Right-sizing interprofessional team training for serious-illness communication: A strength-based approach.

Objective: Palliative care communication skills help tailor care to patients' goals. With a palliative care physician shortage, non-physicians must gain these serious illness communication skills. Historically, trainings have targeted physician-only groups; our goal was to train interprofessional teams. Methods: Workshops were conducted to teach palliative care communication skills and interprofessional communication. Participants completed surveys which included questions from the Interpersonal Reactivity Index, the Ekman Faces tool, the Consultation and Relational Empathy measure, open-ended questions about empathy, and measures of effective interprofessional practice. Results: Participants felt the workshop improved their ability to listen (p < 0.001), understand patients' concerns (p < 0.001), and show compassion (p = 0.008). It increased the perceived value of peer observation (p < 0.001) and ability to reflect (p = 0.02) during complex conversations. Different types of professionals adopted different communication goals, though all affirmed the importance of active listening. Participants felt they improved their ability to work within an interprofessional team. Conclusions: The course effectively trained 71 clinicians, the majority non-physicians, in serious illness communication and interprofessional team communication skills, and could be reproduced in similar settings. Innovation: We adapted an approach common to physician-only trainings to diverse interprofessional groups, added a team-based component using Applied Improvisation, and demonstrated its effectiveness.

Embedding an Education Intervention about Shared Decision Making into an RCT: Ensuring competency and fidelity.

Objective: To describe the outcomes of training nephrology clinicians and clinical research participants, to use the Best Case/Worst Case Communication intervention, for discussions about dialysis initiation for patients with life-limiting illness, during a randomized clinical trial to ensure competency, fidelity to the intervention, and adherence to study protocols and the intervention throughout the trial. Methods: We enrolled 68 nephrologists at ten study sites and randomized them to receive training or wait-list control. We collected copies of completed graphic aids (component of the intervention), used with study-enrolled patients, to measure fidelity and adherence. Results: We trained 34 of 36 nephrologists to competence and 27 completed the entire program. We received 60 graphic aids for study-enrolled patients for a 73% return rate in the intervention arm. The intervention fidelity score for the graphic aid reflected completion of all elements throughout the study. Conclusion: We successfully taught the Best Case/Worst Case Communication intervention to clinicians as research participants within a randomized clinical trial. Innovation: Decisions about dialysis are an opportunity to discuss prognosis and uncertainty in relation to consideration of prolonged life supporting therapy. Our study reveals a strategy to evaluate adherence to a communication intervention in real time during a clinical study.

Gender influences resident physicians' perception of an employee-to-employee recognition program: a mixed methods study.

BACKGROUND: Burnout is prevalent in medical training. While some institutions have implemented employee-to-employee recognition programs to promote wellness, it is not known how such programs are perceived by resident physicians, or if the experience differs among residents of different genders. METHODS: We used convergent mixed methods to characterize how residents in internal medicine (IM), pediatrics, and general surgery programs experience our employee-to-employee recognition ("Hi-5″) program. We collected Hi-5s received by residents in these programs from January 1, 2021-December 31, 2021 and coded them for recipient discipline, sex, and PGY level and sender discipline and professional role. We conducted virtual focus groups with residents in each training program. MAIN MEASURES AND APPROACH: We compared Hi-5 receipt between male and female residents; overall and from individual professions. We submitted focus group transcripts to content analysis with codes generated iteratively and emergent themes identified through consensus coding. RESULTS: Over a 12-month period, residents received 382 Hi-5s. There was no significant difference in receipt of Hi-5s by male and female residents. Five IM, 3 surgery, and 12 pediatric residents participated in focus groups. Residents felt Hi-5s were useful for interprofessional feedback and to mitigate burnout. Residents who identified as women shared concerns about differing expectations of professional behavior and communication based on gender, a fear of backlash when behavior does not align with gender stereotypes, and professional misidentification. CONCLUSIONS: The "Hi-5" program is valuable for interprofessional feedback and promotion of well-being but is experienced differently by men and women residents. This limitation of employee-to-employee recognition should be considered when designing equitable programming to promote well-being and recognition.

