Abstract
Background
Physician trainees are not provided with routine practice opportunities to have a serious illness conversation, which includes a discussion of patient expectations, concerns, and preferences regarding an advancing illness.
Objective
To test the acceptability of incorporating a serious illness conversation into routine trainee practice.
Methods
Residents in an internal medicine program conducted a serious illness conversation in the ambulatory care setting with the assistance of a conversation guide. Semi-structured interviews determined trainees’ perceptions of the educational intervention. Patients were surveyed to understand their experience.
Results
Twenty-one trainees had at least one opportunity to practice having a serious illness conversation and completed a majority of the conversation elements. In semi-structured interviews, trainees expressed the belief that the serious illness conversation should be an important component of routine patient care, understood that patients are willing to have these conversations, discovered that patients did not have a clear understanding of their prognosis, and said that time is the main barrier to having these conversations more consistently. Patients found the conversation to be important (92%), reassuring (83%), and of higher quality than the communication of a usual doctor visit (83%).
Conclusions
With preparation, time, and a conversation guide, trainees completed the elements of a serious illness conversation and found it to be an important addition to their routine practice. Patients found the conversation to be important, reassuring, and of better quality than their usual visits.
Keywords: Graduate medical education, Communication training, Palliative care, Advance care planning
Introduction
In order for physicians to provide effective care to seriously ill patients, they must feel comfortable initiating and navigating conversations that align care plans with patients’ expectations, preferences, and concerns. These conversations, often referred to as “serious illness conversations” [1], are a crucial component of advance care planning. Given all of its benefits—decreasing unwanted medical treatments at the end of life, and increasing satisfaction and hospice enrollment—advance care planning has become a priority for the Institute of Medicine and the Centers for Medicare and Medicaid [2–8]. Even though patients report that they find these conversations valuable, and reassuring, and expect their physicians to initiate them [9–11], not enough physicians set aside the time. If they do, it is often late in the illness trajectory [12–15].
The reasons are complex. One study shows that physician trainees feel that they lack time and are hesitant to discuss death with patients and families [12]. Other reasons physicians may shy away from these conversations include lack of experience or skill, belief that it is upsetting to patients or will deprive them of hope, belief that patients should initiate the discussion, and discomfort with communicating a prognosis [14, 16, 17]. When physicians do start these conversations, they focus on symptoms, prognosis, and biomedical details rather than on spiritual and social concerns, which tend to be more important to patients [15, 18]. In fact, when presented with opportunities to start such a conversation—for example, when patients express concerns and questions about the future—physicians often change the subject or deny the expressed emotion [19].
Research suggests that as physicians gain experience having these conversations with their patients, they are more likely to initiate such a conversation and feel comfortable communicating a prognosis, and they are less likely to believe that it takes too much time or is upsetting to patients [14]. In order to prepare trainees to have these serious illness conversations with their future patients, they require routine opportunities to practice in training [7, 20, 21].
Current interventions to improve trainee communication skills often consist of didactic lectures, watching videos, or role playing. The teaching is done in intensive workshops that require time away from clinical duties. Though opportunities for role playing with standardized patients appear promising, most of these interventions have shown little retention of benefit [21–23]. More recent interventions have focused on sustained educational activities that include practice using communication skills with patients in a continuity clinic. Interventions that include practice and experiential learning are most promising and increase trainees’ willingness to initiate a serious illness conversation and boost their confidence in eliciting a patient’s values, preferences, and concerns [24, 25].
This is not surprising, since experiential learning theory suggests that skill acquisition in medicine occurs when trainees have a concrete experience, reflect on that experience, formulate conceptualizations and generalizations, and test them in a new situation [26–28]. In order for trainees to attain competence in communication, they require the opportunity for steady practice and feedback as they would receive in other clinical duties [27].
We aimed to test the acceptability of having physician trainees practice serious illness conversations with their patients in a standard format ambulatory care clinic encounter. This was done as a separate clinical experience under the supervision of a palliative medicine attending and with the assistance of a conversation guide [29, 30]. The objective was to show that physician trainees could independently complete most elements of a serious illness conversation and find it to be a valuable addition to their training.
