to seek feedback, coupled with providing a sense of safety and adequate time for observation and providing feedback were suggested. Tensions between faculty and resident perceptions regarding feedback-seeking related to fear of being found deficient, the emotional costs related to corrective feedback and perceptions that completing clinical work is more valued than learning.
Conclusion:
Resident feedback-seeking is influenced by multiple factors requiring attention to both faculty and learner roles. Further study of specific influences and strategies to mitigate the tensions will inform how best to support residents in seeking feedback.
Thematic analysis is a poorly demarcated, rarely acknowledged, yet widely used qualitative analytic method within psychology. In this paper, we argue that it offers an accessible and theoretically flexible approach to analysing qualitative data. We outline what thematic analysis is, locating it in relation to other qualitative analytic methods that search for themes or patterns, and in relation to different epistemological and ontological positions. We then provide clear guidelines to those wanting to start thematic analysis, or conduct it in a more deliberate and rigorous way, and consider potential pitfalls in conducting thematic analysis. Finally, we outline the disadvantages and advantages of thematic analysis. We conclude by advocating thematic analysis as a useful and flexible method for qualitative research in and beyond psychology.
To investigate the strength of association between trainees' self-assessments of the quality of their end-of-life communication skills and the assessments of their patients, patients' families, and clinician-evaluators.
As part of a randomized trial, pre-intervention survey data were collected at two sites from internal medicine trainees and their patients, patients' families, and clinician-evaluators. In this observational analysis, comparisons using regression analysis were made between (1) trainees' scores on a scale of perceived competence at communication about end-of-life care and (2) patients', families', and clinician-evaluators' scores on a questionnaire on the quality of end-of-life communication (QOC). Secondary analyses were performed using topic-focused subscales of these measures.
Internal medicine trainees (143) were studied with both self-assessment and external assessments. No significant associations were found between trainee perceived competence scores and primary outcome measures (p>0.05). Of the 12 secondary subscale analyses, trainees' self-ratings were significantly associated with external assessments for only one comparison, but the association was in the opposite direction with increased trainee ratings being significantly associated with decreased family ratings on "treatment discussions." We also examined the correlation between ratings by patients, family, and clinician-evaluators, which showed significant correlations (p<0.05) for 7 of 18 comparisons (38.9%).
Trainee self-evaluations do not predict assessments by their patients, patients' families, or their clinician-evaluators regarding the quality of end-of-life communication. Although these results should be confirmed using the same measures across all raters, in the meantime efforts to improve communication about end-of-life care should consider outcomes other than physician self-assessment to determine intervention success.
Although communication skills training (CST) enhances patient-centred skills and attitudes, the literature indicates a problematic transfer of these from education into practice.
We explored 'lived' experiences of medical students and doctors to gain a better understanding of the impact of CST on patient-centredness in the transition to real practice.
From a phenomenological perspective, we conducted 15 interviews and 11 focus groups with 4-9 participants/group (n = 67) at two universities and carried out constant comparative analysis.
The gap between education and practice is the central phenomenon. Although CST raises students' communication awareness and self-efficacy in an 'ideal' context, this paradoxically seems to jeopardize their ability to bridge the gulf. In addition, CST does not come to grips with students' attitudes. However, CST appears to be successful in equipping students with long-lasting 'handles'. Yet students need more support to mould the provided 'ideal' models into their own unique style of context-specific patient-centred behaviour. This implies: raising students' awareness of own attitudes and communication styles, offering a more realistic training ground, integrating CST with clinical experience and translating the primary-care-rooted concept of patient-centredness into various specialization contexts.
CST could raise its impact by supporting students' recycling processes towards a personal style of context-sensitive patient-centredness.
In order to improve the understanding of educational needs among residents caring for the critically ill, narrative accounts of 19 senior physician trainees participating in level of care decision-making were analyzed. In this multicentre qualitative study involving 9 university centers in Canada, in-depth interviews were conducted in either English or French, and the transcripts then underwent a hermeneutic phenomenological analysis. The resident was the central figure in the narrated incident, along with the patients' relatives and other attending physicians. The vast majority of interviews recounted negative experiences that involved delivering bad news to patients' families and managing difficult communications with them and with physician colleagues. Emotional distress and suffering were often part of their decision-making process. Narrating their experiences was viewed as a positive event. Data analysis uncovered 6 general themes that were organized into 2 categories, the first one grouping together themes related to interactions with the patients' families and the second comprising themes related to interactions with physician coworkers. The findings suggest that physician trainees' narratives are a rich source of data regarding what constitutes meaningful training experiences and what they learn from them. Educational approaches that incorporate the telling of stories would allow students to express their feelings, doubts, and opinions about their work experiences and could thus foster personal and emotional learning in critical care.
Medical teachers trained in conventional educational systems need faculty development to prepare them to function effectively in a competency-based medical education (CBME) system. Faculty development can provide knowledge about CBME, training in new teaching techniques in different domains of medical practice, and new strategies for providing the authentic and regular assessment that is an essential aspect of CBME. A systems-wide approach as well as efforts to provide training in CBME to individual teachers in both the undergraduate and postgraduate systems will be important. The wide implementation of CBME will be challenging and slow, and will meet with resistance, but various strategies can be used address these challenges. Faculty development is fundamental to the effectiveness of those strategies.