Emphasis of Diversity, Equity, and Inclusion on US Adult Infectious Disease Fellowship Program Websites in the Era of Virtual Recruitment.

Women and underrepresented-in-medicine applicants value a climate for diversity when selecting graduate medical education training programs. Climate may not be accurately represented during virtual recruitment. Optimizing program websites may help overcome this barrier. We reviewed websites for adult infectious disease fellowships that participated in the 2022 National Resident Matching Program for emphasis on diversity, equity, and inclusion (DEI). Fewer than half expressed DEI language in their mission statement or had a dedicated DEI statement or webpage. Programs should consider emphasizing their commitment to DEI prominently on their websites, which may help recruit candidates from diverse backgrounds.

Using nominal group technique to determine skills that applied improvisation can teach health profession education learners.

Objective: Applied improvisation (AI) is an approach used in health professions (HP) education to teach skills essential for clinical practice such as communication, teamwork, and empathy. Little is known about which skills can be developed using AI, or those which an AI should prioritize. Our research aims to identify skills essential to include in an AI curriculum for HP learners. Methods: A modified nominal group technique (NGT) was conducted to identify and prioritize specific skills which can be taught using AI. This involved silent generation of ideas, round robin, discussions, 2-rounds of preliminary voting, and a final ranking survey to determine a prioritized list of skills to include in an AI curriculum for HP learners. Results: Six content experts participated in the NGT meeting. Initially, 83 skills were identified, and through NGT, a final list of 11 skills essential to an AI curriculum were determined including: adaptability, affirmation of others, acceptance, active listening, being present, cooperation, collaboration with other, advancement, compassionate communication, sharpened non-verbal communication, resilience. Conclusion: Essential skills for an AI curriculum relate to adaptability, attunement, collaboration, affirmation, and advancement. Innovation: This study is a novel application of NGT as a strategy to organize an approach to curriculum innovations.

Discussion-based interprofessional education: A positive step toward promoting shared understanding between surgical residents and nurses.

Interprofessional education during medical training may improve communication by promoting collaboration and the development of shared mental models between professions. We implemented a novel discussion-based intervention for surgical residents and nurses to promote mutual understanding of workflows and communication practices. General surgery residents and inpatient nurses from our institution were recruited to participate. Surveys and paging data were collected prior to and following the intervention. Surveys contained original questions and validated subscales. Interventions involved facilitated discussions about workflows, perceptions of urgency, and technology preferences. Discussions were recorded and transcribed for qualitative content analysis. Pre and post-intervention survey responses were compared with descriptive sample statistics. Group characteristics were compared using Fisher's exact tests. Eleven intervention groups were conducted (2-6 participants per group) (n = 38). Discussions achieved three aims: Information-Sharing (learning about each other's workflows and preferences), 2) Interpersonal Relationship-Building (establishing rapport and fostering empathy) and 3) Interventional Brainstorming (discussing strategies to mitigate communication challenges). Post-intervention surveys revealed improved nurse-reported grasp of resident schedules and tailoring of communication methods based on workflow understanding; however, communication best practices remain limited by organizational and technological constraints. Systems-level changes must be prioritized to allow intentions toward collegial communication to thrive.

How to Use Improv to Help Interprofessional Students Respond to Status and Hierarchy in Clinical Practice.

Hierarchy and status and power differentials in current health care practice persist, despite recognition of their ethical issues and movement toward collaborative practice. As interprofessional education continues to emphasize shifting from individual siloed practice to team-based approaches to improving patient safety and outcomes, addressing status and power is key to mutual respect and trust cultivation. What has become known as medical improv applies techniques of theater improvisation to health professions education and practice. This article shares how an improv exercise called Status Cards prompts participants to recognize their responses to status and how this awareness can be applied to improve their interactions in real encounters with patients, colleagues, and others in health care contexts.

