Development of an Actor Rehearsal Guide for Communication Skills Courses.

BACKGROUND: Established models of serious illness communication training frequently include role play with simulated patient actors. Yet preparing for communication courses can feel challenging, as most faculty have minimal experience directing actors, and no literature exists to guide faculty in how to lead course rehearsals. METHODS: A team of palliative care educators partnered with a seasoned acting teacher to design and implement a faculty guide for directing actors during communication course rehearsals. Their approach involved a series of brainstorming sessions, creation and piloting of a draft rehearsal guide and revisions based on actor and faculty feedback. RESULTS: The actor rehearsal guide offers a stepwise approach to beginning a rehearsal, rehearsing a patient case, giving feedback to the actor and ensuring the actor responds appropriately to learners of varied skill levels. From early 2021 to late 2022, the team used the guide to prepare for 36 courses, which trained 446 clinicians. Faculty and actors noted that the guide fostered predictable and efficient rehearsals. CONCLUSIONS: A novel actor rehearsal guide can support preparation for communication courses at a single institution. Next steps include disseminating the guide to other institutions and evaluating the guide's impact on faculty and actors' experience of rehearsals and learners' experience of training.

Defining Key Elements of a Clinical Experience in Hospice and Palliative Medicine for Medical Residents in the United States.

Training in hospice and palliative medicine (HPM) is essential for practicing internists, who routinely care for patients and families facing serious illness. Program directors and medical residents acknowledge the importance of palliative medicine skills, and trainees themselves desire more such training. The ACGME has also recognized the importance of HPM training for medical residents, establishing in its 2022 Common Program Requirements for Internal Medicine a new expectation that all residents have a clinical experience in HPM. However, internal medicine residencies vary significantly in their approach to teaching HPM skills, and what constitutes a useful clinical experience in HPM has not been well-described. In this perspective, we draw from the available literature and our experience as educators to propose 5 core elements for creating an optimal HPM experience for medical residents. These include practice with symptom management and communication in serious illness, exposure to interdisciplinary care, appreciation of the continuum of care settings for HPM delivery, and an understanding of the key principles of hospice care. We then describe the relevance of each element and offer educational strategies regarding how each can be achieved.

Something Lost and Something Gained: Navigating the Bedside Teaching Role as a Hospice and Palliative Medicine Educator.

Hospice and palliative medicine (HPM) educators must often give up the satisfaction of working one-on-one with patients, to allow learners the opportunity to practice key communication skills and form their own therapeutic bonds with patients. Though the loss of that primary relationship with patients may feel challenging, educators may find new opportunity for professional impact and satisfaction by investing in their relationship with learners. This case discussion explores the challenges of bedside teaching in HPM, including the educator's looser connection with patients, need to withhold their own communication skills, and decision of when to interject into a trainee-patient conversation. We then propose strategies to help educators find renewed professional fulfillment in the teacher-learner relationship. By partnering intentionally with learners before, during, and after shared visits, inviting informal reflection between encounters, and preserving independent clinical time, we believe educators may cultivate a more sustainable and meaningful clinical teaching practice.

Topical Review: Teaching Serious News Delivery in Eye Care.

SIGNIFICANCE: Eye doctors regularly convey serious illness news to their patients. There is an evolving understanding of how medical educators can effectively teach this vital communication skill during real-time patient care. This article proposes teaching strategies to improve clinical optometric education related to serious illness conversations.Effectively conveying serious illness news is an essential skill in optometry practice. Established protocols can help optometrists navigate these nuanced, emotional, and complex conversations with patients, yet protocols for teaching this skill in eye care settings have not been described. Clinical educators need discrete strategies for making such pivotal communication skills learnable in an environment where patient care, teaching priorities, and limited resources are regularly juggled. Despite the importance of this competency, limited study has focused on teaching optometry learners to deliver serious eye news. In this article, we explore the importance of optometry talk, serious news delivery tools, and considerations for optometric educators teaching serious news delivery. We then adapt specific strategies from medical education to help optometry educators teach serious news delivery in clinical settings.

The Tween Years: Thriving as a Mid-Career Academic Hospice and Palliative Medicine Clinician.

In the young and rapidly evolving field of hospice and palliative medicine (HPM), the transition from early to mid-career can be a precarious time. The high rates of burnout and low rates of work-life balance and satisfaction found in mid-career jeopardize our field's ability to maintain a healthy workforce. In this series, we present three cases that highlight common issues encountered during the early to mid-career transition in academic HPM and present several strategies for navigating challenges. A web of mentors/connections, academic map, and continuing education to enhance teaching skills are several concrete tools explored. To sustain a robust HPM workforce, such practical and structured supports during the particularly challenging mid-career transition are crucial.

Perspectives of internal medicine residents on approaching serious illness conversations.