Despite evidence-based recommendations for communication and decision making about life-sustaining treatment, resident physicians' actual practice may vary. Few prior studies have examined these conversations qualitatively to uncover why ineffective communication styles may persist.
To explore how discussions about life-sustaining treatment occur and examine the factors that influence physicians' communicative practices in hopes of providing novel insight into how these processes can be improved. PARTICIPANTS AND APPROACH: We conducted and recorded 56 qualitative semi-structured interviews with participants from 28 matched dyads of a resident physician and a hospitalized patient or their surrogate decision maker with whom cardiopulmonary resuscitation was discussed. Transcripts were analyzed and coded using the constant comparative method to develop themes.
Resident physicians introduced decisions about resuscitation in a scripted, depersonalized and procedure-focused manner. Decision makers exhibited a poor understanding of the decision they were being asked to make and resident physicians often disagreed with the decision. Residents did not advocate for a particular course of action; however, the discussions of resuscitation were framed in ways that may have implicitly influenced decision making.
Residents' communication practices may stem from their attempt to balance an informed choice model of decision making with their interest in providing appropriate care for the patient. Physicians' beliefs about mandatory autonomy may be an impediment to improving communication about patients' choices for life-sustaining treatment. Redefining the role of the physician will be necessary if a shared decision making model is to be adopted.
To describe how medical residents discuss do-not-resuscitate (DNR) orders with patients.
Prospective observational study.
Inpatient medical wards of one university tertiary care center, one urban city public hospital, and one Veterans Affairs medical center.
Thirty-one medical residents self-selected 31 of their English-speaking, competent patients, with whom they had DNR discussions.
Three independent observers rated audiotaped discussions about DNR orders between the medical residents and their patients. Ratings assessed whether the physicians met standard criteria for requesting informed consent (e.g., disclosed the nature, benefits, risks, and outcomes), addressed the patients' values, and attended to the patients' emotional concerns.
The physicians often did not provide essential information about cardiopulmonary resuscitation (CPR). While all the physicians mentioned mechanical ventilation, only 55% mentioned chest compressions and 32% mentioned intensive care. Only 13% of the physicians mentioned the patient's likelihood of survival after CPR, and no physician used a numerical estimate. The discussions lasted a median of 10 minutes and were dominated in speaking time by the physicians. The physicians initiated discussions about the patients' personal values and goals of care in 10% of the cases, and missed opportunities to do so.
Medical ethicists, professional societies, and the public recommend more frequent discussions about DNR orders. Even when housestaff discuss resuscitation with patients, they may not be accomplishing the goal of increasing patient autonomy. Research and education must focus on improving the quality, as well as the quantity, of these discussions.
The questions patients are asked about their preferences with regard to life-sustaining treatment usually focus on specific interventions, but the outcomes of treatment and their likelihood affect patients' preferences.
We administered a questionnaire about treatment preferences to 226 persons who were 60 years of age or older and who had a limited life expectancy due to cancer, congestive heart failure, or chronic obstructive pulmonary disease. The study participants were asked whether they would want to receive a given treatment, first when the outcome was known with certainty and then with different likelihoods of an adverse outcome. The outcome without treatment was specified as death from the underlying disease.
The burden of treatment (i.e., the length of the hospital stay, extent of testing, and invasiveness of interventions), the outcome, and the likelihood of the outcome all influenced treatment preferences. For a low-burden treatment with the restoration of current health, 98.7 percent of participants said they would choose to receive the treatment (rather than not receive it and die), but 11.2 percent of these participants would not choose the treatment if it had a high burden. If the outcome was survival but with severe functional impairment or cognitive impairment, 74.4 percent and 88.8 percent of these participants, respectively, would not choose treatment. The number of participants who said they would choose treatment declined as the likelihood of an adverse outcome increased, with fewer participants choosing treatment when the possible outcome was functional or cognitive impairment than when it was death. Preferences did not differ according to the primary diagnosis.
Advance care planning should take into account patients' attitudes toward the burden of treatment, the possible outcomes, and their likelihood. The likelihood of adverse functional and cognitive outcomes of treatment requires explicit consideration.
Realizing medical education is on the brink of a major paradigm shift from structure- and process-based to competency-based education and measurement of outcomes, the authors reviewed the existing medical literature to provide practical insight into how to accomplish full implementation and evaluation of this new paradigm. They searched Medline and the Educational Resource Information Clearinghouse from the 1960s until the present, reviewed the titles and abstracts of the 469 articles the search produced, and chose 68 relevant articles for full review. The authors found that in the 1970s and 1980s much attention was given to the need for and the development of professional competencies for many medical disciplines. Little attention, however, was devoted to defining the benchmarks of specific competencies, how to attain them, or the evaluation of competence. Lack of evaluation strategies was likely one of the forces responsible for the three-decade lag between initiation of the movement and wide-spread adoption. Lessons learned from past experiences include the importance of strategic planning and faculty and learner buy-in for defining competencies. In addition, the benchmarks for defining competency and the thresholds for attaining competence must be clearly delineated. The development of appropriate assessment tools to measure competence remains the challenge of this decade, and educators must be responsible for studying the impact of this paradigm shift to determine whether its ultimate effect is the production of more competent physicians.
