An Embedded Curriculum to Teach Critical Incident Debriefing to Internal Medicine Residents.

Background Internal medicine residents frequently experience distressing clinical events; critical event debriefing is one tool to help mitigate their effects. Objective To evaluate the effectiveness of a 1-hour workshop teaching residents a novel, efficient approach to leading a team debrief after emotionally charged clinical events. Methods An internal needs assessment identified time and confidence as debriefing barriers. In response, we created the STREAM (Structured, Timely, Reflection, tEAM-based) framework, a 15-minute structured approach to leading a debrief. Senior residents participated in a 1-hour workshop on the first day of an inpatient medicine rotation to learn the STREAM framework. To evaluate learning outcomes, participants completed the same survey immediately before and after the session, and at the end of their 4-week rotation. Senior residents at another site who did not complete the workshop also evaluated their comfort leading debriefs. Results Fifty out of 65 senior residents (77%) participated in the workshop. After the workshop, participants felt more prepared to lead debriefs, learned a structured format for debriefing, and felt they had enough time to lead debriefs. Thirty-four of 50 (68%) workshop participants and 20 of 41 (49%) comparison residents completed the end-of-rotation survey. Senior residents who participated in the workshop were more likely than nonparticipants to report feeling prepared to lead debriefs. Conclusions A brief workshop is an effective method for teaching a framework for leading a team debrief.

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.

The Role of the Palliative Medicine Clinician in the Family Conference.

Facilitating a family conference is a core skill for a palliative medicine clinician, yet the role of the palliative medicine consultant in a family conference has not been clearly defined in the literature. Most educational articles describe a structured approach to a family conference that focuses on the role of the person leading the conference, who may be a palliative medicine specialist or a member of the primary team caring for the patient. For the palliative medicine clinician, balancing the roles of communication facilitator and palliative consultant is nuanced and requires a specific framework and set of skills. In this article, we review the literature on family conferences focusing on facilitation and communication by the palliative care consultant during the conferences, and outline specific ways the palliative medicine clinician can contribute to family conferences. Our hope is that this framework helps guide palliative medicine clinicians and others seeking more specialized training in palliative medicine to be more intentional with their contributions to family conferences in the future. We also hope that this framework will help palliative medicine educators training future specialists.

Efficacy of a Communication-Priming Intervention on Documented Goals-of-Care Discussions in Hospitalized Patients With Serious Illness: A Randomized Clinical Trial.

Importance: High-quality goals-of-care communication is critical to delivering goal-concordant, patient-centered care to hospitalized patients with chronic life-limiting illness. However, implementation and documentation of goals-of-care discussions remain important shortcomings in many health systems. Objective: To evaluate the efficacy, feasibility, and acceptability of a patient-facing and clinician-facing communication-priming intervention to promote goals-of-care communication for patients hospitalized with serious illness. Design, Setting, and Participants: This randomized clinical trial enrolled patients from November 6, 2018, to February 18, 2020. The setting was 2 hospitals in an academic health care system in Seattle, Washington. Participants included hospitalized adults with chronic life-limiting illness, aged 65 years or older and with markers of frailty, or aged 80 years or older. Data analysis was performed from August 2020 to August 2021. Intervention: Patients were randomized to usual care with baseline questionnaires (control) vs the Jumpstart communication-priming intervention. Patients or surrogates in the intervention group and their clinicians received patient-specific Jumpstart Guides populated with data from questionnaires and the electronic health records (EHRs) that were designed to prompt and guide a goals-of-care discussion. Main Outcomes and Measures: The primary outcome was EHR documentation of a goals-of-care discussion between randomization and hospital discharge. Additional outcomes included patient-reported or surrogate-reported goals-of-care discussions, patient-reported or surrogate-reported quality of communication, and intervention feasibility and acceptability. Results: Of 428 eligible patients, this study enrolled 150 patients (35% enrollment rate; mean [SD] age, 59.2 [13.6] years; 66 women [44%]; 132 [88%] by patient consent and 18 [12%] by surrogate consent). Seventy-five patients each were randomized to the intervention and control groups. Compared with the control group, the cumulative incidence of EHR-documented goals-of-care discussions between randomization and hospital discharge was higher in the intervention group (16 of 75 patients [21%] vs 6 of 75 patients [8%]; risk difference, 13% [95% CI, 2%-24%]; risk ratio, 2.67 [95% CI, 1.10-6.44]; P = .04). Patient-reported or surrogate-reported goals-of-care discussions did not differ significantly between groups (30 of 66 patients [45%] vs 36 of 66 patients [55%]), although the intrarater consistency of patient and surrogate reports was poor. Patient-rated or surrogate-rated quality of communication did not differ significantly between groups. The intervention was feasible and acceptable to patients, surrogates, and clinicians. Conclusions and Relevance: In this randomized clinical trial, a patient-facing and clinician-facing communication priming intervention for seriously ill, hospitalized patients promoted EHR-documented goals-of-care discussions before discharge with good feasibility and acceptability. Communication-priming interventions should be reexamined in a larger randomized clinical trial to better understand their effectiveness in the inpatient setting. Trial Registration: ClinicalTrials.gov Identifier: NCT03746392.

