A Comparison of Palliative Care Delivery between Ethnically Chinese and Non-Chinese Canadians in the Last Year of Life.

BACKGROUND: Ethnically Chinese adults in Canada and the United States face multiple barriers in accessing equitable, culturally respectful care at the end-of-life. Palliative care (PC) is committed to supporting patients and families in achieving goal-concordant, high-quality serious illness care. Yet, current PC delivery may be culturally misaligned. Therefore, understanding ethnically Chinese patients' use of palliative care may uncover modifiable factors to sustained inequities at the end-of-life. OBJECTIVE: To compare the use and delivery of PC in the last year of life between ethnically Chinese and non-Chinese adults. DESIGN: Population-based cohort study. PARTICIPANTS: All Ontario adults who died between January 1st, 2012, and October 31st, 2022, in Ontario, Canada. EXPOSURES: Chinese ethnicity. MAIN MEASURES: Elements of physician-delivered PC, including model of care (generalist; specialist; mixed), timing and location of initiation, and type of palliative care physician at initial consultation. KEY RESULTS: The final study cohort included 527,700 non-Chinese (50.8% female, 77.9 ± 13.0 mean age, 13.0% rural residence) and 13,587 ethnically Chinese (50.8% female, 79.2 ± 13.6 mean age, 0.6% rural residence) adults. Chinese ethnicity was associated with higher likelihoods of using specialist (adjusted odds ratio [aOR] 1.53, 95%CI 1.46-1.60) and mixed (aOR 1.32, 95%CI 1.26-1.38) over generalist models of PC, compared to non-Chinese patients. Chinese ethnicity was also associated with a higher likelihood of PC initiation in the last 30 days of life (aOR 1.07, 95%CI 1.03-1.11), in the hospital setting (aOR 1.24, 95%CI 1.18-1.30), and by specialist PC physicians (aOR 1.33, 95%CI 1.28-1.38). CONCLUSIONS: Chinese ethnicity was associated with a higher likelihood of mixed and specialist models of PC delivery in the last year of life compared to adults who were non-Chinese. These observed differences may be due to later initiation of PC in hospital settings, and potential differences in unmeasured needs that suggest opportunities to initiate early, community-based PC to support ethnically Chinese patients with serious illness.

Naming racism as a root cause of inequities in palliative care research: a scoping review.

BACKGROUND: Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist. OBJECTIVE: To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings. METHODS: Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results. RESULTS: We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common. CONCLUSION: While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.

When words are your scalpel, what and how information is exchanged may be differently salient to assessors.

PURPOSE: Variable assessments of learner performances can occur when different assessors determine different elements to be differently important or salient. How assessors determine the importance of performance elements has historically been thought to occur idiosyncratically and thus be amenable to assessor training interventions. More recently, a main source of variation found among assessors was two underlying factors that were differently emphasised: medical expertise and interpersonal skills. This gave legitimacy to the theory that different interpretations of the same performance may represent multiple truths. A faculty development activity introducing assessors to entrustable professional activities in which they estimated a learner's level of readiness for entrustment provided an opportunity to qualitatively explore assessor variation in the context of an interaction and in a setting in which interpersonal skills are highly valued. METHODS: Using a constructivist grounded theory approach, we explored variation in assessment processes among a group of palliative medicine assessors who completed a simulated direct observation and assessment of the same learner interaction. RESULTS: Despite identifying similar learner strengths and areas for improvement, the estimated level of readiness for entrustment varied substantially among assessors. Those who estimated the learner as not yet ready for entrustment seemed to prioritise what information was exchanged and viewed missed information as performance gaps. Those who estimated the learner as ready for entrustment seemed to prioritise how information was exchanged and viewed the same missed information as personal style differences or appropriate clinical judgement. When presented with a summary, assessors expressed surprise and concern about the variation. CONCLUSION: A main source of variation among our assessors was the differential salience of performance elements that align with medical expertise and interpersonal skills. These data support the theory that when assessing an interaction, differential salience for these two factors may be an important and perhaps inevitable source of assessor variation.

