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Ellis D, Mazzola E, Wolfe J, Kelleher C. Comparing Pediatric Surgeons' and Palliative Care Pediatricians' Palliative Care Practices and Perspectives in Pediatric Surgical Patients. J Pediatr Surg 2024; 59:37-44. [PMID: 37827879 DOI: 10.1016/j.jpedsurg.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE The nature of interactions between surgical and pediatric palliative care (PPC) teams caring for seriously ill children is unknown. This study compares pediatric surgeons' and PPC physicians' perspectives and practices regarding PPC in surgical patients. METHODS A survey was administered to members of the American Pediatric Surgical Association and Pediatric Interest Group of the American Academy of Hospice and Palliative Medicine. RESULTS One hundred twenty-four pediatric surgeons (31% female, 17.2 mean years of experience) and 71 PPC physicians (69% female, 10.1 mean years of experience) participated. Forty-three percent of surgeons reported consulting PPC often for children with serious illnesses. However, most PPC physicians (67%), said they are rarely/never consulted by surgeons (p = 0.002). PPC physicians were more likely to report that PPC involvement was too late (43% vs 21%, p = 0.005). More surgeons than PPC physicians felt that an appropriate time for PPC consultation was during serious illness deterioration (30% vs 7%, p = 0.05), whereas PPC physicians preferred consultation at diagnosis (54% vs 34%, p = 0.05). More PPC physicians (67%) than surgeons (17%) agreed that invasive interventions could be considered a form of PPC (p = 0.002). The most reported barrier to PPC consultation by surgeons (29%) was concern that parents would think the surgical team was giving up. PPC physicians were more likely to perceive barriers to consultation by surgeons than surgeons themselves (p < 0.001). CONCLUSION While pediatric surgeons value PPC involvement, surgical culture and misperception of parental resistance to PPC involvement lead to palliative care consultation only when illness acuity and severity are high, the possibility of curability is low, and death seems imminent. Seeking to understand patient and family priorities in care, managing patient and parental psychological distress, and treating non-surgical symptoms are areas where PPC can improve patient care. Barriers to PPC use and self-reported knowledge gaps in PPC provision may be mitigated by formalized PPC training for surgeons and intentional collaboration between the two groups. TYPE OF STUDY Survey. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Danielle Ellis
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA.
| | - Emanuele Mazzola
- Department of Data Science, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Joanne Wolfe
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cassandra Kelleher
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
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2
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Lin J, Cook M, Siegel T, Marterre B, Chapman AC. Time is Short: Tools to Integrate Palliative Care and Communication Skills Education into Your Surgical Residency. JOURNAL OF SURGICAL EDUCATION 2023; 80:1669-1674. [PMID: 37385930 DOI: 10.1016/j.jsurg.2023.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 07/01/2023]
Abstract
The need to integrate palliative care (PC) training into surgical education has been increasingly recognized. Our aim is to describe a set of PC educational strategies, with a range of requisite resources, time, and prior expertise, to provide options that surgical educators can tailor for different programs. Each of these strategies has been successfully employed individually or in some combination at our institutions, and components can be generalized to other training programs. Asynchronous and individually paced PC training can be provided using existing resources published by the American College of Surgeons and upcoming SCORE curriculum modules. A multiyear PC curriculum, with didactic components of increasing complexity for more advanced residents, can be applied based on available time in the didactic schedule and local expertise. Simulation-based training in PC skills can be developed to provide objective competency-based training. Finally, a dedicated rotation on a surgical palliative care service can provide the most immersive experience with steps toward clinical entrustment of PC skills for trainees.
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Affiliation(s)
- Joseph Lin
- Department of Surgery, University of California San Francisco, San Francisco, California; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Mackenzie Cook
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Timothy Siegel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon; Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Buddy Marterre
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; Section of Gerontology and Geriatric Medicine, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Allyson Cook Chapman
- Department of Surgery, University of California San Francisco, San Francisco, California; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, California.