Identifying Patterns in Preoperative Communication about High-Risk Surgical Intervention: A Secondary Analysis of a Randomized Clinical Trial.

INTRODUCTION: Surgeons are entrusted with providing patients with information necessary for deliberation about surgical intervention. Ideally, surgical consultations generate a shared understanding of the treatment experience and determine whether surgery aligns with a patient's overall health goals. In-depth assessment of communication patterns might reveal opportunities to better achieve these objectives. METHODS: We performed a secondary analysis of audio-recorded consultations between surgeons and patients considering high-risk surgery. For 43 surgeons, we randomly selected 4 transcripts each of consultations with patients aged ≥60 y with at least 1 comorbidity. We developed a coding taxonomy, based on principles of informed consent and shared decision making, to categorize surgeon speech. We grouped transcripts by treatment plan and recorded the treatment goal. We used box plots, Sankey diagrams, and flow diagrams to characterize communication patterns. RESULTS: We included 169 transcripts, of which 136 discussed an oncologic problem and 33 considered a vascular (including cardiac and neurovascular) problem. At the median, surgeons devoted an estimated 8 min (interquartile range 5-13 min) to content specifically about intervention including surgery. In 85.5% of conversations, more than 40% of surgeon speech was consumed by technical descriptions of the disease or treatment. "Fix-it" language was used in 91.7% of conversations. In 79.9% of conversations, no overall goal of treatment was established or only a desire to cure or control cancer was expressed. Most conversations (68.6%) began with an explanation of the disease, followed by explanation of the treatment in 53.3%, and then options in 16.6%. CONCLUSIONS: Explanation of disease and treatment dominate surgical consultations, with limited time spent on patient goals. Changing the focus of these conversations may better support patients' deliberation about the value of surgery.Trial registration: ClinicalTrials.gov Identifier: NCT02623335. HIGHLIGHTS: In decision-making conversations about high-risk surgical intervention, surgeons emphasize description of the patient's disease and potential treatment, and the use of "fix-it" language is common.Surgeons dedicated limited time to eliciting patient preferences and goals, and 79.9% of conversations resulted in no explicit goal of treatment.Current communication practices may be inadequate to support deliberation about the value of surgery for individual patients and their families.

Best Case/Worst Case: protocol for a multisite randomised clinical trial of a scenario planning intervention for patients with kidney failure.

INTRODUCTION: Given the burdens of treatment and poor prognosis, older adults with kidney failure would benefit from improved decision making and palliative care to clarify goals, address symptoms, and reduce unwanted procedures. Best Case/Worst Case (BC/WC) is a communication tool that uses scenario planning to support patients' decision making. This article describes the protocol for a multisite, cluster randomised trial to test the effect of training nephrologists to use the BC/WC communication tool on patient receipt of palliative care, and quality of life and communication. METHODS AND ANALYSIS: We are enrolling attending nephrologists, at 10 study sites in the USA, who see outpatients with advanced chronic kidney disease considering dialysis. We aim to enrol 320 patients with an estimated glomerular filtration rate of ≤24 mL/min/1.73 m2 who are age 60 and older and have a predicted survival of 18 months or less. Nephrologists will be randomised in a 1:1 ratio to receive training to use the communication tool (intervention) at study initiation or after study completion (wait-list control). Patients in the intervention group will receive care from a nephrologist trained to use the BC/WC communication tool. Patients in the control group will receive usual care. Using chart review and surveys of patients and caregivers, we will test the efficacy of the BC/WC intervention with receipt of palliative care as the primary outcome. Secondary outcomes include intensity of treatment at the end of life, the effect of the intervention on quality of communication (QOC) between nephrologists and patients (using the QOC scale), the change in quality of life (using the Functional Assessment of Chronic Illness Therapy-Palliative Care scale) and receipt of dialysis. ETHICS AND DISSEMINATION: Approvals have been granted by the Institutional Review Board at the University of Wisconsin (ID: 2022-0193), with each study site ceding review to the primary IRB. All nephrologists will be consented and given a copy of the consent form. No patients or caregivers will be recruited or consented until their nephrology provider has chosen to participate in the study. Results will be disseminated via submission for publication in a peer-reviewed journal and at national meetings. TRIAL REGISTRATION NUMBER: NCT04466865.