Improved communication with family members of critically ill patients can decrease the prolongation of dying in the intensive care unit (ICU), but few data exist to guide the conduct of this communication.
Our objective was to identify missed opportunities for physicians to provide support for or information to family during family conferences.
We identified ICU family conferences in four hospitals that included discussions about withdrawing life support or delivery of bad news. Fifty-one conferences were audiotaped, including 214 family members. Thirty-six physicians led the conferences and some physicians led more than one. We used qualitative methods to identify and categorize missed opportunities, defined as an occurrence when the physician had an opportunity to provide support or information to the family and did not.
Fifteen family conferences (29%) had missed opportunities identified. These fell into three categories: opportunities to listen and respond to family; opportunities to acknowledge and address emotions; and opportunities to pursue key principles of medical ethics and palliative care, including exploration of patient preferences, explanation of surrogate decision making, and affirmation of nonabandonment. The most commonly missed opportunities were those to listen and respond, but examples from other categories suggest value in being aware of these opportunities.
Identification of missed opportunities during ICU family conferences provides suggestions for improving communication during these conferences. Future studies are needed to demonstrate whether addressing these opportunities will improve quality of care.
Residents are often responsible for eliciting patients' treatment preferences at the end of life (EOL), yet we have a limited understanding of their competence in this task.
To assess the competence of medical residents to discuss advance directives (AD) with patients using two measures: self-assessment (perceived competence) and self-reported behaviors (behavioral competence). To examine the relationship between educational experiences and these two measures of competence.
Cross-sectional self-report questionnaire.
Internal medicine residents from two university- and one community-based program.
The 282 respondents (84% response) had an average of 6.2 EOL discussions per month. Few residents reported having received useful feedback from a resident (8%) or an attending (7%) about their ability to discuss ADs. Even fewer reported that work rounds (4%) or attending rounds (5%) were frequently forums for learning about EOL care. Mean perceived competence was 3.8 (range, 1-5). In multivariable analyses, greater perceived competence was significantly associated with higher postgraduate year (p < 0.001), having residents demonstrate exemplary AD discussions (p < 0.001), and less formal education (p < 0.01). Behavioral competence was significantly associated with reporting that work rounds were useful for learning about EOL care (p = 0.002), less formal education (p = 0.02) and a greater number of EOL discussions per ward month (p = 0.009). The correlation between perceived and behavioral competence (r = 0.25, p = 0.001) was modest but statistically significant.
Many residents view themselves as competent to discuss ADs with patients but fail to engage in recommended behaviors for such discussions. Increasing experiential learning may be the most promising means of enhancing residents' abilities to discuss EOL issues with patients.
Initiatives to improve end-of-life care are hampered by our nascent understanding of what quality care means to patients and their families. The primary purpose of this study was to describe what seriously ill patients in hospital and their family members consider to be the key elements of quality end-of-life care.
After deriving a list of 28 elements related to quality end-of-life care from existing literature, focus groups with experts and interviews with patients, we administered a face-to-face questionnaire to older patients with advanced cancer and chronic end-stage medical disease and their family members in 5 hospitals across Canada to assess their perspectives on the importance. We compared differences in ratings across various subgroups of patients and family members.
Of 569 eligible patients and 176 family members, 440 patients (77%) and 160 relations (91%) agreed to participate. The elements rated as "extremely important" most frequently by the patients were "To have trust and confidence in the doctors looking after you" (55.8% of respondents), "Not to be kept alive on life support when there is little hope for a meaningful recovery" (55.7%), "That information about your disease be communicated to you by your doctor in an honest manner" (44.1%) and "To complete things and prepare for life's end - life review, resolving conflicts, saying goodbye" (43.9%). Significant differences in ratings of importance between patient groups and between patients and their family members were found for many elements of care.
Seriously ill patients and family members have defined the importance of various elements related to quality end-of-life care. The most important elements related to trust in the treating physician, avoidance of unwanted life support, effective communication, continuity of care and life completion. Variation in the perception of what matters the most indicates the need for customized or individualized approaches to providing end-of-life care.
Treatment of suffering is a core mission of medicine. Communication about treatment planning with the patient and family, called the goals of care discussion, offers the opportunity to provide effective relief. Such communication is particularly important near the end of life, because many medical decisions are determined then by emotional considerations and personal values.
To define common unintended clinician behaviors, which impair discussion about goals of care near the end of life. To discuss the relationship between: (1) the medical decision-making responsibilities of patient and family, (2) clinician communication, (3) iatrogenic suffering, (4) the impact on medical decision-making, and (5) patient and family outcomes.
Thematic literature review.
The authors discuss how omission of the integral emotional and social elements of the goals of care discussion are reflected in five unintended clinician behaviors, each of which may impair medical decision-making and unknowingly induce patient and family suffering. We posit that such impaired decision-making and suffering may contribute to demands for ineffective, life-sustaining interventions made by the patient and family or, conversely, to requests for hastened death.