Virtual home-based palliative care during COVID-19: A qualitative exploration of the patient, caregiver, and healthcare provider experience.

BACKGROUND: Due to the COVID-19 pandemic, many community palliative healthcare providers shifted from providing care in a patient's home to providing almost exclusively virtual palliative care, or a combination of in-person and virtual care. Research on virtual palliative care is thus needed to provide evidence-based recommendations aiming to enhance the delivery of palliative care during and beyond the pandemic. AIM: To explore the experiences and perceptions of community palliative care providers, patients and caregivers who delivered or received virtual palliative care as a component of home-based palliative care during the COVID-19 pandemic. DESIGN: Qualitative study using phone and video-based semi-structured interviews. Data were analyzed using thematic analysis. SETTING/PARTICIPANTS: A total of 37 participants, including community palliative care patients/caregivers (n = 19) and healthcare providers (n = 18) recruited from sites in Ottawa and Toronto, Ontario, Canada. RESULTS: Overall, participants preferred in-person palliative care compared to virtual care, but suggested virtual care could be a useful supplement to in-person care. The findings are presented in three main themes: (1) Impact of COVID-19 pandemic on community palliative care services; (2) Factors influencing transition from exclusively virtual model of care back to a blended model of care; and (3) Recommended uses and implementation of virtual palliative care. CONCLUSIONS: Incorporating virtual palliative care into healthcare provider practice models (blended care models) may be the ideal model of care and standard practice moving forward beyond the COVID-19 pandemic, which has important implications toward organization and delivery of community palliative care services and funding of healthcare providers.

Race and birth country are associated with discharge location from hospital: A retrospective cohort study of demographic differences for patients receiving inpatient palliative care.

BACKGROUND: While past studies investigated access to palliative care among marginalized groups, few assessed whether there are differences in clinical process indicators based on demographics among those receiving palliative care. We aimed to: describe demographics among patients receiving inpatient palliative care; and evaluate whether demographic variables are associated with differences in disposition (i.e., discharge location), length of stay (LOS), and timing of inpatient palliative care referral and consultation. METHODS: Retrospective cohort study using electronic medical record data to study patients seen by inpatient palliative care at Mount Sinai Hospital in Toronto, Canada between April 2018 to March 2019. Primary outcome was disposition. Secondary outcomes were LOS, time from admission to palliative referral, and time from referral to consultation. We summarized quantitative data descriptively and used fisher exact tests to explore relationships between categorial variables. For continuous outcomes, we ran one-way ANOVA tests. FINDINGS: A total of 187 patients were referred to palliative care and met inclusion criteria. Mean age was 68·8 and 55·6% were female. 46·7% were born in Canada, 58·2% were White and 78·4% preferred English communication. Variables significantly associated with disposition were: birth country (p = 0·04), and race/ethnicity (p = 0·03). Language (F ratio = 3·6, p = 0·004) was significantly associated with time from admission to palliative care referral. No variables were associated with LOS or time from referral to consult. INTERPRETATION: Inequalities in disposition, and how long it takes to refer to palliative care may exist. Further studies should focus on understanding the underlying practices that constructed, and maintained these inequalities in care. FUNDING: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Qualitative Evaluation of a Novel Educational Tool to Communicate Individualized Hip Fracture Prognostic Information to Patients and Surrogates: My Hip Fracture (My-HF).

