Abstract
Background:
Home hemodialysis (HHD) prevalence is low in the United States; thus, nephrology fellows may have limited HHD clinical experience and be hesitant to counsel suitable patients. We describe a formative HHD counseling simulation scenario, part of a previously described nephrology-specific formative Objective Structured Clinical Examination (OSCE) that assesses fellow counseling skills using validated assessment instruments.
Methods:
During a 20-minute simulation, fellow performance was assessed by a standardized patient using the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS) and by faculty using an HHD-specific Mini-Clinical Evaluation Exercise (Mini-CEX). Overall, EEC-GRS and Mini-CEX scores were the primary outcome measures. After the simulation, fellows were surveyed anonymously regarding satisfaction with the scenario and HHD clinical experience/education. Program directors reported HHD curriculum components. Fellow performance was analyzed by training year.
Results:
Four programs (19 fellows: 10 first-year, nine second-year) participated. All had an HHD curriculum. Three offered HHD training courses but no HHD clinic. One had a longitudinal HHD clinic (two first-year and two second-year fellows) but did not offer a training course. There were no significant differences in overall EEC-GRS or Mini-CEX scores between first- and second-year fellows. No fellow had an unsatisfactory overall score. On the post-OSCE survey (37% response rate), six of seven (86%) responding fellows agreed/strongly agreed that the simulation increased their “comfort in discussing HHD with a patient.”
Conclusion:
This educational, formative HHD counseling scenario, part of a previously described OSCE, is a low-risk opportunity for fellows to practice patient communication skills and appears to increase fellow comfort in discussing HHD.
Introduction
In the United States, the Centers for Medicare & Medicaid Services (CMS) is focused on reducing costs and improving end-stage kidney disease outcomes by increasing transplantation and home dialysis.1,2 Home dialysis prevalence has increased, but home hemodialysis (HHD) rates remain low. 3 Patients are unevenly distributed geographically and are less prevalent in urban and high social deprivation index areas. 2 Some nephrology fellows have little to no clinical HHD experience and may be hesitant to counsel patients. 4 Lack of pre-dialysis counseling and education are barriers to patient selection of home dialysis.5,6
We previously described a formative “Breaking Bad News” (BBN) objective structured clinical examination (OSCE) (for nephrology fellows that assesses interpersonal communication skills (ICSs), professionalism, and medical knowledge (MK). 7 This OSCE simulates patient counseling for acute and long-term kidney replacement therapy and kidney biopsy, using previously validated instruments, the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS), and the Mini-Clinical Evaluation Exercise (Mini-CEX).8,9 Here, we describe an additional educational scenario for the existing OSCE that simulates counseling a patient considering HHD.
Methods
The HHD counseling scenario was designed to be added to a previously published formative OSCE. 7 Existing scenarios simulate counseling for acute dialysis in a critically ill patient, chronic kidney replacement therapy, and kidney biopsy. The HHD scenario clinical summary (Supplement) describes a patient failing peritoneal dialysis due to recurrent infections who is considering HHD therapy.
Fellows were given the opportunity to review the HHD core curriculum before the day of the OSCE. 10 Simulated patients (SPs) and fellows received the clinical summary before the simulation. The encounter lasted 15 minutes, followed by a five-minute feedback session. Fellows were reassured beforehand that they might not be able to finish within the allotted time.
The SPs were trained to portray the patient, rate fellow performance, and provide feedback. They assessed fellow ICS and professionalism using the previously validated, open-source, eight-component EEC-GRS, which includes a summary/overall patient satisfaction rating.7,8 The overall rating is on a five-point scale with a midpoint rating of 3 (Satisfactory; “I would return to this clinician”).
Faculty observed the encounter via a one-way glass mirror or real-time camera/video recorder after receiving the same clinical summary as the fellow and SP. They assessed ICS, professionalism, and MK using an HHD-specific anchored five-point Likert scale Mini-CEX, which included an overall rating (3 = Satisfactory for Level of Training) (Supplement).7,9
After the encounter, fellows, SPs, and faculty met for a five-minute feedback session. Subsequently, all were invited to complete online anonymous feedback/satisfaction surveys.