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3
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Hornor M, Khan U, Cripps MW, Cook Chapman A, Knight-Davis J, Puzio TJ, Joseph B. Futility in acute care surgery: first do no harm. Trauma Surg Acute Care Open 2023; 8:e001167. [PMID: 37780455 PMCID: PMC10533797 DOI: 10.1136/tsaco-2023-001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/25/2023] [Indexed: 10/03/2023] Open
Abstract
The consequences of the delivery of futile or potentially ineffective medical care and interventions are devastating on the healthcare system, our patients and their families, and healthcare providers. In emergency situations in particular, determining if escalating invasive interventions will benefit a frail and/or severely critically ill patient can be exceedingly difficult. In this review, our objective is to define the problem of potentially ineffective care within the specialty of acute care surgery and describe strategies for improving the care of our patients in these difficult situations.
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Affiliation(s)
- Melissa Hornor
- Surgery, Loyola University Chicago, Maywood, Illinois, USA
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
| | - Uzer Khan
- Surgery, Texas Christian University, Fort Worth, Texas, USA
| | - Michael W Cripps
- Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Allyson Cook Chapman
- Medicine and Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Knight-Davis
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
- Surgery, The Ohio State University College of Medicine and Public Health, Columbus, Ohio, USA
| | - Thaddeus J Puzio
- General Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Bellal Joseph
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
- Surgery, University of Arizona Medical Center—University Campus, Tucson, Arizona, USA
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4
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Lin JA, Im CJ, O'Sullivan P, Kirkwood KS, Cook AC. The surgical resident experience in serious illness communication: A qualitative needs assessment with proposed solutions. Am J Surg 2021; 222:1126-1130. [PMID: 34565516 PMCID: PMC9365675 DOI: 10.1016/j.amjsurg.2021.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/04/2021] [Accepted: 09/13/2021] [Indexed: 11/21/2022]
Abstract
Background: Serious illness communication skills are important tools for surgeons, but training in residency is limited. Methods: Thirteen senior surgical residents at an academic center were interviewed about their experiences with serious illness communication. Conventional content analysis was performed using established communication frameworks and inductive development of themes. Results: Residents had frequent conversations and employed known communication strategies. Three themes highlighted challenges they face. Illness severity included factors attributed to the illness that made serious illness communication more challenging: symptoms, poor prognosis, and urgency. Knowledge and feelings included the factual understanding and emotional experience of residents, patients, and families. Academic structure included hierarchy and the residents’ dual role as learners and teachers. On reflection, residents identified needing greater experiential practice, analogous to learning procedural skills. Conclusions: Surgical residents regularly face serious illness conversations with little training beyond observation of role models. Dedicated training may help meet this need.
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Affiliation(s)
- Joseph A Lin
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Cecilia J Im
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Patricia O'Sullivan
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Kimberly S Kirkwood
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Allyson C Cook
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
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5
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Purcell LN, Tignanelli CJ, Maine R, Charles A. Predictors of Change in Code Status from Time of Admission to Death in Critically Ill Surgical Patients. Am Surg 2020. [DOI: 10.1177/000313482008600334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Racial and gender disparities in end-of-life decision-making practices have not been well described in surgical patients. We performed an eight-year retrospective analysis of surgical patients within the Cerner Acute Physiology and Chronic Health Evaluation Outcomes database. ICU patients with documented admission code status, and death or ICU discharge code status, respectively, were included. Logistic regression analysis was performed to assess change in code status. Of 468,000 ICU patients, 97,968 (20.9%) were surgical, 63,567 (95%) survived, and 3,343 (5%) died during their hospitalization. Of those, 50,915 (80.1%) and 2,625 (78.5%) had complete code status data on admission and discharge or death, respectively. Women were less likely than men to remain full code at ICU discharge and death (n = 20,940, 95.6% and n = 141, 11.9% vs n = 29,320, 97.4% and n = 233, 16.3%, P < 0.001). Compared with whites, blacks and other minorities had a 0.46 odds (95% confidence interval [CI]: 0.33–0.64, P < 0.001) and 0.54 odds (95% CI: 0.34–0.85, P = 0.01) of changing from full code status before death, respectively. Before ICU discharge, blacks and other minorities had a 0.56 odds of changing from full code status when compared with whites (95% CI: 0.40–0.79, P < 0.001 vs 95% CI: 0.36–0.87, P = 0.01, respectively). Women were more likely to be discharged or die after a change in code status from full code (odds ratio 1.27, 95% CI: 1.06–1.07, P < 0.001; odds ratio 1.39, 95% CI: 1.09–1.79, P = 0.009). Men and minorities are more likely to be discharged from the ICU or die with a full code status designation.
