Virtual Geritalk: Improving serious illness communication of clinicians who care for older adults

Abstract

Context:

High quality communication is essential to older adults’ medical decision-making, quality of life, and adjustment to serious illness. Studies have demonstrated that Geritalk, a two day (16 hours total) in-person communication skills training improves self-assessed preparedness, skill acquisition, and sustained practice of communication skills. Due to the COVID-19 pandemic, Geritalk was adapted to a virtual format (4 days, 10 hours total).

Objectives:

Our study evaluated the change in participants’ self-assessed preparedness for serious illness communication before and after the virtual course and satisfaction with the course, and compared these findings to responses from a prior in-person Geritalk course.

Methods:

Geriatrics and Palliative Medicine fellows at three urban academic medical centers completed surveys, which employed 5-point Likert scales, before and after the virtual course to assess satisfaction with the course and preparedness for serious illness communication.

Results:

Of the 20 virtual Geritalk participants, 17 (85%) completed the pre-course assessment, and 14 (70%) completed the post-course assessment. Overall, satisfaction with the course was high (mean 4.9 on a 5‐point scale). Compared to in-person Geritalk participants, virtual course participants reported comparable and significant (p <.01) improvements in mean self-reported preparedness across all surveyed communication skills.

Conclusion:

We show that a virtual communication skills training is feasible and effective. Our findings suggest that the innovative virtual Geritalk course has the potential to increase access to communication skills training, improve serious illness communication skills, and in turn, improve the quality of care received by older adults with serious illness.

Introduction:

In the context of increasing life expectancy,¹ a growing number of older adults live with serious illnesses that adversely impact quality of life, lead to functional impairment, and carry a high risk of mortality.² Given high acute healthcare utilization, older adults with serious illness and their caregivers benefit from frequent, longitudinal communication with clinicians about which treatments are aligned with their goals and values and which treatments they would not want to receive.³ Serious illness communication has been shown to improve outcomes, including strengthening patients’ trust in their providers,⁴ improving quality of life for patients at the end of life and their bereaved caregivers,⁵ while also reducing healthcare costs.⁶

Both the Institute of Medicine and the American College of Physicians High Value Task Force have identified patient-physician communication as a crucial part of caring for older adults with serious illness.^7,8 Furthermore, patients expect clinicians to initiate conversations and want information about their serious illness.^9–12 Yet, providers report inadequate preparation across several domains of serious illness communication, including sharing serious news,¹³ prognostication,¹⁴ and responding to patients’ emotions.^15,16 Provider communication skills do not organically improve over time or with experience and, like other procedures in healthcare, require training with the guidance of skilled educators.^3,17,18

Given a pressing need to improve provider communication skills, intensive training programs have been developed and studied. There is now a strong evidence base to support communication skills training.^3,19–22 Yet, these programs have not been widely implemented in undergraduate, graduate, or continuing medical education.³ A significant barrier to expansion is the resource intensity required for communication courses that include applying skills via deliberate practice. In particular, these courses require faculty to undergo in-depth facilitation training, clinician learners to have protected time away from revenue-generating clinical work, and administrative support for course coordination. Finally, in-person courses often require funding for learner course fees and travel, as well as educator time, which can be costly.

The COVID-19 pandemic simultaneously increased the demand for communication skills training and forced a shift from in-person to virtual instruction. This shift presented an unexpected opportunity to understand whether a virtual course, which is less resource intensive, can be successfully implemented. Specifically, our team redesigned the in-person Geritalk course, an evidence-based communication skills training course for Geriatrics and Palliative Medicine fellows, to a virtual format. The Geritalk course was originally adapted from the methods and programs that are now known as VitalTalk,³ the gold standard in serious illness communication training, and is tailored to address the complexities of communication with seriously ill older adults and their caregivers.