In May 2023, the scenario was beta-tested as part of the annual BBN OSCE at Walter Reed National Military Medical Center. 7 Five fellows, two SPs, and five faculty provided feedback. All (12 of 12) were satisfied/very satisfied with the simulation, and all agreed/strongly agreed that it allowed assessment of fellow communication skills regarding HHD risks, benefits, and logistics. Two felt the time allotted was too short. For the finalized scenario, we adopted suggestions that the HHD core curriculum should be reviewed beforehand 10 and some clinical summary clarifications.
We then tested fellow performance and satisfaction with the HHD scenario. The study flow diagram, patient clinical summary, OSCE description, program director checklist, Mini-CEX, and post-OSCE survey are in the Supplement. Each program was assigned a random number. Program directors assigned anonymous numbers to fellows (differentiated by training year), faculty, and SPs. Outcome data were forwarded to the principal investigator (CMY) using the anonymous numbers. Program directors indicated HHD curriculum components prior to testing.
Statistical Analysis
Primary outcomes were overall EEC-GRS and Mini-CEX scores; the secondary outcome was one or more unsatisfactory scores (≤2) on a Mini-CEX sub-component. Percentages, means (SDs), and counts were reported as appropriate. Comparisons between groups were made using Fisher’s exact test or unpaired t-test (2-tailed) as appropriate, with P < .05 considered significant.
We estimated that 17 fellows in each group were necessary to differentiate between overall EEC-GRS or Mini-CEX scores of 3 ± 1 vs 4 ± 1 (alpha = 0.05; beta = 0.80). 7 Because recruitment fell short of this, we performed an exploratory analysis of first- vs second-year fellow scores, presuming that second-year fellows had more didactic and clinical HHD exposure than first-years.
Results
We approached 12 nephrology programs (77 fellows). Seven programs (37 fellows) agreed to participate, and four programs (19 fellows) were able to proceed. Of these 19 fellows, 10 were first-year, and nine were second-year. Simulations took place between January and June 2024.
All programs had an HHD curriculum. Three (15 fellows: eight first-year, seven second-year) offered HHD training course attendance but had no block/longitudinal HHD clinic experience. One (four fellows: two first-year and two second-year) provided a longitudinal HHD clinic experience (both years) but did not offer a training course. All offered didactics, and three offered experience with dialysis machines used for HHD.
Table 1 shows fellow HHD training experience and OSCE HHD scenario performance overall and by training year. No fellow had an unsatisfactory overall score on the EEC-GRS or Mini-CEX. The percentage with unsatisfactory Mini-CEX sub-component scores was not significantly different between training years. The Mini-CEX sub-component domain most frequently rated unsatisfactory (five fellows) was “Explains the process of HHD training and transition to home.”
Performance of Fellows on the Home Hemodialysis (HHD) Counseling Scenario.
Note. EEC-GRS and Mini-CEX scores are reported as mean ± SD. EEC-GRS = Essential Elements of Communication-Global Rating Score; SP = simulated patient; Mini-CEX = Mini-Clinical Evaluation Exercise.
No fellow had an unsatisfactory overall score on the EEC-GRS or the Mini-CEX.
Unpaired t-test.
Fisher’s exact test.
Mini-CEX subcomponent domains with unsatisfactory scores:
Domain 2: risks and benefits.
Domain 3: addressing patient fears.
Domain 5: HHD training and transition to home.
Seven of 19 fellows (37%) responded to, and seven of seven (100%) fellows completed the post-OSCE survey: four first-year and three second-year (Supplement Figure 1). None had personally cared for HHD patients during the fellowship. Three had discussed HHD with a patient planning chronic kidney replacement therapy. Six of seven (86%) agreed/strongly agreed that the simulation increased their “comfort in discussing HHD with a patient.” Five of seven rated the HHD OSCE as “Excellent” or “Good”; two of seven rated it as “Fair.” Two indicated that they needed more time for the encounter, and one indicated that they personally needed more patient experience.
One faculty preceptor completed the survey, rating it “excellent,” with the strength being fellows’ ability to address HHD benefits and barriers, but not enough time to fully address these as a weakness. One program director indicated that the exercise allowed identification of HHD curriculum gaps, specifically information about HHD training and transition to home.
