Development of a Simulation-Based Mastery Learning Curriculum for Late Goals of Care Discussions.

INTRODUCTION: Fellows in critical care medicine (CCM) routinely help patients and families navigate complex decisions near the end of life. These "late goals of care" (LGOC) discussions require rigorous skills training and impact patient care. Innovation is needed to ensure that fellow training in leading these discussions is centered on reproducible competency-based standards. The aims of this study were to (1) describe the development of a simulation-based mastery learning (SBML) curriculum for LGOC discussions and (2) set a defensible minimum passing standard (MPS) to ensure uniform skill acquisition among learners. INNOVATION: We developed an SBML curriculum for CCM fellows structured around REMAP, a mnemonic outlining foundational components of effective communication around serious illness. A multidisciplinary expert panel iteratively created an LGOC discussion assessment tool. Pilot testing was completed to refine the checklist, set the MPS, and assess skill acquisition. OUTCOMES: The LGOC discussion assessment tool included an 18-item checklist and 6 scaled items. The tool produced reliable data (k ≥ 0.7 and ICC of ≥ 0.7). Using the Mastery Angoff method, the panel set the MPS at 87%. Ten CCM fellows participated in the pilot study. Performance on the checklist significantly improved from a median score of 52% (IQR 44%-72%) at pretest to 96% (IQR 82%-97%) at post-test (P = 0.005). The number of learners who met the MPS similarly improved from 10% during pre-testing to 70% during post-testing (P = 0.02). COMMENT: We describe the development of a LGOC SBML curriculum for CCM fellows which includes a robust communication skills assessment and the delineation of a defensible MPS.

Society for Simulation in Healthcare Guidelines for Simulation Training.

BACKGROUND: Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist. METHODS: Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. OBJECTIVE: These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare. RESULTS: Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided. CONCLUSIONS: The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

Clinical Experience Is Not a Proxy for Competence: Comparing Fellow and Medical Student Performance in a Breaking Bad News Simulation-Based Mastery Learning Curriculum.

BACKGROUND: It is unknown whether traditional medical education ensures competence among fellows in the key skill of breaking bad news (BBN). While simulation-based mastery learning (SBML) has been used to train fourth-year medical students (M4s) in BBN, it is unclear if it adds similar value for fellows. OBJECTIVE: We examined the effect of traditional medical training on BBN skills by comparing baseline fellow and M4 skills and confidence and assessed the impact of a BBN SBML curriculum for fellows. METHODS: Fellows training in six programs at Northwestern University from November 2018 to May 2019 were eligible for inclusion. Fellows completed a BBN SBML curriculum including a pretest, individualized feedback using a previously published assessment tool, and ongoing deliberate practice until all achieved a minimum passing standard (MPS). The primary outcomes were checklist and scaled item scores on the assessment tool. Fellow performance was compared to a historical M4 cohort. RESULTS: Twenty-eight of 38 eligible fellows completed the curriculum and were included for analysis. Fellows reported significantly more experience and confidence in BBN compared to M4s, yet their pre-training performance was significantly worse on checklist (57.1% vs 65.0%, P = .02) and scaled items; only 4% reached the MPS. After training, fellow performance significantly improved on checklist (57.1% to 92.6%, SD = 5.2%, P < .001) and scaled items; all reached the MPS. CONCLUSIONS: Despite higher confidence and BBN clinical experience, fellows performed worse than untrained M4s, confirming that experience is not a proxy for skill. Programs must develop competency-based assessments to ensure entrustment of communication skills.

Promoting Readiness for Residency: Embedding Simulation-Based Mastery Learning for Breaking Bad News Into the Medicine Subinternship.