Clinical presentation, complications, and outcomes of hospitalized COVID-19 patients in an academic center with a centralized palliative care consult service.

BACKGROUND AND AIMS: Palliative care is a critical component of the response of a healthcare system to a pandemic. We present risk factors associated with mortality and highlight an operational palliative care consult service in facilitating early identification of risk factors to guide goal-concordant care and rational utilization of finite healthcare resources during a pandemic. METHODS: In this case series of 100 consecutive patients hospitalized with COVID-19, we analyzed clinical data, treatment including palliative care, and outcomes in patients with SARS-CoV-2 infection admitted to three hospitals in Seattle, Washington. We compared data between patients who were discharged and non-survivors. RESULTS: Age (OR 4.67 [1.43, 15.32] ages 65-79; OR 3.96 [1.05, 14.89] ages 80-97), dementia (OR 5.62 [1.60, 19.74]), and transfer from a congregate living facility (OR 5.40 [2.07, 14.07]), as well hypoxemia and tachypnea (OR 7.00 [2.91, 22.41]; OR 2.78 [1.11, 6.97]) were associated with mortality. Forty-one (41%) patients required intensive care and 22 (22%) invasive mechanical ventilation. Forty-six (46%) patients were seen by the palliative care service, resulting in a change of resuscitation status in 54% of admitted patients. Fifty-eight (58%) patients recovered and were discharged, 34 (34%) died, and eight (8%) remained hospitalized, of which seven ultimately survived and one died. CONCLUSIONS: Older age, dementia, and congregate living were associated with mortality. Early discussions of goals of care facilitated by an operational palliative care consult service can effectively guide goal-concordant care in patients at high risk for mortality during a pandemic. Development of a functional palliative care consult service is an important component of pandemic planning.

Development of a Single-Institution Virtual Internal Medicine Subinternship With Near-Peer Teaching in Response to the COVID-19 Pandemic.

PROBLEM: In March 2020, medical students at the University of Washington School of Medicine were removed from clinical settings in response to the COVID-19 pandemic. As subinternships are required for graduation and an important way to prepare for internship, a virtual subinternship was created to include practical elements of in-person learning and to address limited teaching faculty from COVID-19 inpatient surges. APPROACH: A virtual, interactive subinternship was developed with case-based teaching sessions, communication and critical literature evaluation skill building, professional development, and creation of independent learning plans. Near-peer teachers (NPTs) were selected from graduating senior medical students who matched into internal medicine. In addition to teaching topics from the Clerkship Directors of Internal Medicine curriculum, NPTs engaged in course development, recruited teaching faculty, gathered feedback, and facilitated small groups. Participating students completed pre- and postcourse surveys. OUTCOMES: The 10 students (100%) enrolled in the course who completed both surveys indicated significant improvement in mean scores across 4 domains: evaluating medical literature (3.1/5 to 4.5/5; +1.4, P < .001); developing individual learning plans (3.6/5 to 4.7/5; +1.1, P = .001); perceived ability to efficiently evaluate patients with common internal medicine concerns (3.7/5 to 4.6/5; +0.9, P = .004); and formulating initial diagnostic and therapeutic plans (3.6/5 to 4.6/5; +1.0, P < .001). Themes extracted from open-ended responses included initial skepticism of an online format, the course exceeding expectations, and feeling prepared for internship. NEXT STEPS: Although a virtual subinternship lacks direct patient care, students reported improvement in all 4 domains studied. Future courses would benefit from greater use of simulation and role-playing scenarios for practical skills. The experience with NPTs was encouraging, aiding in the success of the subinternship. The role of NPTs should be cultivated to fill gaps in content delivery and enhance the development of students as educators.

Applying Human-Centered Design to Refinement of the Jumpstart Guide, a Clinician- and Patient-Facing Goals-of-Care Discussion Priming Tool.