Understanding the challenges in the discussion about goals of care near the end of life will facilitate the development of more effective approaches to communication and shared decision-making. The authors hypothesize how decreased suffering through improved communication should diminish the occurrence of depression, anxiety disorders, and complicated grief in the patient and survivors, potentially improving medical outcomes. Proposed experiments to test this hypothesis will address important public health goals.
Advance care planning is the process of establishing a patient's goals and preferences for future care. Previous research has demonstrated a need to improve patient-physician communication around advance care planning. A critical time for advance care planning conversations is the day of admission to the hospital.
A survey of internal medicine residents was administered at Duke University Medical Center and the Brigham and Women's Hospital, 2 major academic teaching centers. Residents were questioned about their approaches to advance care planning on their last on-call admitting day.
Of 347 residents solicited, 292 (84.1%) participated in the survey. Residents reported that they established preferences for cardiopulmonary resuscitation (CPR) with 70.5% of patients, established a health care proxy with 33.7% of patients, discussed goals and values concerning end-of-life care with 32.0% of patients, and asked 35.6% of patients if they had an advance directive. Although 89.0% of residents had observed an advance care planning discussion model, only 66.4% had received teaching and 36.6% had received feedback about advance care planning conversations. In multivariable analysis, having received feedback about advance care planning conversations was associated with a higher percentage of conversations about health care proxy and goals and values related to the end of life.
Residents discuss patient preferences for CPR on the day of admission with most patients. Preparing residents, particularly through feedback, may improve communication around other elements of advance care planning.
Preparing healthcare professionals for teaching is regarded as essential to enhancing teaching effectiveness. Although many reports describe various faculty development interventions, there is a paucity of research demonstrating their effectiveness.
To synthesize the existing evidence that addresses the question: "What are the effects of faculty development interventions on the knowledge, attitudes and skills of teachers in medical education, and on the institutions in which they work?"
The search, covering the period 1980-2002, included three databases (Medline, ERIC and EMBASE) and used the keywords: staff development; in-service training; medical faculty; faculty training/development; continuing medical education. Manual searches were also conducted. Articles with a focus on faculty development to improve teaching effectiveness, targeting basic and clinical scientists, were reviewed. All study designs that included outcome data beyond participant satisfaction were accepted. From an initial 2777 abstracts, 53 papers met the review criteria. Data were extracted by six coders, using the standardized BEME coding sheet, adapted for our use. Two reviewers coded each study and coding differences were resolved through discussion. Data were synthesized using Kirkpatrick's four levels of educational outcomes. Findings were grouped by type of intervention and described according to levels of outcome. In addition, 8 high-quality studies were analysed in a 'focused picture'.
The majority of the interventions targeted practicing clinicians. All of the reports focused on teaching improvement and the interventions included workshops, seminar series, short courses, longitudinal programs and 'other interventions'. The study designs included 6 randomized controlled trials and 47 quasi-experimental studies, of which 31 used a pre-test-post-test design.
Despite methodological limitations, the faculty development literature tends to support the following outcomes: Overall satisfaction with faculty development programs was high. Participants consistently found programs acceptable, useful and relevant to their objectives. Participants reported positive changes in attitudes toward faculty development and teaching. Participants reported increased knowledge of educational principles and gains in teaching skills. Where formal tests of knowledge were used, significant gains were shown. Changes in teaching behavior were consistently reported by participants and were also detected by students. Changes in organizational practice and student learning were not frequently investigated. However, reported changes included greater educational involvement and establishment of collegiate networks. Key features of effective faculty development contributing to effectiveness included the use of experiential learning, provision of feedback, effective peer and colleague relationships, well-designed interventions following principles of teaching and learning, and the use of a diversity of educational methods within single interventions. Methodological issues: More rigorous designs and a greater use of qualitative and mixed methods are needed to capture the complexity of the interventions. Newer methods of performance-based assessment, utilizing diverse data sources, should be explored, and reliable and valid outcome measures should be developed. The maintenance of change over time should also be considered, as should process-oriented studies comparing different faculty development strategies.
Faculty development activities appear highly valued by participants, who also report changes in learning and behavior. Notwithstanding the methodological limitations in the literature, certain program characteristics appear to be consistently associated with effectiveness. Further research to explore these associations and document outcomes, at the individual and organizational level, is required.
Based on a proven six-step model and including examples and questions to guide application of those timeless principles, Curriculum Development for Medical Education is a practical guidebook for all faculty members and administrators responsible for the educational experiences of medical students, residents, fellows, and clinical practitioners. Incorporating revisions driven by calls for reform and innovations in medical education that challenge established teaching models, the third edition includes an awareness of new accreditation standards and regulatory guidelines. The authors have expanded their discussion of survey methodology for needs assessment and stress the importance of writing competency-based goals and objectives that incorporate milestones, entrustable professional activities, and observable practice activities. With updated examples focusing on interprofessional education, collaborative practice, and educational technology, they describe educational strategies that incorporate the new science of learning. A completely new chapter presents the unique challenges of curriculum development for large, long, and integrated curricula. © 1998, 2009, 2016 Johns Hopkins University Press. All rights reserved.