Although the in-person Geritalk course has been shown in prior studies to improve self-assessed preparedness, skill acquisition, and sustained practice of communication skills, the efficacy of the course in a virtual format is unclear.^19,20 Our study aimed to evaluate participant satisfaction with the virtual course and its effectiveness in improving self-reported preparedness for communication challenges as compared to the prior in-person course. This work constitutes a first step in understanding whether virtual training is a scalable approach to improving provider communication with seriously ill older adults.

Methods:

Adaptation from In-Person to Virtual Geritalk Course

Prior to 2020, the Geritalk course took place in person over two 8-hour days and consisted of large group didactic presentations, demonstration of skills by faculty, small group communication skills practice with actors, and reflection exercises focused on improving learning and performance. The course format required six communication experts to devote time exclusively to the course over those two days and for the learners to be protected from clinical responsibilities. A large group space with smaller break out rooms, administrative support for coordination of simulated patient/professional actor time, and funding for printing of materials, supplies, and food for learners were needed.

In 2020, due to the COVID-19 pandemic, the course was transitioned from an in-person to a virtual format with short sessions spread over four days. On each day, fellows met in small groups with communication experts (six fellows for two faculty facilitators) on a virtual video platform. The focus of these synchronous sessions was role play with professional actors focused around deliberate practice of communication skills (90 to 120 minutes) and reflective exercises. Prior to these synchronous sessions, participants were asked to complete asynchronous interactive online communication skills modules (20 to 30 minutes). These modules included pre-recorded videos that demonstrated communication skills through role play performed by facilitators acting as “patients” and “clinicians.” (Supplementary Figure 1) The structure of role play and curricular material were adapted from VitalTalk’s Virtual Mastering Tough Conversations course.²³ Most course materials were distributed virtually, and learners were able to participate from any quiet space either in their workplace or at home. Each synchronous session took place either at the beginning or the end of the clinical workday. The virtual course covered the majority of the content of the prior in-person course, including using basic communication principles, sharing serious news, eliciting goals of care, and discussing life-sustaining treatment. It did not cover counseling families about the signs and symptoms of the dying process, a more advanced content area. We planned to cover this topic in a follow-up training, if the virtual course format was successful. (Figure 1)

Figure 1.

In-Person to Virtual Geritalk Course Transition – Changes to Schedule and Content

Course Participants and Faculty Expertise

All fellows in our Geriatrics, Palliative Medicine, and Integrated Geriatrics/Palliative Medicine fellowship programs at the Icahn School of Medicine at Mount Sinai and its affiliate the James J. Peters Veterans’ Affairs Hospital as well as Palliative Medicine fellows at the University of Pennsylvania participated in the course. Course faculty members were trained by VitalTalk facilitators, each with more than five years of experience teaching communication skills.

Survey Instruments

Course participants completed two anonymous and confidential surveys: pre-course assessment and post-course assessment, which employed five-point Likert scales. The assessments asked learners to evaluate preparedness for communication challenges that frequently arise in clinical practice. Learners also evaluated the course content and structure. On the post-course assessment, learners were asked to identify their level of commitment to ongoing communication skills practice and chose specific communication skills for deliberate practice.

Data Collection and Analysis

All survey responses were collected anonymously and de-identified into a secure RedCap database, which is behind the Mount Sinai firewall. Responses from participants of the virtual Geritalk course were compared to participant responses from the 2011 in-person Geritalk course.¹⁹ We modified the survey instrument for brevity and to reflect the evolution of terminology in the serious illness communication skills course. For example, the in-person course surveys separated a subset of communication challenges by the patient or the family member (e.g., discuss serious news with patient versus discuss serious news with family member) and the virtual surveys merged into one communication challenge (e.g. discuss serious news with patient/family member). Where there was no difference (p >0.05) in the 2011 in-person course responses to “patient” and “family” versions of the same item, we included only the “patient” version of the item. We compared mean Likert responses from the 2011 in-person learners to the 2020 virtual learners using t-tests. Stata 15.1 was used to conduct these analyses. The Institutional Review Board at the Icahn School of Medicine at Mount Sinai determined this study to be exempt from review.