CONTEXT: Human-centered design provides a framework to understand the needs of patients and clinicians who are the target of goals-of-care discussion priming tools. Few studies employ human-centered design to develop and refine their tools. OBJECTIVES: To describe how human-centered design can be applied to the development and refinement of clinician- and patient-facing inpatient goals-of-care discussion guides (Jumpstart guides). METHODS: Human-centered design was applied to the development and refinement of the inpatient Jumpstart guides in four phases: (1) discovering problems based on prior pilots, studies, and research team priorities; (2) further defining problems based on stakeholder and expert review of the current guides; (3) designing solutions based on consensus among stakeholders; and (4) validating solutions after research team review of stakeholder comments. RESULTS: Five initial problems were identified by the research team in phase 1. After expert and stakeholder review in phase 2, 30 additional problems were identified related to Jumpstart guide format, structure, and content. In phase 3, stakeholders proposed solutions to these 35 problems and reached consensus on 32 of these. There was disagreement in 3 areas, including how to frame discussions around cardiopulmonary resuscitation and 2 perceived barriers to inpatient goals-of-care discussions. In phase 4, the research team reviewed all stakeholder input and reached final consensus on solutions to all of the identified problems. CONCLUSION: Human-centered design is a useful tool for enhancing communication interventions in serious illness and can easily be integrated in future development and refinement of clinician- and patient-facing interventions to enhance goals-of-care discussions.

"Tell Me More": Students Can Practice and Self-Evaluate Primary Palliative Care Skills in a Large, Multistate Internal Medicine Clerkship.

Background: Experts recommend integrating palliative care throughout the four-year medical school curriculum, including in required clerkships such as internal medicine (IM). Objective: The aim of this study was to determine whether third-year medical students could gain meaningful experience in primary palliative care during their IM clerkship with observation and feedback from internists and/or IM residents or fellows. Design: We implemented two clinical exercises: (1) perform advance care planning with a patient and (2) participate in the delivery of important news. Students self-reported aspects of their experience in a confidential online survey. Setting/Subjects: Third-year medical students enrolled in a required IM clerkship. Measurements: Students reported the setting in which they completed the exercises, their level of independence, and their level of comfort with advance care planning after completing the exercise. We performed a qualitative analysis of open-ended comments to determine domains, themes, and subthemes and a separate analysis to determine the extent to which the comments suggested learning relevant to the stated learning objectives for each exercise. Results: The majority of students completed both exercises without palliative care specialists present, 76% (196/258) for the advance care planning exercise and 75% (195/259) for important news. Fifty-one percent (132/258) of students completed advance care planning with a significant level of independence, and 70% (182/258) reported being comfortable or very comfortable with advance care planning after completing the exercise. Qualitative analyses of student comments found that the majority of students described learning something related to the stated learning objectives for each exercise and suggested that they gained an appreciation of the complexity of patient-provider interactions around serious illness and palliative care. Conclusion: We found it feasible to integrate clinical exercises in advance care planning and delivering important news into an IM clerkship.

A Novel Curriculum for Medical Student Training in LGBTQ Healthcare: A Regional Pathway Experience.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals face considerable health disparities, often due to a lack of LGBTQ-competent care. Such disparities and lack of access to informed care are even more staggering in rural settings. As the state medical school for the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region, the University of Washington School of Medicine (UWSOM) is in a unique position to train future physicians to provide healthcare that meets the needs of LGBTQ patients both regionally and nationally. OBJECTIVE: To describe our methodology of developing a student-driven longitudinal, region-wide curriculum to train medical students to provide high-quality care to LGBTQ patients. METHODS: A 4-year LGBTQ Health Pathway was developed and implemented as a student-led initiative at the UWSOM. First- and second-year medical students at sites across the WWAMI region are eligible to apply. Accepted Pathway students complete a diverse set of pre-clinical and clinical components: online modules, didactic courses, longitudinal community service/advocacy work, a scholarly project, and a novel clinical clerkship in LGBTQ health developed specifically for this Pathway experience. Students who complete all requirements receive a certification of Pathway completion. This is incorporated into the Medical Student Performance Evaluation as part of residency applications. RESULTS: The LGBTQ Health Pathway is currently in its fourth year. A total of 43 total students have enrolled, of whom 37.3% are based in the WWAMI region outside of Seattle. Pathway students have completed a variety of scholarly projects on LGBTQ topics, and over 1000 hours of community service/advocacy. The first cohort of 8 students graduated with a certificate of Pathway completion in spring 2020. CONCLUSIONS: The LGBTQ Health Pathway at UWSOM is a novel education program for motivated medical students across the 5-state WWAMI region. The diverse milestones, longitudinal nature of the program, focus on rural communities, and opportunities for student leadership are all strengths and unique aspects of this program. The Pathway curriculum and methodology described here serve as a model for student involvement and leadership in medical education. This program enables medical students to enhance their training in the care of LGBTQ patients and provides a unique educational opportunity for future physicians who strive to better serve LGBTQ populations.

Virtual Peer Teaching During the COVID-19 Pandemic.