Purpose: Given the shortage of palliative care specialists in the United States, to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts.
Method: Proposed competencies were derived from existing hospice and palliative medicine fellowship competencies and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a Web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains.
Results: The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate = 72%, 71/98). Using predefined cutoff criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains.
Conclusions: This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community.
(C) 2014 by the Association of American Medical Colleges
IntroductionCommunicating ‘bad news’ to patients and their families can be difficult for physicians.Objective
This qualitative study aimed to examine residents’ perceptions of barriers to delivering bad news to patients and their family members.DesignTwo focus groups consisting of first- and second-year medical and surgical residents were conducted to explore residents’ perceptions of the bad news delivery process. The grounded theory approach was used to identify common themes and concepts, which included: (1) guidelines to delivering bad news, (2) obstacles to delivering bad news and (3) residents’ needs.SettingMcMaster University, Hamilton, Ontario, Canada.SubjectsFirst- and second-year residents.ResultsResidents were able to identify several guidelines important to communicating the bad news to patients and their family members. However, residents also discussed the barriers that prevented these guidelines from being implemented in day-to-day practice. Specifically, lack of emotional support from health professionals, available time as well as their own personal fears about the delivery process prevented them from being effective in their roles. Residents relayed the need for increased focus on communication skills and frequent feedback with specific emphasis on the delivery of bad news. The residents in our study also stressed the importance of processing their own feelings regarding the delivery process with staff.Conclusions
Although most residents realize important guidelines in the delivery of bad news, their own fears, a general lack of supervisory support and time constraints form barriers to their effective interaction with patients.
Performance-based workplace assessments are increasingly important in clinical training. Given the inaccuracy of self-assessment, the provision of external feedback to residents about their clinical skills is necessary for the development of expertise. However, little is known about the processes used by faculty members in giving feedback to residents after observing them with patients. This study explores the factors that underpin faculty members' decisions regarding the feedback they give to residents after directly observing them with patients and the factors that influence how feedback is delivered.
In 2009, 44 general internal medicine faculty staff responsible for out-patient resident teaching from 16 internal medicine residency programmes watched four videotaped scenarios and two live scenarios of standardised residents (SRs) with standardised patients and rated the SRs using the mini-clinical evaluation exercise (mini-CEX) format. Faculty staff also provided feedback to the SRs after the live encounters. After each encounter, faculty staff were individually interviewed using a semi-structured interview. Interviews were videotaped, transcribed and analysed using grounded theory methods.
Two broad themes were identified in faculty members' descriptions of the feedback process: variability in feedback techniques, and the factors that influence how faculty staff think and feel about delivering feedback. Multiple approaches to feedback delivery were observed. Faculty members' tensions in balancing positive and negative feedback, their own perceived self-efficacy, their perceptions of the resident's insight, receptivity, skill and potential, the faculty member-resident relationship and contextual factors impacted the feedback process.
The provision of feedback by faculty staff to residents after observing resident-patient interactions is a complex and dynamic process and is influenced by many factors. Understanding these cognitive and affective factors may provide insight into potential new approaches to faculty development to improve faculty staff's feedback skills and the effectiveness of their feedback.
As the medical education community celebrates the 100th anniversary of the seminal Flexner Report, medical education is once again experiencing significant pressure to transform. Multiple reports from many of medicine's specialties and external stakeholders highlight the inadequacies of current training models to prepare a physician workforce to meet the needs of an increasingly diverse and aging population. This transformation, driven by competency-based medical education (CBME) principles that emphasize the outcomes, will require more effective evaluation and feedback by faculty.Substantial evidence suggests, however, that current faculty are insufficiently prepared for this task across both the traditional competencies of medical knowledge, clinical skills, and professionalism and the newer competencies of evidence-based practice, quality improvement, interdisciplinary teamwork, and systems. The implication of these observations is that the medical education enterprise urgently needs an international initiative of faculty development around CBME and assessment. In this article, the authors outline the current challenges and provide suggestions on where faculty development efforts should be focused and how such an initiative might be accomplished. The public, patients, and trainees need the medical education enterprise to improve training and outcomes now.
Internal medicine residents frequently provide end-of-life care, yet feel inadequately trained and uncomfortable providing this care, despite efforts to improve end-of-life care curricula. Understanding how residents' experiences and attitudes affect their perceived competence in providing end-of-life care is important for targeting educational interventions.
Medicine residents (74) at the University of Washington and Medical University of South Carolina enrolled in a trial investigating the efficacy of a communication skills intervention to improve end-of-life care. On entry to the study in the fall of 2007, residents completed a questionnaire assessing their prior experiences, attitudes, and perceived competence with end-of-life care. Multivariate regression analysis was performed to assess whether attitudes and experiences with end-of-life care were associated with perceived competence, controlling for gender, race/ethnicity, training year, training site, and personal experience with death of a loved one.
Residents had substantial experience providing end-of-life care. In an adjusted multivariate model including attitudes and clinical experience in end-of-life care as predictors, only clinical experience providing end-of-life care was associated with self-perceived competence (P=.015).
