Abstract
Background:
Communication skills are foundational to the practice of medicine and training to build them is recommended. Serious illness communication skills (SICSs) teaching is inconsistently and sparsely taught in postgraduate training and residents report feeling inadequately trained to have difficult conversations. The authors developed an e-module demonstrating high-yield communication skills from a known evidence-based training program to standardize core SICS teaching and questioned how using it before skills practice impacted comfort and preparedness for residents to complete advance care planning (ACP).
Methods:
Family medicine residents at an academic hospital in Toronto, Canada, completed a novel e-module that replaced a typical didactic-lecture introducing core SICS relevant to ACP conversations. Residents then discussed the skills, followed by practicing them deliberately in a structured role-play simulation with feedback by trained facilitators. Residents completed pre- and post-intervention attitudinal surveys.
Results:
Residents preferred a combination of learning modalities and welcomed online and virtual teaching methods for learning SICS. Residents reported higher levels of preparedness for engaging in ACP, delivering serious news, and discussing goals of care post-intervention. Residents showed more interest in discussing ACP post-intervention but questioned feasibility for doing so in busy ambulatory clinics.
Conclusion:
Scalable time-efficient teaching strategies are needed to fill a known education gap. This study demonstrated benefits of incorporating brief e-module learning into residents’ preparation for SICS training using deliberate practice simulation training. The online, interactive virtual training improved resident readiness and comfort for ACP, an area often overlooked in medical education. Moreover, it provides an evidence-informed standardized tool for clinician teachers to seamlessly incorporate into their teaching practices.
Introduction
Communication skills are foundational to the practice of medicine with training to develop these skills being strongly recommended.1,2 Serious illness communication skills (SICS) such as disclosing serious news, responding to emotion, and making treatment recommendations are critical to leading high-quality advance care planning (ACP) conversations and comprise required communication competencies for family medicine residents.3–6 Completing ACP has myriad benefits including leading to better documentation of patients’ end-of-life (EOL) wishes, improved quality of EOL care, and increased patient/family satisfaction of care received. 7 Yet, SICS teaching is inconsistently and sparsely taught in postgraduate training,2,8 and residents report feeling inadequately trained to have difficult conversations. 2 When taught, common postgraduate communication teaching methodologies include observation, didactic lectures, and simulation. 8 These teaching methods are dependent on faculty and learners devoting time synchronously 8 and risk variation in faculty knowledge and teaching proficiency that can lead to undesirable inconsistencies in student learning.
Simulation training from a well-known SICS training organization, VitalTalk (vitaltalk.org), has been used at one of the training sites at our institution since 2018. This evidence informed training program, taught by faculty that completed VitalTalk’s train-the-trainer course to strengthen and standardize local teaching delivery, provides learners and faculty with a structured and replicable approach to developing SICS supporting high-quality ACP. 9
At present, family medicine trainees at one site engage annually in a three-hour workshop, powered by VitalTalk, to learn about and practice SICS guided by the approach described in Childers. 10 The first hour comprises an interactive lecture introducing skills such as sharing serious health information and responding to emotion. The remainder of the workshop focuses on small group sessions dedicated to deliberate practice of SICS with simulated patients using cases tailored specifically for family medicine and have been locally developed.
At our institution, family medicine residents are assigned to train at one of 14 distributed sites, each with its own unique approach to teaching a core curriculum. This results in variability in SICS instruction, if provided at all. We completed a local needs assessment that identified family medicine trainee preferences to learn about SICS asynchronously and before attending simulation training. To respond to these needs, we developed an e-module to standardize the SICS taught in a “powered by VitalTalk workshop”, made it accessible online, and piloted its use during one of our routine workshops. The aim was to test its feasibility with family medicine residents, determine its impact on residents’ preparedness for ACP, and inform potential scaling across the training sites.
Methods
First and second-year family medicine residents at an academic hospital in Toronto, Canada participated in one three-hour virtual SICS workshop powered by VitalTalk. The workshop was integrated into the trainees’ protected teaching schedule and comprised e-module, discussion, and simulation activities. The e-module was created by the lead study author. The workshop structure is outlined in Figure 1.
Outline of structure for the residents’ 3-hour workshop.
Residents completed voluntary and anonymous surveys requesting demographic information and assessing their perceived preparedness for ACP discussions, as well as their attitudes toward ACP training and practice. Surveys were completed online at the beginning and end of the workshop (Appendix 1). We could not find a validated survey that met our criteria, and so the authors developed one for this project.
Survey responses from the Likert scales were recoded to binary positive (>5) and neutral or negative (≤4) then analyzed with McNemar’s test for dependent proportions with Edward’s correction.
Research ethics board exemption was provided by our institution. (QI ID #22–0496).
Results
Demographics
A total of 16 out of 23 (70%) eligible family medicine residents participated in the workshop. Fifteen (94%) were included in the analysis due to an incomplete post-survey from one respondent. Baseline characteristics are reported in Table 1.
Family Medicine Resident Participant Demographics
Preparedness
Residents’ perceived preparedness towards ACP shows improvement consistently across questions, although not statistically significant (Table 2). Residents felt more prepared to engage in ACP discussions (pre = 0%, post = 0.13%, p value = 0.48), to deliver serious news (pre = 0.13%, post = 0.2%, p value = 1), to elicit a patient’s goals of care (pre = 0%, post = 0.13%, p value = 0.48), and to discuss treatment options (pre = 0.067%, post = 0.13%, p value = 1).