INTRODUCTION: Mortality and morbidity are high for older adults after hip fracture (HF), but patients and surrogate decision makers (SDMs) are typically unaware of the poor prognosis. We developed a novel educational tool, My Hip Fracture (My-HF), to provide patients and SDMs of patients hospitalized with acute HF individualized estimates of their post-HF prognosis. We conducted initial usability testing of My-HF in a sample of patients with HF and SDMs. MATERIALS AND METHODS: My-HF provides information about: 1) anatomy and risk factors for HF; 2) Hip fracture treatment received; 3) individualized predicted risk of adverse events and 4) anticipated discharge trajectory. We conducted a qualitative usability study using a convenience sample of hospitalized, post-operative patients with acute HF or SDMs of patients who lacked decision-making capacity. We used semi-structured interviews to obtain feedback. Thematic analysis was used to identify themes and concepts. RESULTS: We conducted interviews with 8 patients and 9 SDMs (mean age of interviewees 70.1 years, 41% female). My-HF was generally well received. Thematic analysis identified legibility and visual appeal, comprehension, numeracy, utility and reflection as prominent themes. Most respondents found My-HF to be useful in improving their understanding of HF and as a potential mechanism for sharing information with other care team members (including family and professionals). Suggestions for improvement of legibility, presentation of the individualized prognosis information and content were identified. DISCUSSION: Patients and SDMs are generally accepting of My-HF and found it useful for communicating individualized prognostic information. Feedback identified areas for improvement for future iterations of the tool. CONCLUSION: My-HF presents a means of addressing the gap in understanding of prognosis post-HF as a part of patient-centered care. Further evaluation will be needed to assess the impact of My-HF on patient and SDM reported outcomes as we transition from a paper to smart-phone enabled web application.

mHOMR: a prospective observational study of an automated mortality prediction model to identify patients with unmet palliative needs.

OBJECTIVE: Identification of patients with shortened life expectancy is a major obstacle to delivering palliative/end-of-life care. We previously developed the modified Hospitalised-patient One-year Mortality Risk (mHOMR) model for the automated identification of patients with an elevated 1-year mortality risk. Our goal was to investigate whether patients identified by mHOMR at high risk for mortality in the next year also have unmet palliative needs. METHOD: We conducted a prospective observational study at two quaternary healthcare facilities in Toronto, Canada, with patients admitted to general internal medicine service and identified by mHOMR to have an expected 1-year mortality risk of 10% or more. We measured patients' unmet palliative needs-a severe uncontrolled symptom on the Edmonton Symptom Assessment Scale or readiness to engage in advance care planning (ACP) based on Sudore's ACP Engagement Survey. RESULTS: Of 518 patients identified by mHOMR, 403 (78%) patients consented to participate; 87% of those had either a severe uncontrolled symptom or readiness to engage in ACP, and 44% had both. Patients represented frailty (38%), cancer (28%) and organ failure (28%) trajectories were admitted for a median of 6 days, and 94% survived to discharge. CONCLUSIONS: A large majority of hospitalised patients identified by mHOMR have unmet palliative needs, regardless of disease, and are identified early enough in their disease course that they may benefit from a palliative approach to their care. Adoption of such a model could improve the timely introduction of a palliative approach for patients, especially those with non-cancer illness.

A Clinical Communication Tool (Loop) for Team-Based Care in Pediatric and Adult Care Settings: Hybrid Mixed Methods Implementation Study.

BACKGROUND: Communication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record. OBJECTIVE: The objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research. METHODS: The study was a hybrid type II mixed methods design to simultaneously evaluate Loop's clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system. RESULTS: We recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop's potential value for engaging the patient and caregiver, and for improving communication within the patient's circle of care, Loop's relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care. CONCLUSIONS: Fundamental structural and implementation challenges persist toward realizing Loop's potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.

Residents' reflections on end-of-life conversations: how a palliative care clinical rotation creates meaningful learning opportunities.

BACKGROUND: Good communication at the end-of-life is important for patient outcomes and satisfaction. However, many healthcare providers are hesitant to engage in these conversations due to inadequate training. Classroom and bedside palliative care training have been effective in improving resident communication with patients at the end-of-life, yet the educational mechanisms that promote development remain uncharacterized. The purpose of this study was to better understand how family medicine residents are trained to have goals of care (GOC) conversations during a clinical rotation at a specialized palliative care center. METHODS: We conducted 15 semi-structured interviews with first- and second-year family medicine residents who completed a 4-week palliative care rotation at a specialized palliative care center between July 2013 and June 2014. We asked residents about their educational experiences during the rotation, which included both inpatient and home-visit experiences. Using thematic analysis, we identified and described recurrent experiences reported by participants related to their exposure to and development of GOC conversations. RESULTS: Participants reported feeling more comfortable approaching GOC conversations at the end of the rotation. Residents noted two elements of their training experience that may have facilitated this development: a constructive learning environment that included time and support during and after GOC conversations, and learning activities that provided various levels of supervision and independence. CONCLUSIONS: A palliative care rotation may be an optimal environment for developing GOC conversation skills. Direct observation of learners and fewer time pressures provide important opportunities for mentoring, support, feedback and reflection, which were all noted to facilitate GOC conversation development.