Residents with more clinical experience during training had greater self-perceived competence providing end-of-life care. Increasing the quantity and quality of the end-of-life care experiences during residency with appropriate supervision and role modeling may lead to enhanced skill development and improve the quality of end-of-life care. The results suggest that cultivating bedside learning opportunities during residency is an appropriate focus for educational interventions in end-of-life care education.
If the pace of increase in life expectancy in developed countries over the past two centuries continues through the 21st century, most babies born since 2000 in France, Germany, Italy, the UK, the USA, Canada, Japan, and other countries with long life expectancies will celebrate their 100th birthdays. Although trends differ between countries, populations of nearly all such countries are ageing as a result of low fertility, low immigration, and long lives. A key question is: are increases in life expectancy accompanied by a concurrent postponement of functional limitations and disability? The answer is still open, but research suggests that ageing processes are modifiable and that people are living longer without severe disability. This finding, together with technological and medical development and redistribution of work, will be important for our chances to meet the challenges of ageing populations.
Physicians play a key role in the provision of quality end-of-life (EOL) care but often lack requisite knowledge and skills. Residency programs must ensure training in palliative/EOL care to address this gap.
To guide the development of curricula, we assessed internal medicine residents' attitudes, knowledge, perceived competence, and learning priorities in EOL care.
Cross-sectional, self-administered, descriptive survey using a convenience sample. Subjects: Internal medicine residents at five universities across Canada.
Of a total of 318 internal medicine residents, 185 (58%) participated in the survey. The majority (81.7%) agreed learning from dying patients was meaningful although 48.1% felt guilty, and 40.6% a failure at least sometimes after a patient's death. Two thirds had provided care to more than 10 dying patients. Most (73%) had conducted at least 3 family meetings; 26.7% were never observed. Mean self-assessed preparedness to provide EOL care was 6.1 +/- 2 (scale 0-10) and mean comfort level 3.2 +/- 0.8 (scale 0-5). Residents reported more than average competence in 50% of EOL competencies listed with record keeping highest (3.6 +/- 0.7) and use of nonpharmacologic interventions for pain lowest (2.2 +/- 0.8). Priority for learning was rated above average for all EOL competencies listed with use of opioids for management of pain highest (4.1 +/- 0.9) and discussing euthanasia lowest (3.1 +/- 1.3).
Internal medicine residents value opportunities to learn from dying patients but often lack supervision and experience emotional distress. Comparing residents' attitudes, perceptions of competence, and learning priorities provide insights into why certain EOL competencies are more challenging to teach and can guide development of meaningful educational experiences.
Internal medicine programs are now required to integrate palliative care into teaching conferences, and palliative care content is already tested on the American Board of Internal Medicine examination. Previous research has focused on integration of palliative care into existing rotations and seminars, but none has studied a required inpatient palliative care rotation.
We evaluate the impact of a required palliative care rotation for internal medicine residents in four domains: pain management, non-pain symptom management, communication/ethics, and terminal care.
All second-year internal medicine residents (R2s) completed a required 2-week rotation in inpatient palliative care, and were asked to complete a previously validated palliative care examination immediately before and within 2 weeks after the rotation. During the same year, all interns (R1s) were also asked to complete this examination, as were third-year residents (R3s) who had completed the rotation one year earlier, to provide a basis for comparison. Participation in the examination was voluntary for all.
All interns (100%), and 71% and 87% of R2s and R3s, respectively, completed the examination. Mean examination scores improved by 12.4% between internship and start of the palliative care rotation, and by an additional 9.7% by the end of the rotation. Mean examination scores were consistent from the R2 to the R3 year. At all levels, residents scored well above the national average on the examination. Scores improved in all domains measured.
Palliative care knowledge, as tested by objective examination, improves during internal medicine residency at our institution and specifically over the course of a required, 2-week palliative care rotation. Further study is warranted to determine the relative contributions to this improvement from the palliative care rotation itself, the institutional culture and/or Rochester residents' preexisting interest in the bio-psychosocial model.
Medical residents commonly discuss resuscitation decisions with hospitalized patients. Previous studies suggest that the quality of these discussions is poor.
To learn about residents' experience with do-not-resuscitate (DNR) discussions and their attitudes toward them.
Medical house officers on the wards of three teaching hospitals were eligible to participate. A subset had previously audiotaped actual DNR discussions as part of a study that described the quality of discussions. In a self-administered questionnaire, house officers rated their performance conducting a recent DNR discussion, stated their attitudes, and described their experience learning to talk to patients about these issues.
One hundred one (88%) of 115 residents responded to the survey. Eighty-six (90%) of 96 stated they had done a good job with the discussion and 78 (77%) of 101 reported feeling comfortable discussing the topic with patients. Ninety-four (94%) of 100 residents said they discuss code status with all seriously ill patients and while on the medical wards they conduct a median of one DNR discussion per week. On average, they had observed four discussions conducted by more senior clinicians. One third of the residents had never been observed talking to patients about DNR decisions and 71% had been observed two or fewer times.
These findings help explain the observations about the quality of DNR discussions. House staff "see" and "do" these discussions, but are not taught through observation and feedback. We recommend that communication about end-of-life treatment decisions be treated as a medical skill to be taught with the same rigor as other clinical procedures.
