A Call to Action: Using Curriculum Mapping at Four Medical Schools in Massachusetts to Advance Serious Illness Communication Training in Undergraduate Medical Education.

Background: Practicing physicians require serious illness communication (SIC) skills to ensure high-quality, humanistic care for patients and families as they face life-changing medical decisions. However, a majority of U.S. medical schools do not require formal training in SIC and fail to provide students deliberate practice before graduation. The Massachusetts Medical Schools' Collaborative was created to ensure that students receive foundational SIC training in undergraduate medical education. This Collaborative developed a curriculum-mapping tool to assess SIC at four medical schools. Objective: We aimed to understand existing educational activities across four medical schools and identify opportunities to build longitudinal, developmentally based curricular threads in SIC. Design: From July 2019 to April 2021, faculty, staff, and medical students assessed current educational activities related to five core competencies in SIC, adapted for students from national competencies for palliative medicine fellows, using a curriculum mapping tool. Measurements: The group selected 23 keywords and collected metrics to describe the timing, instruction and assessment for each school's educational activities. Results: On average, there were only 40 hours of required curricula in SIC over four years. Over 80% of relevant SIC hours occurred as elective experiences, mostly during the postclerkship phase, with limited capacity in these elective experiences. Only one school had SIC educational activities during the clerkship phase when students are developing clinical competencies. Assessment methods focused on student participation, and no school-assessed clinical performance in the clerkship or postclerkship phase. Conclusions: Medical schools are failing to consistently train and ensure basic competency in effective, compassionate SIC. Curriculum mapping allows schools to evaluate their current state on a particular topic such as SIC, ensure proper assessment, and evaluate curricular changes over time. Through the deliberate inclusion of SIC competencies in longitudinal curriculum design, we can fill this training gap and create best practices in undergraduate medical education.

Development of Objectives to Inform a National Standardized Primary Palliative Care Curriculum for Health Professions Students.

Introduction: Despite recent educational advances, the need for a national standardized primary palliative care curriculum for health professions students remains evident. Methods: An interprofessional leadership team developed a set of core learning objectives built on previously published competencies. A survey was then sent to palliative care experts for feedback and consensus. Results: Twenty-eight of 31 objectives met a 75% consensus threshold, 2 were combined with others, and 12 were refined based on survey feedback. Discussion: With interprofessional input at all stages, we finalized a comprehensive list of 26 learning objectives for a primary palliative care curriculum targeting health professions students. These objectives will be widely available through an online course but can also be adopted for use by individual educators across health professions institutions. These objectives and related curriculum are critical to producing practice-ready clinicians who are prepared to care for the burgeoning population of seriously ill patients.

Paving the way for universal medical student training in serious illness communication: the Massachusetts Medical Schools' Collaborative.

BACKGROUND: Patients with serious illness look to their clinicians for discussion and guidance on high-stakes treatment decisions, which are complex, emotional and value-laden. However, required training in serious illness communication is rare in U.S. medical schools, with efforts at curricular reform stymied by competing institutional demands, lack of resources and accreditation requirements. We describe an approach to building and scaling medical student training in serious illness communication through the creation of a statewide collaborative of medical schools. METHODS: The Massachusetts Medical Schools' Collaborative is a first-of-its-kind group that promotes longitudinal, developmentally-based curricula in serious illness communication for all students. Convened externally by the Massachusetts Coalition for Serious Illness Care, the collaborative includes faculty, staff, and students from four medical schools. RESULTS: The collaborative started with listening to member's perspectives and collectively developed core competencies in serious illness communication for implementation at each school. We share early lessons on the opportunities, challenges and sustainability of our statewide collective action to influence curricular reform, which can be replicated in other topic areas. CONCLUSIONS: Our next steps include curriculum mapping, student focus groups and faculty development to guide successful and enduring implementation of the competencies to impact undergraduate medical education in Massachusetts and beyond.

Specialty-Aligned Palliative Care: Responding to the Needs of a Tertiary Care Health System.

BACKGROUND: Expanding specialty palliative care within complex health systems involves consideration of patients' unmet needs, clinicians' perceptions of palliative care, and the availability of palliative care resources. Prior to this quality improvement (QI) project, palliative care services in our health system primarily served oncology patients. INTERVENTION: We undertook a prospective strategic planning process that included executive sponsorship and engagement of institutional leaders and clinicians to help define which palliative care services were most needed by the health system. MEASURES: We interviewed and surveyed a broad range of clinicians including physicians, nurse practitioners, and social workers. OUTCOMES: The two most prominent themes that emerged from the stakeholder engagement process were clinicians' wish for specialty-aligned interprofessional palliative care teams and for expansion of nononcology palliative care access. CONCLUSION: Careful needs assessment and stakeholder engagement can result in goal-directed and data-driven expansion of palliative care services within tertiary health care systems.