Palliative Care Transitions From Acute Care to Community-Based Care-A Systematic Review.

CONTEXT: Although the literature on transitions from hospital to the community is extensive, little is known about this experience within the context of palliative care (PC). OBJECTIVE: We conducted a systematic review to investigate the impact of receiving palliative care in hospital on the transition from hospital to the community. METHODS: We systematically searched MEDLINE, Embase, ProQuest, and CINAHL from 1995 until April 10, 2018, and extracted relevant references. Eligible articles were published in English, included adult patients receiving PC as inpatients, and explored transitions from hospital to the community. RESULTS: A total of 1514 studies were identified and eight met inclusion criteria. Studies were published recently (>2012; n = 7, 88%). Specialist PC interventions were delivered by multidisciplinary care teams as part of inpatient PC triggers, discharge planning programs, and transitional care programs. Common outcomes reported with significant findings consisted of length of stay (n = 5), discharge support (n = 5), and hospital readmissions (n = 6) for those who received inpatient PC. Most studies were at high risk of bias. CONCLUSION: Heterogeneity of study designs, outcomes, findings, and poor methodological quality renders it challenging to draw conclusions regarding PC's impact on the transition from hospital to home. Further research should use standardized outcomes with randomized controlled trial and/or propensity matched cohort designs.

The interaction of socioeconomic status with place of death: a qualitative analysis of physician experiences.

BACKGROUND: Home is a preferred place of death for many people; however, access to a home death may not be equitable. The impact of socioeconomic status on one's ability to die at home has been documented, yet there remains little literature exploring mechanisms that contribute to this disparity. By exploring the experiences and insights of physicians who provide end-of-life care in the home, this study aims to identify the factors perceived to influence patients' likelihood of home death and describe the mechanisms by which they interact with socioeconomic status. METHODS: In this exploratory qualitative study, we conducted interviews with 9 physicians who provide home-based care at a specialized palliative care centre. Participants were asked about their experiences caring for patients at the end of life, focusing on factors believed to impact likelihood of home death with an emphasis on socioeconomic status, and opportunities for intervention. We relied on participants' perceptions of SES, rather than objective measures. We used an inductive content analysis to identify and describe factors that physicians perceive to influence a patient's likelihood of dying at home. RESULTS: Factors identified by physicians were organized into three categories: patient characteristics, physical environment and support network. Patient preference for home death was seen as a necessary factor. If this was established, participants suggested that having a strong support network to supplement professional care was critical to achieving home death. Finally, safe and sustainable housing were also felt to improve likelihood of home death. Higher SES was perceived to increase the likelihood of a desired home death by affording access to more resources within each of the categories. This included better health and health care understanding, a higher capacity for advocacy, a more stable home environment, and more caregiver support. CONCLUSIONS: SES was not perceived to be an isolated factor impacting likelihood of home death, but rather a means to address shortfalls in the three identified categories. Identifying the factors that influence ability is the first step in ensuring home death is accessible to all patients who desire it, regardless of socioeconomic status.

Exploring Canadian Physicians' Experiences Providing Medical Assistance in Dying: A Qualitative Study.

