Training in Serious Illness Conversations Boosts Confidence of Students, Interns
Key findings
- The Ariadne Labs Serious Illness Care Program includes a structured guide with specific, tested vocabulary for conducting serious illness conversations
- At Massachusetts General Hospital, the program was adapted for the training of 81 final-year medical students and 156 first-year residents over the course of a year
- Learner satisfaction was high (86%–91%), and 94% of students supported offering the training to their peers, suggesting the concepts are not too advanced for that learner level
- Among both students and residents, confidence significantly increased in all communication domains queried after the session
- The research team plans to adapt the training for online delivery
Ariadne Labs, a joint center of Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, introduced the Serious Illness Care Program (SICP) in 2015 to improve conversations with seriously ill patients about their goals and values. The core of the program is a simple conversation guide.
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Multiple studies have shown that training practicing clinicians to use the SICP improves the number, timing, quality, and accessibility of serious illness conversations and reduces patient anxiety and depression.
Juliet Jacobsen, MD, DPH, attending physician in the Division of Palliative Care and Geriatric Medicine at Massachusetts General Hospital, and colleagues recently adapted the training for medical students and interns. In the Journal of Pain and Symptom Management, they report it improved trainees' confidence in conducting serious illness conversations and the likelihood that residents would document such discussions in the electronic health record (EHR).
Methods
In 13 workshops conducted over a year, the team trained 81 final-year medical students and 156 first-year residents. The standard Ariadne program is available under a Creative Commons license that allows modification, and Mass General added two training emphases: the communication skills needed to explore a patient's prognostic awareness and respond to emotion.
The workshops lasted 2.5 hours:
- First hour—Large group session consisting of a brief guided reflection on participants' personal experiences with serious illness conversations, presentation of the evidence base for the SICP, orientation to the structure of the Serious Illness Conversation Guide (SICG), demonstration of how to use the SICG with a patient and, for resident training, a brief orientation on how to document conversations in the EHR
- Remaining 90 minutes—Role play in groups composed of five to seven learners, a standardized patient, and one or two palliative care–trained facilitators who gave feedback
Immediately after the workshop, learners were asked to rate their confidence in specific communication skills "before participating in the training" and "after participating in the training."
Satisfaction
63 students and 69 residents provided anonymous qualitative and quantitative feedback:
- 86% of students and 91% of residents rated the session "very good" or "excellent"
- 94% of students would recommend the training to their peers, and 97% of residents intended to apply it to their practice
Self-efficacy
Self-confidence improved from baseline in all domains queried (P<0.001 for all):
Students (seven-point Likert scale)
- Responding to emotions—an average increase of 0.6 points
- Exploring patient hopes—an average increase of 1.6 points
- Exploring patient worries—an average increase of 1.7 points
- Assessing patient prognostic awareness—an average increase of 1.4 points
- Delivering prognostic information—an average increase of 1.4 points
- Eliciting patient priorities—an average increase of 1.6 points
Residents (five-point Likert scale)
- Ability to use the conversation guide—average increase 2.3 points
- Assessing patient prognostic awareness—an average increase of 1.6 points
- Responding to emotions—an average increase of 0.7 point
- Eliciting patient values and priorities—an average increase of 1.3 points
Free-text feedback indicated the three most valued aspects of the training were the conversation guide, as its structure demystified challenging conversations; the language for responding to emotion; and the concept of eliciting patients' hopes and worries, which was new to many learners.
Documentation
As part of implementing the SICP hospital-wide, the team partnered with Epic Systems to activate a template in the EHR advance care planning navigator that mirrors the structure of the conversation guide. Clinicians can quickly scan prior conversations for relevant patient information and build on other clinicians' prior discussions.
For 12 months after the trainings, the researchers tracked resident documentation of serious illness conversations in the EHR template. Compared with the prior year, resident-led documentation increased 4.5-fold.
Next Steps
Given the profound shift in educational practices during the COVID-19 pandemic, the research group plans to adapt the training to online learning platforms. They hope larger, multisite studies will assess the durability of the training effect on clinician behavior and, ultimately, whether it influences patient quality of life.
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