Impact of Care Coordination on the Content of Communication Between Surgeons and Patients With Rectal Cancer.

Management of patients with rectal cancer can be complex, requiring significant care coordination and decisions that balance functional and oncologic outcomes. Objective: To characterize care coordination occurring during surgical consultation for rectal cancer and consequences of using face-to-face time in clinic for care coordination. Methods: Secondary analysis was performed on audio recordings of clinic visits with colorectal surgeons to discuss surgery for rectal cancer at 5 academic medical centers. Analysis included the content of communication related to types of care coordination, specific details and conditions under which care coordination was conducted, and consequences. Results: The cohort included 18 patients seen by 8 surgeons. Care coordination consumed much of the conversation; on average 23.7% (SD 14.6) of content. Communication about care coordination included gathering information from work-up already performed, logistics for completing further work-up, gathering multidisciplinary opinions, and logistics for treatment planning. Obtaining imaging results was particularly challenging and surgeons went to great lengths to gather this information. To mitigate information gaps, surgeons asked patients about critical clinical details. Patients expressed remorse when they could not provide needed information, relay technical details, or had missing reports. Surgeons voiced frustration at the system related to the need to gather information from multiple sources and coordinate logistics. Surgeons worked to inform patients about their disease and discuss important lifestyle and cancer-related tradeoffs. However, the ability to solicit patient input and engage in shared decision making was often limited by incomplete data or conditioned on approval by a multidisciplinary tumor board. Conclusion: Much of the conversation between surgeons and patients with rectal cancer is consumed by care coordination. Organizing care coordination outside of the clinic visit would likely improve the experience for both patients and surgeons, addressing both clinician burnout and variation in management and outcomes.

Applying VitalTalkTM Techniques to Best Case/Worst Case Training to Increase Scalability and Improve Surgeon Confidence in Shared Decision-making.

OBJECTIVE: Best Case/Worst Case (BC/WC) is a communication tool designed to promote shared decision-making for high-risk procedures near the end of life. This study aimed to increase scalability of a BC/WC training program and measure its impact on surgeon confidence in and perceived importance of the methodology. DESIGN: A prospective cohort pre-post study; December 2018 to January 2019. SETTING: Multi-center tertiary care teaching hospital. PARTICIPANTS: Forty-eight resident surgeons from general surgery and otolaryngology. RESULTS: Learners were 24 to 37 years old with 52% in post graduate year 1 to 2. Although learners encountered high-stakes communication (HSC) frequently (3.6 [0.7] on 5-point Likert scale), most reported no HSC training in medical school (74.5%) or residency (87.5%). BC/WC training was accomplished with an instructor to learner ratio of 1-to-5.3. After training, learner confidence improved on all measured communication skills on a 5-point scale (e.g., exploring patient's values increased from 3.6 [0.8] to 4.1 [0.6], p = <0.0001); average within-person improvement was 0.72 (0.6) points across all skills. Perceived importance improved across all skills (e.g., basing a recommendation on patient's values increased from 4.4 [0.8] to 4.8 [0.5], p = 0.0009); average within-person improvement was 0.46 (0.5) points across all skills. Learners reported this training would likely help them in future interactions (4.4 [0.73] on 5-point scale) and 95.2% recommended it be offered to resident physicians in other residency programs and to attending surgeons. CONCLUSIONS: Formal training in BC/WC increases learners' perception of both the importance of HSC skills and their confidence in exercising those skills in clinical practice. VitalTalkTM methodology permitted scaling training to 5.3 learners per instructor and was highly recommended for other surgeons. Ongoing training, such as this, may support more patient-centered decision-making and care.

Best case/worst case for the trauma ICU: Development and pilot testing of a communication tool for older adults with traumatic injury.