Discussion
This educational, formative HHD OSCE scenario permits fellows to practice counseling a patient for HHD and assess their ICS skills and MK with validated tools (EEC-GRS and Mini-CEX).7-9 Program directors may use the results to evaluate the curriculum. The scenario may be added to the existing “Breaking Bad News” OSCE or used as a stand-alone exercise. 7
Second-year fellows did not have better overall EEC-GRS or Mini-CEX scores than first-years. All fellows had the opportunity to review the HHD core curriculum before the simulation, 10 and this may have led to better Mini-CEX performance. The EEC-GRS scores did not differ significantly between first- and second-year fellows in the original three-scenario BBN OSCE, suggesting that fellows (who are late in post-graduate training) achieve effective ICS and professionalism counseling skills earlier in training. 7
On the survey, responding fellows were satisfied with/recognized the purpose of the scenario, and comfort with counseling a patient for HHD increased. Faculty (one surveyed and one directly) reported that the scenario produced actionable feedback and identification of knowledge and curriculum gaps.
Strengths
Scenario content was developed by an HHD unit director (NG), used at a program with a robust longitudinal HHD clinic, and based on an HHD core curriculum. 10 Validated assessment tools were used. It was beta-tested at a program without an HHD clinic experience, and fellows, faculty, and SPs were satisfied with the content. The pre-OSCE review of an HHD core curriculum permits fellows, regardless of direct HHD clinic experience, to review concepts before the simulation. 10 The MK required is that of a general nephrologist, who must be able to counsel patients about HHD.1,2,5,6,10
Weaknesses
The study was underpowered. We approached 12 programs; four were able to participate. Only one had direct HHD clinic experience. Thus, we were unable to test the effect of HHD clinic experience on overall EEC-GRS and Mini-CEX scores, which would have required 17 fellows per group (and > one program per group). The response rate for the voluntary, anonymous, online fellow survey was only 37%. This is less than for the original BBN OSCE (a paper-based survey, done immediately after the OSCE, using an anonymous fellow identifier), but it is greater than the 22% response seen in our recent survey of fellows regarding HHD curriculum.4,7
Several programs could not access a simulation center and did not participate. Practical alternatives might include having a staff member, rather than an SP, portray the patient. Faculty might observe fellows counseling a real patient and use the Mini-CEX checklist to assess the interaction. The OSCE could be conducted in the home dialysis clinic, but with an SP or staff portraying the patient, and a webcam activated for the observing faculty. Working from the real clinic environment may increase authenticity.
Conclusion
This educational, formative simulation allows fellows to practice HHD counseling in a low-risk setting, after studying a basic HHD review. 10 It may better prepare them to participate in shared decision-making with patients who have advanced chronic kidney disease (CKD) and are exploring options for kidney replacement therapy. 4
Supplemental Material
sj-docx-1-cjk-10.1177_20543581261450844 – Supplemental material for Addition of a Home Hemodialysis Counseling Scenario to an Existing Formative Objective Structured Clinical Examination (OSCE) for Nephrology Fellows: A Research Letter
Supplemental material, sj-docx-1-cjk-10.1177_20543581261450844 for Addition of a Home Hemodialysis Counseling Scenario to an Existing Formative Objective Structured Clinical Examination (OSCE) for Nephrology Fellows: A Research Letter by Nupur Gupta, Megha R. Joshi, Daniel Landry, Zain Mithani, Ross J. Scalese, Amy N. Sussman and Christina M. Yuan in Canadian Journal of Kidney Health and Disease
Footnotes
Acknowledgements
We would like to thank the fellows (Drs Christopher Middleman, Christina Blum, Matthew Baker, Jason Jones, and Andrew Howard) and faculty (Drs Robert Nee, James D. Oliver III, Brian Y’Barbo, and Sarah Gordon) at Walter Reed National Military Medical Center who beta-tested the scenario in 2023. We would also like to thank all simulation center personnel and standardized patients who administered the scenario.
Ethical Considerations
The protocol, EDO, 2024-136, 968012, was approved as exempt from IRB review per 32 CFR 219.104(d)(2)(i) by the Department of Research Protections, Walter Reed National Military Medical Center (WRNMMC).
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: President-elect, National Forum of ESRD Networks (DL) and Administrator, Nephrology Education Research and Development Consortium (CMY).
Disclaimer
The views expressed are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense or the US government.
Supplemental Material
Supplemental material for this article is available online.
References
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