Concerning Confidence: Serious Illness Conversations During the Medicine Acting Internship.

Background: Despite increased recognition that physician-patient communication represents a key competency for medical trainees, relatively little is known about student exposures to conversations about serious illness. Objective: To characterize student experiences with multiple types of serious illness conversations during their medicine acting internship (AI). Design: This is a cross-sectional survey. Setting/Subjects: Final-year medical students who had completed a medicine AI within one year at one U.S. medical school. Measurements: Exposures to and perceptions of multiple conversation domains (discussions with upset patients/families, breaking bad news, assessing code status, and conversations about limiting or withdrawing life-sustaining treatments). Results: We collected 82 survey responses (78% response rate). Students reported multiple exposures across most domains, some of which included leading conversations without supervision or formal instruction. In most domains, at least 50% of students reported confidence in their ability to lead unsupervised conversations moving forward. Conclusions: After a four-week AI, students reported multiple exposures to a variety of serious illness conversations. Some reported having these conversations without supervision. Student confidence in their ability to lead these conversations independently was higher than has been previously reported in other small studies. Further exploration is required to better understand these trends, and targeted curricular development may be indicated.

Mid-Career Training to Advance Palliative Care.

The demand for specialist palliative medicine physicians, advanced practice providers, and other team members outstrips supply. Traditional paths to specialty practice will not meet projected need. Therefore, innovation and research are required. One innovation is the training of midcareer professionals; those who have been in practice and want to change to palliative care. Barriers to leaving practice and returning to traditional training are high; not the least of which is the opportunity cost. In this roundtable, experts discuss what they have learned from current research, and point the way to additional needed research.

Looking Back, and Ahead: A Call to Action for Increasing the Hospice and Palliative Medicine Specialty Pipeline.

Thanks to the efforts of many individuals and organizations, the field of Hospice and Palliative Medicine (HPM) has undergone unprecedented growth over the last two decades. To meet the needs of seriously ill patients and families in inpatient, outpatient community setting in the future, the field of HPM must develop innovative strategies to expand the specialist workforce pipeline. With 148 programs participating in the National Residency Matching Program and 285 matched applicants in 2019, the specialty of HPM can barely replace those who are retiring or leaving the field. We call for a renewed and coordinated effort to increase the applicant pool for HPM fellowship positions, as well as greater access to specialist HPM training through expanded traditional fellowship programs and innovative specialist training pathways. Without such an expansion, our specialty will struggle to serve those patients and families who need us most.

Integrating Advance Care Planning Into Practice.

Advanced respiratory diseases progress over time and often lead to death. As the condition worsens, patients may lose medical decision-making ability. Advance care planning (ACP) is a process in which patients receive information about their diagnosis and prognosis; discuss values, goals, and fears; articulate preferences about life-sustaining treatments and end-of-life care; and appoint a surrogate medical decision maker. This process may result in written documentation of patient preferences or the appointment of a health-care power of attorney (HCPOA). ACP discussions have multiple benefits for patients and their surrogate decision makers, including ensuring that the care provided is aligned with the patient's goals and preferences and decreasing stress, anxiety, and burden in surrogates. Time and provider comfort are often cited barriers to ACP, so it may be necessary for clinicians to gain experience in conversations and identify the patients most likely to benefit from ACP discussions. Two new Current Procedural Terminology (CPT) codes, 99497 and 99498, have been recognized by the Centers for Medicare and Medicaid Services (CMS) as of January 1, 2016 and are intended to incentivize clinicians to engage in ACP discussions with their patients earlier and with more frequency. This manuscript reviews the benefits and barriers to ACP in patients with advanced respiratory disease and provides guidance on the use of the new CPT codes for reimbursement of these conversations.