BACKGROUND: "Best Case/Worst Case" (BC/WC) is a communication tool to support shared decision making in older adults with surgical illness. We aimed to adapt and test BC/WC for use with critically ill older adult trauma patients. METHODS: We conducted focus groups with 48 trauma clinicians in Wisconsin, Texas, and Oregon. We used qualitative content analysis to characterize feedback and adapted the tool to fit this setting. Using rapid sequence iterative design, we developed an implementation tool kit. We pilot tested this intervention at two trauma centers using a pre-post study design with older trauma patients in the intensive care unit (ICU). Main outcome measures included study feasibility, intervention acceptability, quality of communication, and clinician moral distress. RESULTS: BC/WC for trauma patients uses a graphic aid to document major events over time, illustrate plausible scenarios, and convey uncertainty. We enrolled 86 of 116 eligible patients and their surrogates (48 pre/38 postintervention). The median patient age was 72 years (51-95 years) and mean Geriatric Trauma Outcome Score was 126.1 (±30.6). We trained 43 trauma attendings and trauma fellows to use the intervention. Ninety-four percent could perform essential tool elements after training. The median end-of-life communication score (scale 0-10) improved from 4.5 to 6.6 (p = 0.006) after intervention as reported by family and from 4.1 to 6.0 (p = 0.03) as reported by nurses. Moral distress did not change. However, there was improvement (less distress) reported by physicians regarding "witnessing providers giving false hope" from 7.34 to 5.03 (p = 0.022). Surgeons reported the tool put multiple clinicians on the same page and was useful for families, but tedious to incorporate into rounds. CONCLUSION: BC/WC trauma ICU is acceptable to clinicians and may support improved communication in the ICU. Future efficacy testing is threatened by enrollment challenges for severely injured older adults and their family members. LEVEL OF EVIDENCE: Therapeutic, level III.

Exploring empathy in genetic counseling students and new genetic counselors.

Although empathy is widely recognized as an important trait for healthcare professionals, little research has examined empathy attributes in genetic counselors. Decreases in empathy levels have been recognized in other healthcare professionals over the span of their professional education program. This research sought to characterize empathy levels in first- and second-year genetic counseling students and recent (2017) graduates, and to determine whether there are differences in empathy levels displayed by genetic counseling students at different points in their training. Additionally, this research examined whether experiences prior to graduate school, including specific aspects of advocacy experience, correlated with differences in self-reported empathy levels among genetic counseling students and new genetic counselors. An online survey was administered to first- and second-year genetic counseling students and practicing genetic counselors to determine whether there were differences in empathy levels between these groups, and to analyze for associations between pre-graduate school advocacy work and levels of empathy as measured by the Interpersonal Reactivity Index (IRI). We identified significant differences in self-reported empathy levels in several of the subscales of the IRI between first-year students and second-year students, and between first-year students and recent graduates. Furthermore, we identified significantly lower scores on the personal distress subscale of the IRI in participants who engaged in advocacy work for longer than 12 months when compared to participants who engaged in advocacy work for between 6 and 12 months. Other advocacy and educational characteristics were also examined for correlations with IRI scores, and no significant associations were identified between these additional factors and self-reported empathy scores. Practice implications and recommendations for future research are discussed.

Interprofessional Improv: Using Theater Techniques to Teach Health Professions Students Empathy in Teams.