Methods
Over a six-month period, all second- and third-year internal medicine trainees on their ambulatory rotation were assigned to a general medicine clinic session where the clinical encounter was dedicated to having a serious illness conversation with a patient suffering from a chronic, serious illness. In order to support trainees in this unique clinical practice, they were precepted by an attending who is board certified in Hospice and Palliative Medicine and were provided with a conversation guide modeled after the Ariadne Labs’ Serious Illness Conversation Guide [30]. The conversation guide is at the heart of Ariadne Labs’ Serious Illness Care Program that is meant to provide clinicians with the language to have important conversations with their patients. The conversation guide is shown in Fig. 1.
Fig. 1.
Conversation guide adapted from the Ariadne Labs’ Serious Illness Conversation Guide
At the beginning of their ambulatory month in which they would participate in the educational intervention, trainees received a short introduction to the educational objectives, watched a video demonstration of a serious illness conversation, and engaged in role play to practice using the conversation guide. The clinic encounter was modeled after a standard ambulatory care clinic encounter with the following components: (1) the physician trainee encounters the patient/caregiver for a serious illness conversation and then leaves the room, (2) the trainee presents the contents of the encounter to the palliative medicine attending and together they formulate a plan, (3) the trainee and attending return to the patient’s exam room for role modeling and wrap up with the patient, and (4) the attending and trainee debrief the encounter.
Patient Selection
Appropriate patients received a scripted phone call invitation to attend the clinic. The clinic was described to patients as an “opportunity to discuss your health and what to expect in the future.” Patients with a chronic, serious illness were identified by hospital record search using the following criteria: (1) admitted to the hospital in the previous 6 months for either lung disease, liver disease, heart failure, or stroke/dementia; and (2) a physician trainee had previously written a clinic note in their chart. This criteria were based on one suggested method to identify serious illness patients: patients previously admitted to the hospital with a specific serious illness diagnosis code [31]. Patients whose primary doctor is an attending physician were excluded so as not to interfere with their long-standing relationships.
Evaluation Process
The acceptability of the educational intervention was assessed in several ways. (1) When the trainee presented the contents of the serious illness conversation, the palliative medicine attending tracked completion of the nine elements of the conversation as outlined in the conversation guide. (2) At the completion of the clinical experience, trainees and patients were surveyed on a five-point Likert scale. Trainees were asked specific demographic information and whether the educational intervention was a helpful addition to their training. Patients were surveyed by a separate member of the research team to determine their perceptions of the encounter. (3) Trainees were interviewed about their experience by a separate member of the research team in a semi-structured fashion using open-ended questions.
Data Analysis
Survey data was analyzed using descriptive statistics. Two members of the research team separately performed content analysis of the semi-structured interviews to code and categorize data into common themes until saturation.
Ethical Approval
Our institutional review board approved the evaluation of our educational intervention. Trainee participation in the clinic was required as an educational innovation. A trainee’s clinic performance was not used for evaluation purposes. Patient participation was by invitation only, and since the clinical encounter is within standard medical practice, no formal informed consent was obtained prior to the clinic encounter. Informed consent was obtained from all trainees and patients who were willing to complete the survey. All interviews and survey responses were de-identified.
Results
During the pilot period, twenty-one physician trainees completed at least one serious illness conversation. Twelve trainees completed one conversation and nine trainees completed two conversations. The majority of these trainees were foreign medical graduates (90%) with a first language other than English (67%) (Table 1).
Table 1.
Baseline characteristics for 21 physician trainees who received the educational intervention
| Demographic variables | Number |
|---|---|
| Gender (%) | |
| Female | 5 (23%) |
| Male | 14 (67%) |
| Medical school | |
| US (%) | 2 (10%) |
| Foreign medical graduate (%) | 19 (90%) |
| First language | |
| English (%) | 7 (33%) |
| Other (%) | 14 (67%) |
| Level of training | |
| PGY2 (%) | 9 (43%) |
| PGY3 (%) | 11 (52%) |
| PGY4 (%)1 | 1 (5%) |
1One trainee is completing a 4-year Med/Derm program.
In the 30 clinical encounters, trainees were able to introduce the purpose and goal of the conversation (77%), ask permission (58%), and assess their patient’s understanding (81%) (Table 2). In only half of all conversations were trainees able to relay useful prognostic information (48%), though trainees did consistently assess their patient’s goals, fears, and sources of strength. Of note, trainees did not routinely report their patient’s emotional reactions (13%) to their attending physician.
Table 2.