CONTEXT: Medical assistance in dying (MAiD) allows a practitioner to administer or prescribe medication for the purpose of ending a patient's life. In 2016, Canada was the latest country, following several European countries and American states, to legalize physician-assisted death. Although some studies report on physicians' attitudes toward MAiD or describe patient characteristics, there are few studies that explore the professional challenges faced by physicians who provide MAiD. OBJECTIVES: The objective of the study was to explore the professional challenges faced by Canadian physicians who provide MAiD. METHODS: Sixteen physicians from across Canada who provide MAiD completed in-depth, semistructured telephone interviews. An inductive thematic analysis approach guided data collection and the iterative, interpretive analysis of interview transcripts. Three members of the research team systematically co-coded interview transcripts, and the emerging themes were developed with the broader research team. NVivo was used to manage the coded data. RESULTS: Participants described three challenges associated with providing MAiD: 1) their relationships with other MAiD providers were enhanced and relationships with objecting colleagues were sometimes strained; 2) they received inadequate financial compensation for time, and 3) they experienced increased workload, resulting in sacrifices to personal time. Although these providers did not intend to stop providing MAiD at the time of the interview, they indicated their concerns about whether they would be able to sustain this service over time. CONCLUSION: Physicians described relationship, financial, and workload challenges to providing MAiD. We provide several recommendations to address these challenges and help ensure the sustainability of MAiD in countries that provide this service.

The Perceived Ease of Use and Usefulness of Loop: Evaluation and Content Analysis of a Web-Based Clinical Collaboration System.

BACKGROUND: Patients with complex health care needs require the expertise of many health care providers. Communication, collaboration, and patient-centered care positively impact care quality and patient outcomes. Few technologies exist that facilitate collaboration between providers across settings of care and also engage the patient. We developed a Web-based clinical collaboration system, Loop, to address this gap. The likelihood of a technological system's uptake is associated with its perceived ease of use and perceived usefulness. We engaged stakeholders in the conceptualization and development of Loop in an effort to maximize its intuitiveness and utility. OBJECTIVE: This study aimed to report end users' perceptions about the ease of use and usefulness of Loop captured during usability tests of Loop. METHODS: Participants represented three user types (patients, caregivers, and health care providers) recruited from three populations (adults with cancer, adolescents and young adults with cancer, and children with medical complexity). We conducted usability testing over three iterative cycles of testing and development in both laboratory-based and off-site environments. We performed a content analysis of usability testing transcripts to summarize and describe participant perceptions about the ease of use and usefulness of Loop. RESULTS: Participants enjoyed testing Loop and were able to use the core functions-composing, posting, and reading messages-with little difficulty. They had difficulty interpreting certain visual cues and design elements or the purpose of some features. This difficulty negatively impacted perceived ease of use but was primarily limited to auxiliary features. Participants predicted that Loop could improve the efficiency and effectiveness of communication between care team members; however, this perceived usefulness could be compromised by disruptions to personal workflow such as additional time or task requirements. CONCLUSIONS: Loop was perceived to have value as a collaboration system; however, usability testing findings indicate that some design and functional elements need to be addressed to improve ease of use. Additionally, participant concerns highlight the need to consider how a system can be implemented so as to minimize impact on workflow and optimize usefulness.

My Team of Care Study: A Pilot Randomized Controlled Trial of a Web-Based Communication Tool for Collaborative Care in Patients With Advanced Cancer.