Improving Serious Illness Communication: Testing the Serious Illness Care Program with Trainees.

BACKGROUND: Early conversations about patients' goals and values improve care, but clinicians struggle to conduct them. The systems-based Serious Illness Care Program (SICP) helps clinicians have more, better, and earlier conversations. Central to this approach is a clinician conversation guide for patient encounters. While the SICP works for practicing clinicians, it has not been tested with medical trainees. INTERVENTION: We adapted the SICP training to emphasize assessing prognostic awareness and responding to emotion. We developed a 2.5-hour SICP workshop for medical students and medical interns that included large- and small-group work, practice with an actor, and interdisciplinary clinician facilitators. We trained 81 students and 156 interns and obtained anonymous quantitative and qualitative feedback. OUTCOMES: Eighty-six percent of students and 91% of residents rated the session as "very good" or "excellent" and >90% of all learners would either recommend this training or intended to apply this to their practice. Post-session learner confidence increased in all communication skills. Learners said the training provided a helpful framework and useful language for these conversations. Resident documentation of serious illness conversations in the medical record increased dramatically during the year following training commencement. CONCLUSIONS: Grounded in principles of adult learning theory, this training was rated highly by trainees and resulted in demonstrable practice change. These early learners were more flexible and willing to try this approach than practicing clinicians who tend to resist or revert to old habits. A Guide represents a new paradigm for teaching communication skills and is valued by early learners.

Role of Palliative Care in the Outpatient Management of the Chronic Heart Failure Patient.

PURPOSE OF REVIEW: Patients with heart failure (HF) have an increased symptom burden and complex psychosocial and decision-making needs that necessitate the integration of palliative care. However, in the current era, palliative care is frequently evoked for these patients only at the end-of-life or in the inpatient setting; rarely is palliative care proactively utilized in outpatients with HF. The purpose of this review is to evaluate the current state of palliative care and heart failure and to provide a roadmap for the integration of palliative care into outpatient HF care. RECENT FINDINGS: Recent studies, including PAL-HF, CASA, and SWAP-HF, have demonstrated that structured palliative care interventions may improve quality of life, depression, anxiety, understanding of prognosis, and well-being in HF. HF is associated with high mortality risk, significant symptom burden, and impaired quality of life. Palliative care can meet many of these needs; however, in the current era, palliative care consultations in HF occur late in the disease course and too often in the inpatient setting. Primary palliative care should be provided to all outpatients with heart failure based on their needs, with referral to secondary palliative care provided based on certain triggers and milestones.

Palliative Care and Communication Training in Neurosurgery Residency: Results of a Trainee Survey.

OBJECTIVE: Neurosurgeons care for critically ill patients near the end of life, yet little is known about how well their training prepares them for this role. We surveyed a random sample of neurosurgery residents to describe the quantity and quality of teaching activities related to serious illness communication and palliative care, and resident attitudes and perceived preparedness to care for seriously ill patients. METHODS: A previously validated survey instrument was adapted to reflect required communication and palliative care competencies in the 2015 the Accreditation Council for Graduate Medical Education (ACGME) Milestones for Neurological Surgery. The survey was reviewed for content validity by independent faculty neurosurgeons, piloted with graduating neurosurgical residents, and distributed online in August 2016 to neurosurgery residents in the United States using the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Joint Section on Neurotrauma and Critical Care email listserv. Multiple choice and Likert scale responses were analyzed using descriptive statistics. RESULTS: Sixty-two responses were recorded between August 2016 and October 2016. Most respondents reported no explicit teaching on: explaining risks and benefits of intubation and ventilation (69%), formulating prognoses in neurocritical care (60%), or leading family meetings (69%). Compared to performing craniotomies, respondents had less frequent practice leading discussions about withdrawing life-sustaining treatment (61% vs. 90%, p < 0.01, "weekly or more frequently"), and were less often observed (18% vs. 87%, p < 0.01) and given feedback on their performance (11% vs. 58%, p < 0.01). Nearly all respondents (95%) felt "prepared to discuss withdrawing life-sustaining treatments," however half (48%) reported they "would benefit from more communication training during residency." Most (87%) reported moral distress, agreeing that they "participated in operations and worried whether surgery aligned with patient goals." CONCLUSIONS: Residents in our sample reported limited formal training, and relatively less observation and feedback, on required ACGME competencies in palliative care and communication. Most reported preparedness in this domain, but many were receptive to more training. Better quality and more consistent palliative care education in neurosurgery residency could improve competency and help ensure that neurosurgical care aligns with patient goals.