Resident Reported Level of Preparedness towards Key ACP Topics before and after Training
Attitudes towards the training
Over half of the residents preferred a combination of teaching methods (n = 8, 53%) including e-module, discussion, and simulation, over any single educational modality alone for ACP learning. Over half the residents (n = 9, 60%) preferred to learn pre-simulation knowledge through an e-module instead of a didactic lecture and most agreed the e-module (n = 13, 87%) and simulation (n = 13, 87%) was beneficial to their learning. Only 4/15 residents provided written feedback and no themes identified.
Attitudes towards ACP
Post-intervention, residents reported a higher level of agreement with the following statements: “I have had sufficient practice with discussing ACP” (pre = 0.27%, post = 0.33%, p value = 1), and “My residency program has provided sufficient education on ACP” (pre = 0.2%, post = 0.53%, p value = 0.074). The training significantly increased their willingness to initiate ACP conversations (pre = 0.47%, post = 0.6%, p value = 0.48), but there was minimal change to residents’ views that ACP is feasible during routine clinic visits (pre = 0.2%, post = 0.33%, p value = 0.25). (Table 3).
Residents’ Perceived Level of Agreement towards ACP and Residency Training Pre and Post Intervention
Discussion
This Canadian study, focusing on a virtual VitalTalk-powered SICS workshop for family medicine residents, showcased the effectiveness of incorporating both e-module and simulation learning. Introducing practical, evidence-based SICS through an e-module followed by deliberate practice with observed feedback resulted in an increase in family medicine residents’ perceived preparedness to engage in ACP.
Previous studies using VitalTalk-powered workshops have shown improvement in the same direction in preparedness to use skills, however necessitated more time to complete.11,12 The ever-increasing demands on both learner and faculty time, combined with a palliative care workforce shortage, 13 makes it imperative to find scalable, resource-efficient methods of teaching this important competency.
This study demonstrated that incorporating e-module learning into a known three-hour virtual SICS workshop is feasible. The e-module may also be used independently from a workshop and standardizes the evidence-based teaching of foundational SICS for sites. Once learners are given access to the e-modules, they can be reviewed online at any time and from anywhere. Should the e-modules prove to be an equally effective way of teaching learners these concepts, this will open up new possibilities of aligning instruction with best practices in education, such as distributed practice. 14 In addition to being beneficial for learners, having access to a standardized e-module enables faculty to have a clear standard they can teach from and evaluate learners against, as well as incorporate into their curriculum. Furthermore, we postulate that the e-module may also have benefits to skill building, honing practice, and teaching acumen for faculty unable to access or devote the time to continuing medical education courses on this topic through observing the skills and structure in the e-modules.
Residents welcomed the multimodal teaching methods used in this study. The novel 30-minute e-module replaced a didactic lecture and made time for facilitated discussion, which provides residents with the opportunity to learn through social learning with an experienced facilitator and peers. Moreover, additional time-savings may extend to faculty interested in incorporating the already-prepared e-module into their teaching. Finally, asynchronous pre-workshop completion of the e-module could add further benefit by affording more time for deliberate skills practice in simulation.
Residents in this study felt more prepared to engage in ACP but did not agree that ACP was feasible in a routine family clinic visit, even after completing the training. This may be owing to the perceived time required for fulsome and iterative ACP conversations that may not be conducive to the busy family medicine clinic environment. Future studies are needed to assess how best to train clinicians to practically deliver ACP in the clinic setting.
Limitations
Our study has several limitations, including the small sample size from a single institution, which may impact generalizability of the findings, as well as reliance on unvalidated self-assessment metrics. Additionally, this study did not include follow-up measures to determine if preparedness towards ACP was maintained over time or if it translates into skill competency in practice. Future research is needed to determine the type and amount of SICS training needed to support longitudinal behavior change, and importantly if integrating SICS into practice is associated with good patient-reported experience measures 15 related to ACP and subsequent goal-concordant care.
Additionally, many postgraduate programs may be unable to add to their existing busy curricula or may prioritize other competencies 5 in their curriculum. At our institution, core protected teaching across sites occurs weekly for three hours, and therefore, this workshop has the potential to be scaled across at training sites. This would either require investment in faculty development or utilizing an already-trained cohort of teaching faculty to virtually deliver the programming across sites, which may be cost-saving.
Conclusion
Effective communication is an essential competency for practicing clinicians and plays a pivotal role in delivering serious illness care. This pilot study described a novel and scalable SICS online teaching tool that, combined with simulated role-play, enhanced resident knowledge and preparedness towards ACP. Next steps include evaluating the asynchronous use of the e-module before the workshop and assessing faculty attitudes toward incorporating the e-module into curriculum, aiming to expedite the closure of the communication skills teaching gap.
Footnotes
Author Disclosure Statement
Drs. Lewin, Kaasa, Mizdrak, and James completed VitalTalk faculty development training. They completed this training to hone and strengthen skills to deliver simulation based serious illness communication skills training. Faculty are licensed to use VitalTalk materials and teaching tools at their local institution. The distributed teaching sites in this study are a part of one educational institution.
Funding Information
This project was funded by a generous donation made to the UHN Foundation for the Department of Supportive Care to enhance serious illness care. It funded the development and delivery of the online e-module and the standardized patients used for simulation training.