PROBLEM: Health professionals need to learn how to relate to one another to ensure high-quality patient care and to create collaborative and supportive teams in the clinical environment. One method for addressing both of these goals is teaching empathy during professional training to foster connection and commonality across differences. The authors describe a pilot improvisational theater (improv) course and present the preliminary outcomes showing its impact on interprofessional empathy. APPROACH: In 2016-2017, the authors piloted a 15-hour course to teach interprofessional empathy to health professions students at the University of Wisconsin-Madison using improv techniques. The authors used a convergent mixed-methods design to evaluate the course's impact on interprofessional empathy. Students enrolled in the course (intervention group, n = 45) and a comparison group (n = 41) completed 2 validated empathy questionnaires (Interpersonal Reactivity Index [IRI], Consultative and Relational Empathy [CARE] measure) and a facial expression recognition task to measure empathy in the pre- and postintervention periods. Differences were examined using paired t tests. Semistructured interviews were conducted with 8 course participants to gain a deeper understanding of the course's effects. OUTCOMES: The intervention group's mean scores on 5 CARE items improved significantly: ease, care, explain, help, and plan. On the IRI, personal distress levels decreased significantly in both the intervention and comparison groups. In the interviews, students who took the class reported a positive impact on their interprofessional relationships and on their ability to think on their feet. They also reported improv influenced other areas of their lives, including patient care and interactions with people outside their work life. NEXT STEPS: The authors have continued to offer the course. They aim to conduct a randomized controlled study with medical students and test durability by measuring empathy again 3-6 months following the intervention.

Opportunities to Improve Shared Decision Making in Dialysis Decisions for Older Adults with Life-Limiting Kidney Disease: A Pilot Study.

Background: Lack of awareness about the life-limiting nature of renal failure is a significant barrier to palliative care for older adults with end-stage renal disease. Objective: To train nephrologists to use the best case/worst case (BC/WC) communication tool to improve shared decision making about dialysis initiation for older patients with limited life expectancy. Design: This is a pre-/postinterventional pilot study. Setting/Subjects: There were 16 nephrologists and 30 patients of age 70 years and older with estimated glomerular filtration rate (eGFR) <20 mL/min per 1.73 m2 in outpatient nephrology clinics, in Madison, WI. Measurements: Performance of tool elements, content of communication about dialysis, shared decision making, acceptability of the intervention, decisions to pursue dialysis, and palliative care referrals were measured. Results: Fifteen of 16 nephrologists achieved competence performing the BC/WC tool with standardized patients, executing at least 14 of 19 items. Nine nephrologists met with 30 patients who consented to audio record their clinic visit. Before training, clinic visits focused on laboratory results and preparation for dialysis. After training, nephrologists noted that declining kidney function was "bad news," presented dialysis and "no dialysis" as treatment options, and elicited patient preferences. Observer-measured shared decision-making (OPTION 5) scores improved from a median of 20/100 (interquartile range [IQR] 15-35) before training to 58/100 (IQR 55-65). Patients whose nephrologist used the BC/WC tool were less likely to make a decision to initiate dialysis and were more likely to be referred to palliative care. Conclusions: Nephrologists can learn to use the BC/WC tool with older patients to improve shared decision making about dialysis, which may increase access to palliative care.

A Curriculum to Increase Empathy and Reduce Burnout.

PURPOSE: Empathy is essential for good patient care. It underpins effective communication and high-quality, relationship-centered care. Empathy skills have been shown to decline with medical training, concordant with increasing physician distress and burnout. METHODS: We piloted a 6-month curriculum for interns (N = 27) during the 2015-2016 academic year at the University of Wisconsin-Madison. The course included: (1) review of literature on physician well-being and clinical empathy, (2) instruction on the neurobiology of empathy and compassion, (3) explanation of stress physiology and techniques for mitigating its effects, (4) humanities-informed techniques, and (5) introductions to growth mindset and mindful awareness. To measure effectiveness, we compared empathy and burnout scores before and after the course. RESULTS: The course was well-attended. Intern levels of burnout and empathy remained stable over the study period. In multivariable modeling, we found that for each session an intern attended, their emotional exhaustion declined by 3.65 points (P = 0.007), personal accomplishment increased by 2.69 points (P = 0.001), and empathic concern improved by 0.82 points (P = 0.066). The course was well-liked. Learners reported applying course content inside and outside of work and expressed variable preferences for content and teaching methods. CONCLUSION: Skills in empathic and self-care can be taught together to reduce the decline of empathy and well-being that has been seen during internship. In this single-center pilot, resident physicians reported using these skills both inside and outside of work. Our curriculum has the potential to be adopted by other residency programs.