Social Worker-Aided Palliative Care Intervention in High-risk Patients With Heart Failure (SWAP-HF): A Pilot Randomized Clinical Trial.

Importance: Palliative care considerations are typically introduced late in the disease trajectory of patients with advanced heart failure (HF), and access to specialty-level palliative care may be limited. Objective: To determine if early initiation of goals of care conversations by a palliative care-trained social worker would improve prognostic understanding, elicit advanced care preferences, and influence care plans for high-risk patients discharged after HF hospitalization. Design, Setting, and Participants: This prospective, randomized clinical trial of a social worker-led palliative care intervention vs usual care analyzed patients recently hospitalized for management of acute HF who had risk factors for poor prognosis. Analyses were conducted by intention to treat. Interventions: Key components of the social worker-led intervention included a structured evaluation of prognostic understanding, end-of-life preferences, symptom burden, and quality of life with routine review by a palliative care physician; communication of this information to treating clinicians; and longitudinal follow-up in the ambulatory setting. Main Outcomes and Measures: Percentage of patients with physician-level documentation of advanced care preferences and the degree of alignment between patient and cardiologist expectations of prognosis at 6 months. Results: The study population (N = 50) had a mean (SD) age of 72 (11) years and had a mean (SD) left ventricular ejection fraction of 0.33 (13). Of 50 patients, 41 (82%) had been hospitalized more than once for HF management within 12 months of enrollment. At enrollment, treating physicians anticipated death within a year for 32 patients (64%), but 42 patients (84%) predicted their life expectancy to be longer than 5 years. At 6 months, more patients in the intervention group than in the control group had physician-level documentation of advanced care preferences in the electronic health record (17 [65%] vs 8 [33%]; χ2 = 5.1; P = .02). Surviving patients allocated to intervention were also more likely to revise their baseline prognostic assessment in a direction consistent with the physician's assessment (15 [94%] vs 4 [26%]; χ2 = 14.7; P < .001). Among the 31 survivors at 6 months, there was no measured difference between groups in depression, anxiety, or quality-of-life scores. Conclusions and Relevance: Patients at high risk for mortality from HF frequently overestimate their life expectancy. Without an adverse impact on quality of life, prognostic understanding and patient-physician communication regarding goals of care may be enhanced by a focused, social worker-led palliative care intervention that begins in the hospital and continues in the outpatient setting. Trial Registration: clinicaltrials.gov Identifier: NCT02805712.

Radiation oncology resident palliative education.

PURPOSE: Although palliative care is recognized as integral to oncology care, limited data exist regarding the extent to which palliative care training is incorporated into radiation oncology residency training in the United States. We aim to characterize US radiation oncology residents' perceived palliative care educational needs and experience to guide future palliative oncology educational interventions. METHODS AND MATERIALS: An 8-person expert panel developed a survey to assess resident perceptions of generalist palliative care education within radiation oncology residency. Domains of palliative oncology education, derived from national guidelines, included symptom management (pain and non-pain), communication about goals of care, advance care planning, psychosocial issues, cultural considerations, spiritual needs, care coordination, and ethical/legal issues. Residents rated adequacy of their training and their perceived competency in each domain. A total of 433 US radiation oncology residents were identified for participation; 404 completed the survey (response rate, 93%). RESULTS: Residents characterized themselves as "not at all/minimally/somewhat confident" in their ability to take care of patients with palliative care issues in the following domains: symptom management (36% pain, 44% non-pain), communication about goals of care (31%), advance care planning (48%), psychosocial (55%), cultural (22%), spiritual (44%), care coordination (50%), and ethical/legal (50%). On average, 79% of residents rated their training as "not/minimally/somewhat" adequate across all domains. Most (96%) view palliative care as an important competency within radiation oncology and 81% desire more palliative care education. CONCLUSIONS: Although the majority of residents view palliative care as an important competency for radiation oncologists, a majority perceived their educational training as inadequate across multiple domains. Most residents desire further palliative oncology care training. These findings suggest efforts should be made to improve palliative care education during radiation oncology training.

Integrating palliative care into routine care of patients with heart failure: models for clinical collaboration.

Heart failure (HF) affects nearly 5.7 million Americans and is described as a chronic incurable illness carrying a poor prognosis. Patients living with HF experience significant symptoms including dyspnea, pain, anxiety, fatigue, and depression. As the illness advances into later stages, symptoms become more intense and refractory to standard treatments, leading to recurrent acute-care utilization and contributing to poor quality of life. Advanced HF symptoms have been described to be as burdensome, if not more than, those in cancer populations. Yet access to and provision of palliative care (PC) for this population has been described as suboptimal. The Institute of Medicine recently called for better access to PC for seriously ill patients. Despite guidelines recommending the inclusion of PC into the multidisciplinary HF care team, there is little data offering guidance on how to best operationalize PC skills in caring for this population. This paper describes the emerging literature describing models of PC integration for HF patients and aims to identify key attributes of these care models that may help guide future multi-site clinical trials to define best practices for the successful delivery of PC for patients living with advanced HF.