Results:

Demographics

Of the 20 virtual Geritalk participants, 17 (85%) completed the pre-course assessment, and 14 (70%) completed the post-course assessment. In our sample of the 17 participants who completed the pre-course assessment, 3 (18%) participants identified as male and 14 (82%) as female. The majority (11, 65%) of participants were Palliative Medicine fellows. The additional participants were Geriatric Medicine fellows (2, 12%) and Integrated Palliative Medicine and Geriatrics fellows (4, 23%). Of the 16 participants in the prior in-person course, all (100%) completed pre-course and post-course assessments. In the in-person sample, 9 (56%) identified as female, and there were 11 Geriatric Medicine fellows (69%) and 5 (31%) Palliative Medicine fellows. (Supplementary Table 1)

Baseline Serious Illness Communication Training and Remote Learning Experience

In our virtual sample, 4 (24%) participants reported no prior training in serious illness communication skills while, in the prior in-person group, 9 (53%) reported no prior training (p <.05). For those with prior training in our sample, the most frequent prior teaching topics were: giving bad news to patients/families about their loved one’s illness, conducting a family conference, discussing code status, and expressing empathy. In the prior in-person course, the most common topics were giving bad news and discussing code status. In the virtual sample, 12 (71%) learners had prior experiences with remote learning. Among those with prior remote learning experience, 9 (74%) reported “never/rarely” having virtual simulated patient sessions with actors playing patients.

Self-Assessed Preparedness for Serious Illness Communication

Compared to participants from the in-person Geritalk, participants from the virtual Geritalk reported comparable and significant (p <.01) improvements in mean self-reported preparedness across all surveyed communication skills. (Figure 2) Furthermore, learners were asked to identify specific communication skills that they wanted to improve after the course. In the virtual Geritalk sample, the mean commitment to improve self-identified communication behaviors was 4.9 as compared to the prior in-person mean of 4.8.

Figure 2.

In-Person versus Virtual Learner Self-Reported Preparedness

Likert Scale: 1 – Not at all prepared, 3 – Somewhat prepared, 5 – Very well prepared p value <.05 for all items that compare pre- and post-course assessments

Overall Learner Course Evaluation

Overall, 13 (93%) respondents rated the educational quality of the course as “excellent” and “strongly agreed” that they would recommend the training to others. All “strongly agreed” that the training should be required for Palliative Medicine fellows, and 13 (93%) “strongly agreed’ that the training should be required for Geriatrics fellows. In addition, 14 (100%) participants rated the training as “very important” to the development of their own clinical skills. Compared to the in-person course, the virtual course had almost equivalent learner evaluation of course quality. (Figure 3) Furthermore, in free-text responses, learners reported positive feedback about the learning experience: “This was one of the most helpful and practical classes I have ever had in all being a physician,” and “The actors and their stories were very realistic - it felt as authentic as a role play can feel.” The most common course feedback was suggesting more time for role play with actors (5, 36%).

Figure 3.

In-Person versus Virtual Learner Geritalk Course Satisfaction

Likert Scale: 1 – Not at all, 3 – A little bit, 5 – A great deal

Remote Learning Evaluation

After the course, 10 (71%) respondents had a “positive/very positive” attitude toward remote learning, as compared to 6 (35%) before the course (p <.05). Learners most often specified the following as positives of remote learning: easy to work with simulated patient actors (9, 64%), no commute (11, 79%), and easy to get feedback (11, 79%). With regard to negatives of remote learning, learners most often specified: lack of separation between work and home (6, 43%) and limited interaction with peers (8, 57%). Only 3 (21%) learners cited technological difficulties as adversely impacting their remote learning experience. Learners reported specific advantages to the virtual format in free text responses: “The patient interactions felt very real, just like telemedicine, you could see them in their homes and when everyone turns off their cameras and you’re interacting with them they’re the only person in your field of vision,” and “I think this was really great for us to experience especially because so many of our family meetings are being held over the phone or video visit right now.”