Frequency that trainees were able to complete elements of the serious illness conversation in thirty encounters. Elements are listed in the order that they appear on the conversation guide
| Conversation element | Frequency completed |
|---|---|
| Introduction to the conversation (%) | 77% |
| Ask permission to have the conversation (%) | 58% |
| Assess understanding of illness (%) | 81% |
| Deliver prognostic information (%) | 48% |
| Respond to or report emotion (%) | 13% |
| Assess goals (%) | 61% |
| Assess fears (%) | 55% |
| Assess sources of strength (%) | 58% |
| Assess family understanding (%) | 39% |
Twelve patients agreed to complete a survey after the clinical experience. Ninety-two percent of patients reported the conversation to be important, 83% said the conversation was reassuring, and 83% found the communication during this encounter to be of higher quality than a usual clinic encounter. None of the patients answered the survey questions in the negative.
Of the 18 trainees who completed a survey after their clinical experience, all reported the educational intervention to be either a somewhat or a very helpful addition to their practice (Table 3).
Table 3.
Eighteen trainees’ and 12 patients’ exit surveys
| Question | Number |
|---|---|
| Trainee | |
| Helpfulness of the educational intervention | |
| Unhelpful (%) | 0 |
| Somewhat unhelpful (%) | 0 |
| Neither (%) | 0 |
| Somewhat helpful (%) | 4 (22%) |
| Helpful (%) | 14 (78%) |
| Patient | |
| Conversation importance | |
| Unimportant (%) | 0 |
| Somewhat unimportant (%) | 0 |
| Neither (%) | 0 |
| Somewhat important (%) | 1 (8%) |
| Important (%) | 11 (92%) |
| Reassuring or distressing | |
| Distressing (%) | 0 |
| Somewhat distressing (%) | 0 |
| Neither (%) | 1 (8%) |
| Somewhat reassuring (%) | 1 (8%) |
| Reassuring (%) | 10 (83%) |
| Communication compared with usual encounter | |
| Worse (%) | 0 |
| Somewhat worse (%) | 0 |
| Neither (%) | 2 (17%) |
| Somewhat better (%) | 0 |
| Better (%) | 10 (83%) |
In semi-structured interviews of ten trainees, several important themes emerged. The four most common themes to emerge were (1) the serious illness conversation is important and beneficial for the patient, (2) though not always easy, patients are generally willing to have a serious illness conversation, (3) trainees realized that their patients generally did not have a clear understanding of their prognosis, and (4) trainees felt that lack of time is the major barrier to having these conversations. Direct quotes illustrating each theme are presented in Table 4.
Table 4.
List of themes emerging from semi-structured interviews with ten physician trainees
| Trainee sentiments (from most to least common) | |
|
1. These conversations are important and patients benefit from them. “I think it’s good for the patients because so many of them don’t know what their prognosis is and it’s better for them to know so they can be more prepared for the future or so they can talk to their family. When I was in the ICU, you see families and they are surprised by how sick the patient is and they don’t know what to do, so it seems good to talk [to the patients] when they are still coming in and walking and they are doing well.” | |
|
2. Even if they aren’t always easy, patients are willing to have these conversations. “When we asked him particularly: what if you don’t have a lot of time left, what kind of stuff would you want to do, and you know, he really kind of bought into it and started talking about what was important to him.” | |
|
3. Patients do not have a clear understanding of their prognosis. “I think we were explaining how sick he was and I remember that he was really surprised at first when we suggested he could get sicker. I think a lot of our patients just think they will go to the doctors and take a lot of medicines and they will be ok, and they don’t understand how the illness will progress.” | |
|
4. Time is the major barrier to having these conversations in the clinic. “I just don’t think we have enough time to fix whatever problem they complained of and then talk about it [their illness], you can do either this or that.” | |
|
5. After their experience, trainees feel more comfortable having these conversations. “Initially, at least, we felt quite uncomfortable having conversations because when someone is walking into an ambulatory clinic the last thing they want to talk about is planning regarding their death. It’s good to engage them in the conversation, bring all the facts, and see what their expectations are. I feel quite comfortable handling these discussions now.” | |
|
6. Trainees appreciate the benefits of having the conversation in the outpatient setting (i.e., not pressured to attain a goal). “Continuing this conversation over a few visits instead of making a decision, because the patients need some time to decide and think about all this stuff so they don’t just end up giving you one answer after one clinic. You do get a lot of useful information out of them such as their overall goals of care in the future, even if they don’t comment on their code status or advance directive.” | |
|
7. Trainees learned to begin the conversation, gauge the patient’s readiness to have the conversation, and assess their prognostic awareness. “We have to steer the conversation based on their understanding of the disease. If they really don’t have any understanding of their medical condition, then we cannot be too advanced, we just have to lay the background. If they are well aware then we should take the next step.” | |
|
8. Trainees appreciated the opportunity to explore their patient’s emotion and empathize with them. “Unfortunately we spend so much time talking about the medical side of things, we often don’t spend the time we need to treat the whole person.” | |
|
9. The conversation guide was helpful. “The handout that we use as a guide, you just know what to say, and how to pose the question, made it very easy after the first patient.” | |
|
10. It can be easier to have the conversation in the hospital because patients know how sick they are. “I think the family and patient see [in the hospital] that they are getting a lot of support mechanically and medically, medication wise, so it’s easier for them to realize that they are at an advanced stage of disease.” | |
|
11. The conversation appeared to make patients distressed or fearful. “Why are we having that discussion and how will that affect them and what their prognosis is? Fear and distress are the biggest emotions that came across.” |
Discussion
Our study demonstrated that with support, guidance, and opportunity, physician trainees were able to complete a serious illness conversation with the help of a conversation guide. This allowed trainees to practice important communication skills without taking time away from clinical duties. Trainees found this model to be an important addition to their training. Patients reported the encounter to be important, reassuring, and of better quality communication than usual.
