Improving the Care of Patients with Serious Illness – What are the Palliative Care Education Needs of Internal Medicine Residents?

Abstract

Background:

Hospitalized patients with serious illness have significant symptom burden and face complex medical decisions that often require goals of care discussions. Given the shortage of specialty palliative care providers, there is a pressing need to improve the palliative care skills of internal medicine (IM) residents, who have a central role in the care of seriously ill patients hospitalized at academic medical centers.

Methods:

We conducted an anonymous survey of IM residents at a large, urban, academic medical center to identify which aspects of palliative care trainees find most important and their knowledge gaps in palliative care. The survey measured trainees’ self-assessed degree of importance and knowledge of core palliative care skills and evaluated frequency of completing advance care planning documentation.

Results:

Overall, 51 (23%) IM residents completed the survey. The majority of trainees considered multiple palliative care skills to be “very important/important”: symptom management, prognostication, introducing the palliative care approach, discussing code status, and breaking serious news. Across these same skills, trainees reported variable levels of knowledge. In our sample, trainees reported completing healthcare proxy forms and Medical Orders for Life-Sustaining Treatment infrequently.

Conclusions:

IM trainees rated core palliative care skills as important to their practice. Yet, they reported knowledge gaps across multiple core palliative care skills that should be addressed given their role as frontline providers for patients with serious illness.

Background:

An aging patient population and increasing burden of serious illness have contributed to the expansion of palliative care programs in U.S. hospitals.¹ Palliative care services focus on understanding patients’ goals and values for medical care and have been shown to improve quality of life, symptom burden, and caregiver outcomes as well as reduce healthcare costs for patients with serious illness.^2–6 Hospitalized patients with serious illness have significant symptom burden and face complex medical decisions that require goals of care discussions.^7,8 Furthermore, although patients are increasingly dying outside of the acute care setting, almost 20% of deaths in the U.S. still occur in the hospital.⁹ Yet, the workforce developed from existing palliative medicine training programs care will be insufficient to meet the palliative care needs of this expanding, complex patient population.¹⁰

Based on numbers preceding the COVID-19 pandemic, one study suggested that by 2038, each palliative care specialist would need to conduct 23 visits per day to care for the population of seriously ill patients.¹¹ The COVID-19 pandemic has only expanded and intensified the demands on existing inpatient palliative care consultation programs.¹² Looking ahead, many argue that a combination of specialty and non-specialty palliative care is essential to meet the needs of this growing population of patients with serious illness. While non-specialists need a set of core palliative care skills, including symptom management and serious illness communication, specialty trained palliative care clinicians have expertise in managing complex or refractory symptoms, complex grief and existential distress, as well as conflict resolution regarding goals of care.¹³

Given the shortage of specialty palliative care providers, there is a pressing need to improve the palliative care skills of internal medicine (IM) residents, who have a central role in the care of seriously ill patients hospitalized at academic medical centers. In fact, a recent survey of IM program directors showed that a vast majority consider palliative care training to be important.¹⁴ Yet, the Accreditation Council for Graduate Medical Education (ACGME) requirements for IM residency training do not include a mandatory palliative care rotation, and the American Board of Internal Medicine (ABIM) licensing exam allocates only 3% of its questions to palliative care and end-of-life care.^15,16

Given this lack of training criteria, there is significant variability in resident education about palliative care.^17–19 Furthermore, despite the expansion of hospital-based palliative care programs and the growing evidence for palliative care interventions, it is unclear if trainees believe that palliative care is an important part of their clinical practice. Engaging trainees, who are adult learners with competing responsibilities, requires that they first “buy in” to the importance of core palliative care skills and then receive targeted education.^20,21 In our study, we conducted a needs assessment of IM residents to evaluate how they rated the importance of palliative care to their practice and to identify their knowledge gaps in palliative care. This data can be used to tailor future palliative care curricular development to resident self-assessed needs.²²

Methods:

Setting & Study Participants

The study was conducted at a large, urban, academic medical center with public, private, and Veterans’ Affairs training experiences. All IM residents (PGY 1–3) were given an opportunity to participate. During the study period, all PGY-2 and 3 IM residents completed a required one-week inpatient palliative care clinical rotation during their intern year with the palliative care consultation team, which is comprised of physicians, nurse practitioners, social workers, and chaplains. We did not collect data on which PGY-1s completed the required one-week palliative care clinical rotation at the time of the survey. This study was conducted as a quality improvement initiative and did not require Institutional Review Board review under the policies of New York University Medical Center.