Raising the bar for the care of seriously ill patients: results of a national survey to define essential palliative care competencies for medical students and residents.

PURPOSE: Given the shortage of palliative care specialists in the United States, to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts. METHOD: Proposed competencies were derived from existing hospice and palliative medicine fellowship competencies and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a Web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains. RESULTS: The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate = 72%, 71/98). Using predefined cutoff criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains. CONCLUSIONS: This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community.

Missed opportunities to train medical students in generalist palliative care during core clerkships.

BACKGROUND: To improve the quality of care for dying patients, experts have called for all clinicians to be able to provide a generalist level of palliative care. Core clinical clerkships provide an opportunity to incorporate palliative care training to address the lack of required palliative care rotations at most U.S. medical schools. OBJECTIVE: The objective of this study was to identify and quantify missed opportunities to train third-year medical students in generalist palliative care during required core clerkships. DESIGN: This study was a cross-sectional survey of third-year students at a leading U.S. medical school without a required palliative care rotation. MEASUREMENTS: Students completed a survey during the last 4 months of the 2012-2013 academic year quantifying and evaluating their experiences caring for dying patients. Attitudes were assessed using a scale from a national survey of students, residents, and faculty. RESULTS: Eighty-eight students responded (response rate [RR]=56%). More than one-quarter (26%) never participated in caring for a patient who died. More than one-half (55%) never delivered significant bad news and 38% never worked with a specialist in palliative medicine. Eighty-four percent of students who cared for a patient who died and 60% of students who delivered significant bad news had one or more of those experiences that were not debriefed. CONCLUSIONS: At an institution without a required palliative care rotation, third-year medical students rarely or never care for patients who die during core clerkships, and when they do, their teams do not debrief or reflect on these experiences. Clinical faculty, including palliative care consultants, can address missed opportunities for palliative care training during core clerkships by augmenting and routinely debriefing students' experiences giving bad news and caring for dying patients.

Assessing the quality of pain care in ambulatory patients with advanced stage cancer.

CONTEXT: Pain is common among patients with advanced cancer despite the dissemination of clinical pain care guidelines. OBJECTIVES: We sought to assess the quality of pain care among patients with advanced disease. METHODS: We reviewed the records of 85 adult ambulatory patients with advanced breast, lung, and gastrointestinal cancer treated in 2004-2006. Patients' screening pain intensity scores were at least 7 of 10. Nurse reviewers completed medical record reviews of care rendered at the index visit and over the subsequent 30 days based on the 2004 National Comprehensive Cancer Network pain guideline. An expert panel then rated the quality of the evaluation, treatment, and overall pain care. We used a multivariable model to analyze guideline compliance and resolution of severe pain. RESULTS: Among advanced cancer patients with severe pain, clinicians adjusted pain medications only half the time and made few timely referrals for pain-related consultations. By 30 days after the index visit, 34% of patients continued to report severe pain. The expert panel judged the overall quality of pain care as "fair" or "poor" in about two-thirds of cases because more timely and effective intervention could have reduced the severity and duration of pain. Resolution of severe pain was associated with adjustment of pain medications at the index visit (adjusted odds ratio 3.8, 95% CI 1.3-10.6). CONCLUSION: There is room for improvement in the pain care of patients with advanced cancer. Additional research is needed to understand the reasons for poor performance.

Physician communication with families in the ICU: evidence-based strategies for improvement.

PURPOSE OF REVIEW: Skilled physician-family communication in the ICU has been shown to improve patient outcomes, but until now little attention has been given to the effect of communication on family satisfaction and bereavement outcomes. The aim of this review is to outline the recent evidence that effective physician communication with families, and proactive palliative care interventions, can improve outcomes for both patients and family members in the ICU. RECENT FINDINGS: New data from the ICU correlates physician ability to identify and respond to emotion and to effectively share prognostic information with improved outcomes. Furthermore, proactive palliative care interventions that promote family meetings, use of empathic communication skills, and targeted palliative care consultations can improve family satisfaction, reduce length of stay in the ICU and reduce adverse family bereavement outcomes. SUMMARY: Empathic communication, skilful discussion of prognosis, and effective shared decision-making are core elements of quality care in the ICU, represent basic competencies for the ICU physician, and should be emphasized in future educational and clinical interventions.