While trainees only completed 1–2 serious illness conversations, they appreciated the opportunity to explore their patients’ emotions, they became aware that patients are willing to have these conversations, and they learned that their patients require the opportunity to learn about their prognoses. Trainees reported learning key communication skills such as how to begin the conversation, gauge their patients’ readiness to have the conversation, and assess their patients’ prognostic awareness. These crucial affective learning points are important for reducing the barriers to these conversations [14].
It is crucial to integrate routine and frequent practice to complement the mandates from medical training institutions that communication practice be incorporated into medical training. We have shown that trainees find it acceptable and important to substitute a serious illness conversation into a routine ambulatory care encounter for select patients and this does not risk upsetting or angering patients. We believe that this model can be replicated by training programs that provide their trainees with ambulatory care practice opportunities.
Another strength of this pilot study is that the population of trainees was mostly foreign-trained with a first language other than English. This should be reassuring to medical educators in internal medicine where international medical graduates comprise up to 40% of their trainees [32]. These results indicate that language and culture may not be a significant barrier to practicing these important conversations.
There are several limitations in the evaluation of this educational intervention. Because this was an acceptability study, we did not measure improvement in trainee communication skills. First, we did not expect we would observe improvement in trainee skills after only 1–2 experiences. Second, measuring skill would have required direct observation of the encounter, and we chose instead to test this model under real-world teaching conditions—where the trainee completes the initial conversation without direct observation by the preceptor.
Most trainees only completed one serious illness conversation, the result of a high patient no-show rate. It was difficult for seriously ill patients to report for clinic since many were often hospitalized or dependent on others for transportation. In our experience, rather than having one isolated clinic for trainees to practice serious illness conversations, it would be preferable to set aside time for these conversations in the ambulatory care clinic.
Finally, only 21 trainees participated in the educational intervention, of which ten participated in the semi-structured interview. While this represents a small sample size, we believe we were able to reach thematic saturation, as no new themes emerged in the final interviews.
Despite the limitations, the results of this pilot study show that physician trainees can be offered routine opportunities to practice having serious illness conversations with their seriously ill patients. Only when serious illness conversations become a standard part of training will our future physicians learn proficiency and make these conversations a clinical priority.
Conclusion
Initiating and conducting serious illness conversations is an important clinical skill, a frequent task in ambulatory care practice, and a stated priority of the Institute of Medicine and Centers for Medicare and Medicaid. While they are expected to know how to communicate, trainees in graduate medical education are not provided with routine practice to learn these skills. With preparation, time, and a conversation guide, trainees can be provided with routine practice opportunities to have serious illness conversations in the ambulatory care clinic. Both trainees and their patients found these conversations important and meaningful. The ability to incorporate this type of routine practice into medical training is an important step in developing confident and competent communicators. Further research should focus on whether more frequent practice opportunities actually lead to improved communication skill.
Credit Statement
Michael Pottash: conceptualization, investigation, formal analysis, writing original draft, and supervision. Lily Joseph: investigation. Gianna Rhodes: investigation.
Compliance with Ethical Standards
Conflict of interest
Conflicts of interests were disclosed.
Human and animal rights and Informed consent
This was an educational research involving human subjects. Informed consent was always attained.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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