Survey Instrument

The survey tool was adapted to meet the needs of the inpatient setting by the Supportive Care Oversight Committee, an interdisciplinary group of palliative care specialists and non-specialists with an interest in improving the care of seriously ill patients. Similar to other trainee surveys, the tool used trainee self-assessment regarding palliative care skills.^23–25 (Supplementary Figure 1) Using Likert scales, trainees rated the degree of importance and knowledge of core palliative care skills, including symptom management and serious illness communication. The survey also evaluated frequency of completing advance care planning (ACP) documentation and comfort with completing ACP documentation. (Figure 1)

Figure 1. Survey Core Palliative Care Domains.

* Healthcare Proxy

** Medical Orders for Life-Sustaining Treatment

Data Collection and Analysis

The survey was conducted between October and November 2018. An email was sent with an anonymous link for survey completion. One reminder email was sent. The anonymous, de-identified data were collected into a password-protected REDCap database. Data analysis was conducted using STATA statistical software.

Results

Demographics

Overall, 51 (23%) of IM residents completed the survey, of which 21 (41%) were interns and 30 (59%) were residents. Overall, 22 (43%) identified as Female, and 36 (71%) planned to pursue sub-specialty fellowship training, of which none planned to pursue a Hospice and Palliative Medicine fellowship.

Importance of Palliative Care

In our sample, 4 (19%) interns and 30 (70%) residents reported prior formal palliative care training, and 18 (86%) interns and 29 (97%) residents rated palliative care as “very important/important” to their practice. When asked about satisfaction with their palliative care education, 6 (29%) interns and 19 (60%) residents were “very satisfied/satisfied.”

Symptom Management

The vast majority of trainees rated the management of physical symptoms as “very important/important” (Pain: 18 (86%) interns, 29 (97%) residents; other symptom management: 19 (90%) interns, 29 (97%) residents). (Figure 2) Only 4 (19%) interns and 18 (60%) residents reporting being “knowledgeable” in pain management, and 6 (29%) interns and 15 (50%) residents reported being “knowledgeable” in other symptom management. Overall, as compared to interns, residents reported higher self-assessed knowledge in pain management (mean 2.1 interns, mean 2.6 residents, p < .05); this difference was not statistically significant for non-pain symptom management. (Figure 3)

Figure 2. Importance of core palliative care domains.

* p < .05 comparing intern and resident knowledge

Figure 3. Knowledge about core palliative care domains.

* p < .05 comparing intern and resident knowledge

Serious Illness Communication

In our sample, the majority of trainees considered multiple palliative care skills to be “very important/important”: prognostication (18 (86%) interns; 26 (87%) residents), introducing the palliative care approach (15 (71%) interns; 26 (87%) residents), discussing code status (19 (90%) interns; 28 (93%) residents), and breaking serious news (19 (90%) interns; 29 (97%) residents). (Figure 2) More than half of the interns (17 (57%)) and one third (9 (30%)) of the residents reported their self-assessed knowledge in prognostication as “not at all knowledgeable.” Interns and residents reported being “very knowledgeable/knowledgeable” (14 interns (67%); 27 (90%) residents) in discussing code status. As compared to interns, more residents reported being “very knowledgeable/knowledgeable” when introducing palliative care (20 (70%) residents; 7 (33%) interns, p < .01) and breaking bad news (23 (77%) residents; 10 (48%) interns, p < .05). (Figure 3)

Advance Care Planning

In our sample, the majority of trainees (18 (86%) interns; 21 (68%) residents) reported completing healthcare proxy (HCP) forms occasionally, defined as two to three times per month. Rates of Medical Orders for Life-Sustaining Treatment (MOLST) form completion were low with 11 (52%) interns and 7 (23%) residents reporting never completing this documentation. Furthermore, 14 (67%) interns and 10 (33%) residents reported never filing ACP notes in the chart. The majority of interns (11, 52%) and almost a third of residents (9, 30%) did not feel comfortable with MOLST forms. With regard to HCP forms, 11 (52%) of interns did not feel comfortable with this documentation. (Table 1)

Table 1.

Advance Care Planning (ACP) Documentation

	Comfort - N(%)			Frequency - N(%)
	Very Comfortable or Comfortable	Somewhat Comfortable	Not Comfortable	Daily	Frequently	Occasionally	Very Rarely	Never
HCP Form
Intern	6 (29)	4 (19)	11 (52)	0	3 (14)	18 (86)	0	0
Resident	26 (87)	3 (10)	1 (3)	2 (6)	7 (25)	21 (69)	0	0
MOLST Form
Intern	3 (14)	7 (33)	11 (53)	0	1 (5)	1 (5)	8 (38)	11 (53)
Resident	14 (47)	7 (23)	9 (30)	0	1 (3)	5 (17)	17 (57)	7 (23)
ACP Note
Intern	4 (19)	5 (24)	12 (57)	0	1 (5)	2 (10)	4 (19)	14 (67)
Resident	8 (27)	8 (27)	14 (47)	0	0	6 (20)	14 (47)	10 (33)

Discussion:

In the context of dramatic growth of specialty palliative care programs in the United States,²⁶ our study sought to evaluate the attitudes and knowledge of IM residents toward core palliative care skills. We found that IM trainees at a large, urban, academic training program reported that palliative care skills are important to their practice, suggesting that the expansion of palliative care and its evidence base have impacted providers’ perspectives. Furthermore, our study identified a gap between trainee assessment of importance of palliative care and their knowledge of core palliative care topics.