BACKGROUND: Navigating serious illness conversations is a critical competency for clinical trainees in any discipline, yet many feel underprepared to engage in such conversations. This study explored the challenges and emotions experienced by residents (junior doctors) when approaching serious illness conversations and how their perceptions might inform the development of effective communication skills curricula. METHODS: Using qualitative methodology, we explored the prior experience of Internal Medicine residents who attended communication skills workshops at Brigham and Women's Hospital between January and May 2020. Using an open-ended questionnaire, we solicited participants' reflections on conducting serious illness conversations. Narratives were de-identified and analysed for key themes. The Mass General Brigham Institutional Review Board approved the study. FINDINGS: Fifty-one out of 70 eligible residents (72.8%) completed the questionnaire. Qualitative analysis identified five key themes: (a) finding the time to do it right, (b) fear of using the wrong words, (c) managing the patient's response and emotion, (d) not knowing how much they can say and (e) finding meaning and fulfilment. Residents also proposed several practical strategies to enhance their communication training. DISCUSSION AND CONCLUSION: Though serious illness conversations were reported as stressful, study participants emphasised that the experiences enabled them to forge meaningful therapeutic relationships and led to a sense of fulfilment. The strategies recommended by our residents offer valuable insights to improve communication training, including through increased simulated and real-time skills practice. Cocreation of curricula by trainees and faculty could potentially address trainees' challenges, promote essential skills, and foster professional identity formation.

Development of a Palliative Care Toolkit for the COVID-19 Pandemic.

The Coronavirus disease 2019 (COVID-19) pandemic has led to high numbers of critically ill and dying patients in need of expert management of dyspnea, delirium, and serious illness communication. The rapid spread of severe acute respiratory syndrome-Coronavirus-2 creates surges of infected patients requiring hospitalization and puts palliative care programs at risk of being overwhelmed by patients, families, and clinicians seeking help. In response to this unprecedented need for palliative care, our program sought to create a collection of palliative care resources for nonpalliative care clinicians. A workgroup of interdisciplinary palliative care clinicians developed the Palliative Care Toolkit, consisting of a detailed chapter in a COVID-19 online resource, a mobile and desktop Web application, one-page guides, pocket cards, and communication skills training videos. The suite of resources provides expert and evidence-based guidance on symptom management including dyspnea, pain, and delirium, as well as on serious illness communication, including conversations about goals of care, code status, and end of life. We also created a nurse resource hotline staffed by palliative care nurse practitioners and virtual office hours staffed by a palliative care attending physician. Since its development, the Toolkit has helped us disseminate best practices to nonpalliative care clinicians delivering primary palliative care, allowing our team to focus on the highest-need consults and increasing acceptance of palliative care across hospital settings.

Exploring and Managing the Impostor Phenomenon in Palliative Care: A Case Series.

The impostor phenomenon (IP) describes the experience of questioning one's abilities and fearing exposure as an intellectual fraud, despite objective evidence of success. The IP has been identified in high-achieving professionals across a variety of disciplines, including clinical medicine, and can be associated with significant anxiety and psychological distress. In this series, we present three authentic cases that demonstrate how the IP may manifest in palliative care practice. Acknowledging the current emphasis on clinician wellness and burnout, we suggest that the IP may be one important source of distress for many early-career clinicians in palliative care. With the physician as the focus of each case, we explore the difficult emotions faced and highlight how palliative care clinicians may be uniquely vulnerable to the IP. We then identify concrete strategies to help clinicians manage feelings of IP and enhance their professional well-being.

Assessment and Management of Patients With Metastatic Spinal Cord Compression: A Multidisciplinary Review.

PURPOSE: Metastatic spinal cord compression (MSCC) can be a catastrophic manifestation of advanced cancer that causes immobilizing pain and significant neurologic impairment. Oncologists can protect their patients by having a high index of suspicion for MSCC when patients present with new or worsening back pain before motor, sensory, bowel, or bladder deficits develop. We provide an updated, evidence-based narrative review of the presentation, diagnosis, and treatment of MSCC. METHODS: This narrative review was conducted by searching MEDLINE and Cochrane Database of Systematic Reviews for relevant literature on the presentation, diagnosis, and treatment of patients with MSCC. The article addresses the key elements of MSCC management germane to the medical oncologist, with special attention given to pain and symptom management, decision making with regard to surgery and radiation therapy, the importance of rehabilitative care, and the value of a multidisciplinary approach. RESULTS: Magnetic resonance imaging of the entire spine is recommended for the diagnosis of MSCC. Treatment includes glucocorticoid therapy, pain management, radiation therapy with or without surgery, and specialized rehabilitation. When formulating a treatment plan, clinicians should consider the patient's care goals and psychosocial needs. CONCLUSION: Prompt diagnosis and treatment of MSCC can reduce pain and prevent irreversible functional loss. Regular collaboration among multidisciplinary providers may streamline care and enhance achievement of treatment goals.

High-dose neuroleptics and neuroleptic rotation for agitated delirium near the end of life.

REASON FOR THE STUDY: Agitated delirium presents unique challenges for hospice and palliative care clinicians. Haloperidol, the recommended neuroleptic, may be ineffective at low dose, or poorly tolerated at higher doses. MAIN FINDINGS: This article reports on two patients with refractory agitated delirium. Both developed extrapyramidal symptoms from haloperidol and required rotation to an alternate neuroleptic. Patient #1 received 2000 mg/day oral chlorpromazine. Patient #2 received greater than 200 mg/day sublingual olanzapine. Control of agitation was achieved, though the doses were substantially higher than has previously reported in the literature. Each patient experienced considerable sedation, though this was an acceptable side effect for the family. Each patient was transferred from the acute care hospital to a location of family preference. There they died within a week of transfer. CONCLUSIONS: Agitated delirium is a palliative care emergency. High doses of neuroleptic medications, with rotation to an alternate neuroleptic when side effects occur with standard haloperidol, may effectively palliate agitated delirium. This remedy can provide the patient with a peaceful dying in a place of their choosing.