BACKGROUND: The management of patients with complex care needs requires the expertise of health care providers from multiple settings and specialties. As such, there is a need for cross-setting, cross-disciplinary solutions that address deficits in communication and continuity of care. We have developed a Web-based tool for clinical collaboration, called Loop, which assembles the patient and care team in a virtual space for the purpose of facilitating communication around care management. OBJECTIVE: The objectives of this pilot study were to evaluate the feasibility of integrating a tool like Loop into current care practices and to capture preliminary measures of the effect of Loop on continuity of care, quality of care, symptom distress, and health care utilization. METHODS: We conducted an open-label pilot cluster randomized controlled trial allocating patients with advanced cancer (defined as stage III or IV disease) with ≥3 months prognosis, their participating health care team and caregivers to receive either the Loop intervention or usual care. Outcome data were collected from patients on a monthly basis for 3 months. Trial feasibility was measured with rate of uptake, as well as recruitment and system usage. The Picker Continuity of Care subscale, Palliative care Outcomes Scale, Edmonton Symptom Assessment Scale, and Ambulatory and Home Care Record were patient self-reported measures of continuity of care, quality of care, symptom distress, and health services utilization, respectively. We conducted a content analysis of messages posted on Loop to understand how the system was used. RESULTS: Nineteen physicians (oncologists or palliative care physicians) were randomized to the intervention or control arms. One hundred twenty-seven of their patients with advanced cancer were approached and 48 patients enrolled. Of 24 patients in the intervention arm, 20 (83.3%) registered onto Loop. In the intervention and control arms, 12 and 11 patients completed three months of follow-up, respectively. A mean of 1.2 (range: 0 to 4) additional healthcare providers with an average total of 3 healthcare providers participated per team. An unadjusted between-arm increase of +11.4 was observed on the Picker scale in favor of the intervention arm. Other measures showed negligible changes. Loop was primarily used for medical care management, symptom reporting, and appointment coordination. CONCLUSIONS: The results of this study show that implementation of Loop was feasible. It provides useful information for planning future studies further examining effectiveness and team collaboration. Numerically higher scores were observed for the Loop arm relative to the control arm with respect to continuity of care. Future work is required to understand the incentives and barriers to participation so that the implementation of tools like Loop can be optimized. TRIAL REGISTRATION: ClinicalTrials.gov NCT02372994; https://clinicaltrials.gov/ct2/show/NCT02372994 (Archived by WebCite at http://www.webcitation.org/6r00L4Skb).

In the Loop: The Organization of Team-Based Communication in a Patient-Centered Clinical Collaboration System.

BACKGROUND: We describe the development and evaluation of a secure Web-based system for the purpose of collaborative care called Loop. Loop assembles the team of care with the patient as an integral member of the team in a secure space. OBJECTIVE: The objectives of this paper are to present the iterative design of the separate views for health care providers (HCPs) within each patient's secure space and examine patients', caregivers', and HCPs' perspectives on this separate view for HCP-only communication. METHODS: The overall research program includes cycles of ethnography, prototyping, usability testing, and pilot testing. This paper describes the usability testing phase that directly informed development. A descriptive qualitative approach was used to analyze participant perspectives that emerged during usability testing. RESULTS: During usability testing, we sampled 89 participants from three user groups: 23 patients, 19 caregivers, and 47 HCPs. Almost all perspectives from the three user groups supported the need for an HCP-only communication view. In an earlier prototype, the visual presentation caused confusion among HCPs when reading and composing messages about whether a message was visible to the patient. Usability testing guided us to design a more deliberate distinction between posting in the Patient and Team view and the Health Care Provider Only view at the time of composing a message, which once posted is distinguished by an icon. CONCLUSIONS: The team made a decision to incorporate an HCP-only communication view based on findings during earlier phases of work. During usability testing we tested the separate communication views, and all groups supported this partition. We spent considerable effort designing the partition; however, preliminary findings from the next phase of evaluation, pilot testing, show that the Patient and Team communication is predominantly being used. This demonstrates the importance of a subsequent phase of the clinical trial of Loop to validate the concept and design.

Are family medicine residents adequately trained to deliver palliative care?

OBJECTIVE: To explore educational factors that influence family medicine residents' (FMRs') intentions to offer palliative care and palliative care home visits to patients. DESIGN: Qualitative descriptive study. SETTING: A Canadian, urban, specialized palliative care centre. PARTICIPANTS: First-year (n = 9) and second-year (n = 6) FMRs. METHODS: Semistructured interviews were conducted with FMRs following a 4-week palliative care rotation. Questions focused on participant experiences during the rotation and perceptions about their roles as family physicians in the delivery of palliative care and home visits. Participant responses were analyzed to summarize and interpret patterns related to their educational experience during their rotation. MAIN FINDINGS: Four interrelated themes were identified that described this experience: foundational skill development owing to training in a specialized setting; additional need for education and support; unaddressed gaps in pragmatic skills; and uncertainty about family physicians' role in palliative care. CONCLUSION: Residents described experiences that both supported and inadvertently discouraged them from considering future engagement in palliative care. Reassuringly, residents were also able to underscore opportunities for improvement in palliative care education.