In this context, trainees were unsatisfied with their palliative care education. Although not directly addressed in the survey, it is possible that lack of satisfaction with their curriculum was related to being unprepared to deliver palliative care to their patients, which they consider important. Medical trainees face significant time pressures and clinical challenges on a daily basis, and these knowledge gaps that limit their practice may be distressing. In fact, lack of confidence in serious illness communication, a core palliative care skill, may lead to burnout, which adversely affects both physician well-being and the quality of patient care.²⁷ Finally, this gap between importance and knowledge suggests that IM trainees were eager for a curriculum focused on core palliative care skills. Although residents reported a statistically significant higher level of knowledge than interns across almost all domains, the absolute difference on the Likert scale was modest and may not have implications for clinical practice. These findings are particularly striking as residents lead IM teams, serving as role models and educators for interns and medical students,²⁸ including about core palliative care domains.

Trainees reported knowledge gaps in serious illness communication, including discussing code status, breaking serious news, and introducing palliative care. Prior studies have shown trainee discomfort with many aspects of serious illness communication.^29,30 Furthermore, we identified a striking gap in trainees’ knowledge regarding prognostication. Prior studies have shown that physicians, including IM residents specifically, prognosticate inaccurately.^31,32.³³ Trainees have reported minimal formal training in discussing prognosis²⁹ and practicing physicians have reported inadequate preparation in prognostication, making patient encounters more stressful.³⁴ This lack of prognostication skills, in both our study and prior studies, has significant implications for patient care. Disclosure of prognosis is crucial to achieving goal-concordant care for patients with serious illness.^35–37

In the setting of reported gaps in ability to prognosticate and communicate effectively with seriously ill patients, it is not surprising that trainees reported low rates of ACP documentation. ACP relies on patient-physician communication and, broadly defined, includes preparing patients and their caregivers to make goal-concordant decisions about medical care as they arise over time, documenting these discussions, completing appropriate advance directives (e.g., healthcare proxy, living will, MOLST) and revisiting decisions over time.³⁸ While prior work has assessed IM trainee comfort with serious illness communication and discussion of advance directives, our study is the first to our knowledge that reports on IM trainees’ completion of ACP documentation.³⁹ Furthermore, we confirm prior findings that trainees are not comfortable with ACP documentation.³⁹ Given that interpretation of ACP documentation is provider dependent,^40,41 this lack of comfort has significant implications for patient care. Dedicated education about ACP documentation will be needed to improve trainee comfort and competence. Our findings are important given the positive association of ACP with quality of life for patients with serious illness and their families and its potential to improve goal-concordant care at the end of life.^42–44

Our study has several limitations. Only one-quarter of residents completed the survey, which may result in response bias as those who completed the survey may be more engaged and knowledgeable. The generalizability may be limited as the residents surveyed were at one urban academic medical center. Finally, resident knowledge was assessed by self-report, which may not reflect actual skills or correlate with patient outcomes. Nevertheless, our study also has several strengths. Intern and resident trainees responded allowing for a comparison between these groups. The residents surveyed practice across three hospital settings, including Veterans’ Affairs, private, and public. Although there are palliative care teams across all training sites, there is minimal required palliative care curriculum, likely comparable or more than other training programs around the country. Finally, the anonymous format allowed residents to freely express their views about core palliative care skills.

Conclusions/Future Directions:

Overall, our study results are encouraging: IM trainees rate core palliative care skills as important to their practice. Yet, they report knowledge gaps across multiple domains of palliative care that should be addressed given their role as frontline providers for patients with serious illness, especially in the setting of the ongoing COVID-19 pandemic. By conducting needs assessments, training programs can better understand the barriers to core palliative care, including trainee interest in the subject matter and knowledge gaps. For trainees who do not report that palliative care is important to their practice, tailored curricula will have to be developed to illustrate the importance of core palliative care skills. Furthermore, objective evaluations of trainee competence will be needed to understand the accuracy of self-assessment in these settings. Finally, curricula need to be implemented and evaluated to see whether they close knowledge gaps and translate to improvements in skills and patient outcomes, such as prognostic awareness and goal-concordant care.