Communicating "bad news" to patients and their families can be difficult for physicians.
This qualitative study aimed to examine residents' perceptions of barriers to delivering bad news to patients and their family members.
Two focus groups consisting of first- and second-year medical and surgical residents were conducted to explore residents' perceptions of the bad news delivery process. The grounded theory approach was used to identify common themes and concepts, which included: (1) guidelines to delivering bad news, (2) obstacles to delivering bad news and (3) residents' needs.
McMaster University, Hamilton, Ontario, Canada.
First- and second-year residents.
Residents were able to identify several guidelines important to communicating the bad news to patients and their family members. However, residents also discussed the barriers that prevented these guidelines from being implemented in day-to-day practice. Specifically, lack of emotional support from health professionals, available time as well as their own personal fears about the delivery process prevented them from being effective in their roles. Residents relayed the need for increased focus on communication skills and frequent feedback with specific emphasis on the delivery of bad news. The residents in our study also stressed the importance of processing their own feelings regarding the delivery process with staff.
Although most residents realize important guidelines in the delivery of bad news, their own fears, a general lack of supervisory support and time constraints form barriers to their effective interaction with patients.
To examine the influence of education and clinical experience on residents' attitudes toward withdrawal of life support.
Self-administered survey.
Four Canadian teaching hospitals.
Residents rotating through four intensive care units.
The survey examined ethics education and experience regarding end-of-life care, importance of factors influencing withdrawal of life support, confidence in decisions, and recommendations for enhancing end-of-life education. The response rate was 83.9% (52 of 62). A minority of residents reported an appropriate amount of formal teaching on ethical principles (17.3%), patient-centered education (28.8%), and informal discussion (28.8%) before their intensive care unit rotation. During their rotation, most residents cared for patients in whom withdrawal of life support was considered. Although they usually attended family meetings, residents were never (34.6%) or rarely (42.3%) the primary discussant. Before the intensive care unit rotation, confidence in withdrawal decisions was related to male sex (p =.001) and previous patient-centered ethics education (p =.02). At the end of the intensive care unit rotation, only resident involvement in family meetings (p =.02) and being the primary discussant at such meetings (p =.01) were associated with confidence. After we adjusted for pre-rotation confidence in withdrawal of life support decision-making, the only predictor of post-rotation confidence was family meeting involvement (p <.001). Residents recommended more patient-centered discussion, observation of attending physicians discussing end-of-life issues, and opportunity to lead family meetings.
Experiential, case-based, patient-centered curricula are associated with resident confidence in withdrawal of life support decisions in the intensive care unit.
Communication of bad news to patients or families is a difficult task that requires skill and sensitivity. Little is known about doctors' formative experiences in giving bad news, what guidance they receive, or what lessons they learn in the process.
To learn the circumstances in which medical residents first delivered bad news to patients or families, the nature of their experience, and their opinions about how best to develop the needed skills.
Confidential mailed survey.
All medicine house officers at 2 urban, university-based residency programs in Boston.
Details of medical residents' first clearly remembered experiences of giving bad news to a patient or family member; year in training; familiarity with the patient; information about any planning prior to, observation of, or discussion after their first experience; and the usefulness of such discussions. We also asked general questions about delivering bad news, such as how often this was done, as well as asking for opinions about actual and desired training.
One hundred twenty-nine of two hundred thirteen surveys (61%) were returned. Most (73%) trainees first delivered bad news while a medical student or intern. For this first experience, most (61%) knew the patient for just hours or days. Only 59% engaged in any planning for the encounter. An attending physician was present in 6 (5%) instances, and a more-senior trainee in 14 (11%) others. Sixty-five percent of subjects debriefed with at least 1 other person after the encounter, frequently with a lesser-trained physician or a member of their own family. Debriefing focused on the reaction of those who were given the bad news and the reaction of the trainee. When there were discussions with more-senior physicians, before or after the encounter, these were judged to be helpful approximately 80% of the time. Most subjects had given bad news between 5 and 20 times, yet 10% had never been observed doing so. Only 81 of 128 (63%) had ever observed an attending delivering bad news, but those who did found it helpful 96% of the time. On 7-point scales, subjects rated the importance of skills in delivering bad news highly, (mean 6.8), believed such skill can be improved (mean 6.6), and thought that more guidance should be offered to them during such activity (mean 5.8).
Medical students and residents frequently deliver bad news to patients and families. This responsibility begins early in training. In spite of their inexperience, many do not appear to receive adequate guidance or support during their earliest formative experiences.
Communication skills training is now internationally accepted as an essential component of medical education. However, learners and teachers in communication skills programs continue to experience problems integrating communication with other clinical skills, ensuring that clinical faculty support and teach communication beyond the formal communication course, extending communication training coherently into clerkship and residency, and applying communication skills in medical practice at a professional level of competence. One factor contributing to these problems is that learners confront two apparently conflicting models of the medical interview: a communication model describing the process of the interview and the "traditional medical history" describing the content of the interview. The resulting confusion exacerbates the above dilemmas and interferes with learners using communication skills training to advantage in real-life practice. The authors propose a comprehensive clinical method that explicitly integrates traditional clinical method with effective communication skills. To implement this more comprehensive approach, they have modified their own Calgary-Cambridge guides to the medical interview by developing three diagrams that visually and conceptually improve the way communication skills teaching is introduced and that place communication process skills within a comprehensive clinical method; devising a content guide for medical interviewing that is more closely aligned with the structure and process skills used in communication skills training; and incorporating patient-centered medicine into both process and content aspects of the medical interview. These enhancements help resolve ongoing difficulties associated with both teaching communication skills and applying them effectively in medical practice.