Technical skill training improves the ability to learn.

BACKGROUND: In the initial phases of surgical training, attentional resources are monopolized by the execution of novel tasks. This consideration can result in overwhelming attentional resources, leaving few for other tasks. Practicing a technical task decreases the attentional resources required for its execution. These resources are then free for redistribution to other, clinically important tasks. This pilot study investigated how laboratory-based surgical training on a technical procedure affects concurrent acquisition of other, nontechnical information. METHODS: After watching an instructional video, 16 first-year surgical residents performed a pyloroplasty procedure and were divided randomly so half received 6 trials of hands-on practice of the procedure (practice group) whereas the other did not (no practice). After 1 week, participants returned to perform the procedure on 2 tests: isolated procedural performance (transfer) and concurrent procedural and listening performance (dual). Procedural and listening performances were compared between groups using expert measures of performance (Global Rating Scale [GRS], task-specific checklist, and number of errors) and written test scores. RESULTS: GRS and error scores reflected greater practice group performance on both tests: transfer test (P < .05 for all measures) and dual test (GRS, P < .05; error, P < .001). Most important, the practice group also retained more clinical information, indicated by higher written test scores (P < .001). CONCLUSION: Findings in this study suggest that practice outside of the operating room may result in a decrease in attentional resources dedicated to technical task execution, thus facilitating trainees' ability to distribute attentional resources between concurrent, clinically important task performances.

Effects of expertise, practice and contextual interference on adaptations to visuo-motor misalignment.

The cognitive demands of endoscopic surgery are amplified when rotations of the displayed surgical field cause discrepancies between intended and actual movements. While Visuo-Motor Misalignment (VMM) often impairs surgical technical performance, motor learning literature has demonstrated adaptation acquisition with practice. It is unknown whether these findings can be generalized to complex tasks of surgery. Two experiments investigated VMM adaptation processes within a laparoscopic context. The first examined the effects of practice and angle of visual rotation while the second investigated if, and how, the Contextual Interference Effect facilitates VMM adaptations. Laparoscopic performance was positively affected with smaller angles of visual rotation (p<.001) and increasing trials (p<.001). While not significant, performance was better after blocked versus random practice. In order to facilitate VMM adaptation acquisition, it is recommended that future simulated trainers incorporate the capacity for practice under visual rotation with flexibility in practice schedule.

Developing criteria for proficiency-based training of surgical technical skills using simulation: changes in performances as a function of training year.

BACKGROUND: Proficiency-based residency training programs can be more efficient than the current duration-based formats. For their successful implementation, appropriate proficiency criteria must be developed. The objective of this study was to investigate the relationship between technical skill performances assessed using computer- and expert-based methods and training year. An assumption was that asymptotes in performance as a function of training year can be used to set the proficiency level for a technical skill, so the value at which the asymptote occurs can be labeled as the proficiency criteria. STUDY DESIGN: Thirty-eight general surgery residents performed one-handed knot tying on bench-top simulators at two levels of difficulty: superficial and deep. Motion-efficiency measures and expert-based measures were used to evaluate performance. Total number of operations (ie, surgical volume) that each trainee participated in during residency was also acquired. RESULTS: On the superficial model, asymptotes were observed at year 1 for motion-efficiency and year 3 for expert-based measures. On the deep model, asymptotes were observed at year 2 for motion-efficiency and year 4 for expert-based measures. CONCLUSIONS: The data demonstrate the challenges associated with defining technical skills proficiency criteria. Different asymptotes were observed for the two assessment methods and neither covaried substantially with surgical volume. These data suggest that this asymptote approach in defining proficiency criteria can be suitable for development of proficiency-based residency training programs. The sensitivity of this approach to the type of assessment method and to the functional difficulty of the simulators used for assessment must be considered.