Bridging Undergraduate and Graduate Medical Education: A Resident-as-Educator Curriculum Embedded in an Internship Preparation Course.

BACKGROUND: Many graduate medical education programs have implemented curricula to develop trainees into the next generation of medical teachers; however, coordination of in-person teaching curricula is challenging due to full trainee schedules. METHODS: To address limited in-person time, we developed a largely asynchronous resident-as-educator curriculum. Our elective curricular activities are embedded within the fourth-year internship preparation course at the University of Wisconsin School of Medicine and Public Health and include trainees from internal medicine, family medicine, and pediatrics. RESULTS: Trainee self-assessment of teaching skills improved after our curriculum, and students evaluated resident sessions favorably. DISCUSSION: Trainees can be effective teachers in an internship preparation course after a brief, asynchronous teaching curriculum. To disseminate our curriculum, we designed a resident-as-educator curriculum website.

Beyond "Read More": An Intervention to Improve Faculty Written Feedback to Learners.

BACKGROUND: High-quality feedback is necessary for learners' development. It is most effective when focused on behavior and should also provide learners with specific next steps and desired outcomes. Many faculty struggle to provide this high-quality feedback. OBJECTIVE: To improve the quality of written feedback by faculty in a department of medicine, we conducted a 1-hour session using a novel framework based on education literature, individual review of previously written feedback, and deliberate practice in writing comments. METHODS: Sessions were conducted between August 2015 and June 2018. Participants were faculty members who teach medical students, residents, and/or fellows. To measure the effects of our intervention, we surveyed participants and used an a priori coding scheme to determine how feedback comments changed after the session. RESULTS: Faculty from 7 divisions participated (n = 157). We surveyed 139 participants postsession and 55 (40%) responded. Fifty-three participants (96%) reported learning new information. To more thoroughly assess behavioral changes, we analyzed 5976 feedback comments for students, residents, and fellows written by 22 randomly selected participants before the session and compared these to 5653 comments written by the same participants 1 to 12 months postsession. Analysis demonstrated improved feedback content; comments providing nonspecific next steps decreased, and comments providing specific next steps, reasons why, and outcomes increased. CONCLUSIONS: Combining the learning of a simple feedback framework with an immediate review of written comments that individual faculty members previously provided learners led to measured improvement in written comments.

Using Implementation Science to Adapt a Training Program to Assist Surgeons with High-Stakes Communication.

OBJECTIVE: Surgeons often conduct difficult conversations with patients near the end of life, yet surgical education provides little formalized communication training. We developed a communication tool, Best Case/Worst Case, and trained surgeons using a one-on-one resource intensive format that was effective but difficult to scale for widespread dissemination. We aimed to generate an implementation package to teach surgeons using fewer resources without sacrificing fidelity. DESIGN, SETTING, AND PARTICIPANTS: We used the Replicating Effectiveness Programs framework to guide our implementation strategy and tested our intervention with 39 surgical residents at 4 institutions from September 2016 to June 2017. The implementation package consisted of: (1) instructional video, (2) checklist to assess competence, (3) learner manual, and (4) instructor manual. We focused on 3 implementation outcomes: feasibility, fidelity, and acceptability to participants. RESULTS: Attendance rates ranged from 16% to 75%. Site leaders had little difficulty identifying suitable instructors; however, resident recruitment proved challenging. Sixty-nine percent of residents completed the post-training assessment and the mean score was 12.8 (range 8-15) using the 15-point checklist. Across sites, 69% strongly agreed that Best Case/Worst Case is better than how they usually approach high-stakes conversations and 100% felt prepared to use the tool after training. Instructors reported that the training provided residents with the necessary skills to perform the fundamental elements of Best Case/Worst Case. CONCLUSIONS: Using implementation science we demonstrated that a resource intensive communication training intervention can be successfully modified for group-learning and wide-scale dissemination. However, we identified barriers to implementation, including challenges with feasibility and programmatic buy-in that inform not only resident education but also communication skills training more broadly.