To compare the effectiveness of information delivered to family members of critically ill patients by junior and senior physicians, we performed a prospective randomized multicenter trial in 11 French intensive care units. Patients (n = 220) were allocated at random to having their family members receive information by only junior or only senior physicians throughout the intensive care unit stay; there were 92 and 93 evaluable cases in the junior and senior groups, respectively, with no significant differences in baseline characteristics. Between Days 3 and 5, one family representative per patient was evaluated for comprehension of the diagnosis, prognosis, and treatment in the patient; satisfaction with information and care; and presence of symptoms of anxiety and depression. No significant differences were found between the two groups for any of these three criteria. Family members informed by a junior physician were more likely to feel they had not been given enough information time (additional time wanted: 3 [0-6.5] vs. 0 [0-5] minutes, p = 0.01) and to have sought additional explanations from their usual doctor (48.9 vs. 34.4%, p = 0.004). Specialty residents, if given opportunities for acquiring experience, can become proficient in communicating with families and share this task with senior physicians.
Relationship-Centered Care acknowledges the central importance of relationships in medical care. In a similar fashion, relationships hold a central position in medical education, and are critical for achieving favorable learning outcomes. However, there is little empirical work in the medical literature that explores the development and meaning of relationships in medical education. In this essay, we explore the growing body of work on the culture of medical school, often termed the "hidden curriculum." We suggest that relationships are a critical mediating factor in the hidden curriculum. We explore evidence from the educational literature with respect to the student-teacher relationship, and the relevance that these studies hold for medical education. We conclude with suggestions for future research on student-teacher relationships in medical education settings.
The authors describe the philosophy and pedagogical approach of an innovative educational program, grounded in principles of relational learning and designed to improve the preparedness of health care professionals for engaging in challenging conversations with patients and families. The Program to Enhance Relational and Communication Skills (PERCS) is a project of The Institute for Professionalism and Ethical Practice at Children's Hospital Boston, developed in collaboration with Education Development Center, Inc. The one-day workshop is interdisciplinary in its structure, includes practitioners with varying levels of professional experience, uses trained actors to portray patients and family members, and involves learners in improvised case scenarios. The program responds to several developments in contemporary health care: medical education reform, changing definitions of professional competence, and calls for greater attention to qualities of compassion, trust, and respect in practitioners' relationships with patients and families. The program's pedagogy responds to these developments by creating a safe climate for relational learning, by enacting emotionally challenging and ethically salient case scenarios, and by integrating patient and family perspectives in novel and substantive ways. By creating a curriculum and learning environment that explicitly embraces the moral experience of learners, the program's developers aim to exert a countercultural influence on the dehumanizing effects of the hidden curriculum.
To explore the ways in which seriously ill hospitalized patients, their family members and physicians interpret the discussion of the patient's preferences for cardiopulmonary resuscitation (CPR).
Resident physicians, their patients, and family members were interviewed following a discussion regarding preferences for CPR. We sought the participants' perceptions of the resulting decision, examined how often these interpretations differed, and explored the communicative factors underlying discrepancies when they occurred.
Fifty-six interviews with 28 matched dyads were completed. In six dyads (21%), the participants reported differing results of the discussion. Two patients had orders to limit their care based on the physician's interpretation of their discussion. Another two patients who did not want resuscitation lacked a DNR order. Two patients did not recall having the conversation. These discrepancies could be attributed to the physician misconstruing the patient's wishes, interference of a family member, and fluctuating preferences.
Discrepant interpretations of a DNR discussion occur with a concerning frequency between resident physicians and their hospitalized patients.
Educational efforts should focus on training physicians to clarify the language used in these discussions, remain vigilant about discerning the patient's preferences, and be aware that these preferences may be contextually fluid.
Creating and Redesigning Curricula: A CanMEDS Guide for Clinical Education. Ottawa, ON: The Royal College of Physicians and Surgeons of Canada
- J Sherbino
- J Lockyer
Sherbino J, Lockyer J. Mind the gap: educational
needs assessment. In: J Sherbino and J Frank, eds.
Creating and Redesigning Curricula: A CanMEDS
Guide for Clinical Education. Ottawa, ON: The Royal
College of Physicians and Surgeons of Canada; 2011.
Royal College of Physicians and Surgeons of Canada
- Canada Ottawa
Ottawa, Canada: Royal
College of Physicians and Surgeons of Canada, 2011.
Available
from:
http://www.royalcollege.ca/cs/groups/public/docum
ents/document/y2vk/mdaw/~edisp/tztest3rcpsced00
910.pdf. Accessed March 10
th
, 2016.