Discussion:

Our study demonstrates the feasibility and effectiveness of a virtual communication skills training course focused on older adults with serious illness. Our findings suggest that virtual communication skills training is comparable to in-person training with regard to learner satisfaction and self-assessed preparedness for communication challenges.

While high-quality communication has been shown to improve outcomes for older adults with serious illness, healthcare systems are not directly incentivized to implement intensive communication skills training for their providers.²⁴ In this context, the virtual Geritalk course is an ideal training program, minimizing resources while maintaining efficacy. Virtual Geritalk learners were able to continue clinical responsibilities, and clinician educators did not have to block out full days to participate in the training. The limited financial investment in the course included actors’ fees, small care packages for learners, and 8 hours of synchronous teaching for each of the course faculty. In addition, fees associated with printing, catering, and space for the training sessions were eliminated. The virtual format allowed learners and educators to be in different locations, which would allow learners from institutions without trained facilitators to access the same quality of communication skills training and institutions with few facilitators to expand their facilitator pool beyond their geographic area at no additional cost. Our experience implementing the virtual Geritalk course suggests that virtual training is a resource-efficient, scalable approach to improve serious illness communication skills.

Learners pointed out specific, unanticipated benefits of conducting the course virtually rather than in-person. In the context of the COVID-19 pandemic, caregivers spend limited time at the bedside with hospitalized patients and in-person family meetings are restricted to small groups.^25,26 Given the shift to outpatient telemedicine, providers often have discussions with patients and caregivers remotely. Learners found navigating communication challenges through virtual role play with actors directly applicable to their clinical work. They commented on the authenticity of the virtual patient encounters and the ease of getting feedback about their communication skills. Few reported technologic difficulties, and learner attitude toward remote learning improved after the course. Even after the acute phase of the COVID-19 pandemic, this transition to virtual care, including serious illness communication with patients and caregivers, is likely to remain an important part of healthcare delivery.²⁷

Our findings build on prior studies’ showing that communication skills do not improve over time without structured training.^3,17,18 Our sample of virtual learners reported more pre-course exposure to didactics and bedside teaching about communication skills than prior in-person learners. This increase in exposure is likely due to the growth of hospital-based palliative care programs nationwide over the past decade.²⁸ However, despite virtual learners having more exposure to didactics and bedside teaching about communication skills than prior in-person learners, the two groups had comparable baseline self-assessed preparedness for communication challenges. Moving away from didactics and bedside teaching, which are often passive and informal, and to intensive training courses represents an important next step in strengthening clinicians’ ability to navigate communication challenges with seriously ill older adults and their caregivers.

Our study has several limitations. All participants were Geriatrics or Palliative Medicine fellows, who likely have a greater interest and motivation to improve their serious illness communication skills. Our sample size was small, and we only compared the pre-course and post-course responses in aggregate and could not compare responses on the individual participant level. Due to feasibility, our study relied on participants’ self-reported preparedness for communication challenges and not direct observation of skill acquisition before and after the course. Furthermore, the virtual course did not cover all of the material from the in-person course, specifically discussing the signs and symptoms of the dying process, which may impact learner preparedness for this particular communication challenge with older adults.

Conclusions/Future Directions:

In conclusion, our study demonstrates that the virtual Geritalk course is a feasible and effective approach to engage providers in communication skills training. The course required fewer resources than an in-person equivalent and was effective in improving learner preparedness for communication challenges. Future work will evaluate whether virtual training: (1) leads to learner communication skill acquisition, (2) is as effective for learners beyond Geriatrics and Palliative Medicine post-graduate trainees, and (3) can be integrated with in-person learning after the pandemic. The virtual format presents a critical opportunity to extend the reach of serious illness communication training, enhance the skills of clinicians, and ultimately improve the quality of care received by older adults with serious illness.

Key Message:

Virtual serious illness communication skills training improves clinicians’ self-assessed skills and requires fewer resources than in-person training. By increasing access to communication skills training, virtual courses can enhance provider communication skills and improve the care of older adults with serious illness.