Virtual peer teaching can be part of the solution to challenges in medical education during the pandemic. We developed an online clinician teacher elective, implemented virtual peer teaching throughout our curriculum, and believe it benefits students, peer teachers, and faculty. We plan to continue virtual peer teaching beyond the pandemic.

Online Module Builds Skills for Internal Medicine Interns in Responding to Emotions During Complex Serious Illness Conversations.

CONTEXT: Responding to emotion cues is an essential skill for communicating with patients and families, but many health care trainees have difficulty applying this skill within the context of a complex conversation. OBJECTIVES: We created an original online module to facilitate deliberate practice of a three-skill framework for responding to emotion cues during complex or nonlinear serious illness conversations. METHODS: Our original online module uses a gamebook format, which prompts trainees to engage in focused and repetitive practice of three well-defined skills for responding to emotion cues in a simulated family conference. We implemented the module as a part of a communication skills curriculum for interns rotating in the intensive care unit. After completing the module, all interns answered an open-ended survey question about their perceived skill acquisition. Results were analyzed by a qualitative method and coded into themes. RESULTS: About 71% of interns (n = 65 of 92) completed the online module and open-ended survey question. About 89% of participants responded that they would use a naming, understanding, respecting, supporting, or exploring statement in response to an emotion cue. Nearly two-thirds of participants articulated their rationale for using naming, understanding, respecting, supporting, or exploring statements (e.g., preparing patients to process complex medical information, eliciting information about patient perspective.) CONCLUSION: Our online emotion cue module is a novel tool for deliberate practice of advanced skills for responding to emotion cues in serious illness conversations. In future studies, we will investigate whether our module's efficacy is enhanced by using it as a part of a flipped classroom curriculum with an in-person simulation session.

Ethics Education During Palliative Medicine Fellowship.

BACKGROUND: Palliative care clinicians frequently encounter situations in which there are ethical dilemmas about the right thing to do. Palliative medicine fellowships are required to include education about ethics. Our fellowship increased fellows' ethics education through monthly didactics, lectures in a professional development series, and a month-long ethics rotation. METHODS: We sought input from graduates of our palliative medicine fellowship about the content and amount of the ethics education they received. Fellowship graduates were invited via e-mail to complete an online survey about the ethics education they received during fellowship. They were asked questions about their work environment, frequency with which they encounter ethical dilemmas, their perspectives on the ethics content, the amount of ethics education they received during fellowship, and their input on ways to improve the ethics education within the fellowship. RESULTS: Twenty-eight (82%) of 34 fellowship graduates completed the survey; 93% noted that they encounter ethical dilemmas in their work, with half encountering these on a daily or weekly basis, and 86% noted that colleagues ask them questions about ethics because of their palliative medicine training. None responded that they had received too much ethics education. Fellowship graduates identified ethics content that has been useful since completing fellowship and suggested ways to improve ethics education for future fellows. CONCLUSION: Graduates of a palliative medicine fellowship encounter ethical dilemmas often and frequently are asked questions about ethics. Palliative medicine fellowships may want to examine their ethics curriculum to ensure that graduating fellows are learning about relevant ethics topics and are comfortable discussing ethical dilemmas with others.

Common Drug Side Effects and Drug-Drug Interactions in Elderly Adults in Primary Care.

Prescribing medications, recognizing and managing medication side effects and drug interactions, and avoiding polypharmacy are all essential skills in the care of older adults in primary care. Important side effects of medications commonly prescribed in older adults (statins, proton pump inhibitors, trimethoprim-sulfamethoxazole and fluoroquinolone antibiotics, zolpidem, nonsteroidal antiinflammatory drugs, selective serotonin reuptake inhibitors, dipeptidyl peptidase 4 inhibitors) were reviewed. Important drug interactions with four agents or classes (statins, warfarin, factor Xa inhibitors, and calcium channel blockers) are discussed.

Sitting at patients' bedsides may improve patients' perceptions of physician communication skills.

Sitting at a patient's bedside in the inpatient setting is recommended as a best practice but has not been widely adopted. Previous studies suggest that a physician's seated posture may increase the patient's perception of time spent in the room but have not included hospitalists. We performed a cluster-randomized trial of seated versus standing physician posture during inpatient rounds on a hospitalist service at an academic medical center. Patients whose physician sat were significantly more likely to rate their physician highly on measures of listening carefully and explaining things in a way that was easy to understand. The average time spent in the patient's room was approximately 12 minutes and was not affected by physician posture. Patients' perception of the time their physician spent in their room was not affected by physician posture. Sitting at the bedside during rounds does not increase the amount of time spent with the patient but may improve patient-physician communication. Journal of Hospital Medicine 2015;11:865-868. © 2015 Society of Hospital Medicine.