PURPOSE: It is challenging to add rigorous, competency-based communication skills training to existing clerkship structures. The authors embedded a simulation-based mastery learning (SBML) curriculum into a medicine subinternship to demonstrate feasibility and determine the impact on the foundational skill of breaking bad news (BBN). METHOD: All fourth-year students enrolled in a medicine subinternship at Northwestern University Feinberg School of Medicine from September 2017 through August 2018 were expected to complete a BBN SBML curriculum. First, students completed a pretest with a standardized patient using a previously developed BBN assessment tool. Learners then participated in a 4-hour BBN skills workshop with didactic instruction, focused feedback, and deliberate practice with simulated patients. Students were required to meet or exceed a predetermined minimum passing standard (MPS) at posttest. The authors compared pretest and posttest scores to evaluate the effect of the intervention. Participant demographic characteristics and course evaluations were also collected. RESULTS: Eighty-five students were eligible for the study, and 79 (93%) completed all components. Although 55/79 (70%) reported having personally delivered serious news to actual patients, baseline performance was poor. Students' overall checklist performance significantly improved from a mean of 65.0% (SD = 16.2%) items correct to 94.2% (SD = 5.9%; P < .001) correct. There was also statistically significant improvement in scaled items assessing quality of communication, and all students achieved the MPS at mastery posttest. All students stated they would recommend the workshop to colleagues. CONCLUSIONS: It is feasible to embed SBML into a required clerkship. In the context of this study, rigorous SBML resulted in uniformly high levels of skill acquisition, documented competency, and was positively received by learners.

The Therapeutic Utility of the Pregnant Palliative Care Physician: A Case Series.

Women physicians are becoming more numerous, with the majority of active hospice and palliative medicine physicians under the age of 50 being women. While this trend has appropriately led to discussions of supporting, recruiting, and retaining women physicians, there is little literature about the effect of women physicians on patients. In particular, little has been written about the effect of a physician's pregnancy. Drawing on psychotherapeutic literature, the authors present seven cases illustrating how pregnancy of the palliative care physician affects patients and families. By recognizing the responses of patients and families and understanding the underlying meaning of the pregnancy, which drives those responses, palliative care physicians can utilize the pregnancy to select therapeutic interventions for the patient and family.

Development of a Simulation-Based Mastery Learning Curriculum for Breaking Bad News.

INTRODUCTION: Physician communication impacts patient outcomes. However, communication skills, especially around difficult conversations, remain suboptimal, and there is no clear way to determine the validity of entrustment decisions. The aims of this study were to 1) describe the development of a simulation-based mastery learning (SBML) curriculum for breaking bad news (BBN) conversation skills and 2) set a defensible minimum passing standard (MPS) to ensure uniform skill acquisition among learners. INNOVATION: An SBML BBN curriculum was developed for fourth-year medical students. An assessment tool was created to evaluate the acquisition of skills involved in a BBN conversation. Pilot testing was completed to confirm improvement in skill acquisition and set the MPS. OUTCOMES: A BBN assessment tool containing a 15-item checklist and six scaled items was developed. Students' checklist performance improved significantly at post-test compared to baseline (mean 65.33%, SD = 12.09% vs mean 88.67%, SD = 9.45%, P < 0.001). Students were also significantly more likely to have at least a score of 4 (on a five-point scale) for the six scaled questions at post-test. The MPS was set at 80%, requiring a score of 12 items on the checklist and at least 4 of 5 for each scaled item. Using the MPS, 30% of students would require additional training after post-testing. COMMENTS: We developed a SBML curriculum with a comprehensive assessment of BBN skills and a defensible competency standard. Future efforts will expand the mastery model to larger cohorts and assess the impact of rigorous education on patient care outcomes.

Palliative care in COPD: an unmet area for quality improvement.

COPD is a leading cause of morbidity and mortality worldwide. Patients suffer from refractory breathlessness, unrecognized anxiety and depression, and decreased quality of life. Palliative care improves symptom management, patient reported health-related quality of life, cost savings, and mortality though the majority of patients with COPD die without access to palliative care. There are many barriers to providing palliative care to patients with COPD including the difficulty in prognosticating a patient's course causing referrals to occur late in a patient's disease. Additionally, physicians avoid conversations about advance care planning due to unique communication barriers present with patients with COPD. Lastly, many health systems are not set up to provide trained palliative care physicians to patients with chronic disease including COPD. This review analyzes the above challenges, the available data regarding palliative care applied to the COPD population, and proposes an alternative approach to address the unmet needs of patients with COPD with proactive primary palliative care.