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Affiliation(s)
- Laura N. Purcell
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Christopher J. Tignanelli
- Division of Acute Care Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota; and
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota
| | - Rebecca Maine
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
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Suwanabol PA, Vitous CA, Perumalswami CR, Li SH, Raja N, Dillon BR, Lee CW, Forman J, Silveira MJ. Surgery Residents' Experiences With Seriously-Ill and Dying Patients: An Opportunity to Improve Palliative and End-of-Life Care. JOURNAL OF SURGICAL EDUCATION 2020; 77:582-597. [PMID: 32063510 DOI: 10.1016/j.jsurg.2019.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/25/2019] [Accepted: 12/21/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To describe how and when surgery residents provided primary palliative care and engaged specialty palliative care services. DESIGN Phase I consisted of a previously validated survey instrument supplemented with additional questions. We then conducted semistructured interviews with a subset of the survey respondents (Phase II). Using thematic analysis, we characterized surgery residents' perceptions of palliative care delivery among surgical patients. SETTING General surgery residency programs across the state of Michigan. PARTICIPANTS General surgery residents across the state of Michigan. All residents in participating programs were invited to complete the survey in Phase I. Phase II consisted of a subset of the survey respondents who underwent semistructured interviews. Interview respondents were sampled to reflect the overall surveyed group. RESULTS Among 119 survey respondents (response rate 70%), all had encountered a palliative care specialist but only 58.8% had been taught when to consult or to refer to palliative care. Survey respondents reported on a multitude of barriers within the clinician, patient and family, and systemic domains. Interviews expanded on survey findings and 4 influential factors of palliative care delivery emerged: (1) Resident Education and Training; (2) Resident Attitudes Toward Palliative Care; (3) Knowledge of Palliative Care; and (4) Training within a Surgical Culture. CONCLUSIONS This study reveals how surgery resident training and experiences impact palliative and end-of-life care for surgical patients at teaching institutions. Knowledge of how and when residents are providing primary palliative care and engaging with palliative care services will inform future knowledge and behavioral interventions for trainees who often provide care for patients nearing the end of life.
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Affiliation(s)
- Pasithorn A Suwanabol
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - C Ann Vitous
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Chithra R Perumalswami
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan; University of Michigan Medical School, Ann Arbor, Michigan
| | - Sylvia H Li
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Nicholas Raja
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Christina W Lee
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Jane Forman
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Clinical Management, Ann Arbor Veterans Affairs Health, Ann Arbor, Michigan
| | - Maria J Silveira
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Cunningham HB, Scielzo SA, Nakonezny PA, Bruns BR, Brasel KJ, Inaba K, Brakenridge SC, Kerby JD, Joseph BA, Mohler MJ, Cuschieri J, Paulk ME, Ekeh AP, Madni TD, Taveras LR, Imran JB, Wolf SE, Phelan HA. Burn Surgeon and Palliative Care Physician Attitudes Regarding Goals of Care Delineation for Burned Geriatric Patients. J Burn Care Res 2020; 39:1000-1005. [PMID: 29771351 DOI: 10.1093/jbcr/iry027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialty's ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.
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Affiliation(s)
- Holly B Cunningham
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Shannon A Scielzo
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Paul A Nakonezny
- Department of Clinical Science and Psychiatry, University of Texas Southwestern, Dallas, TX, USA
| | - Brandon R Bruns
- Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Karen J Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health Science University, Portland, OR, USA
| | - Kenji Inaba
- Division of Acute Care Surgery and Critical Care, University of Southern California, Los Angeles, CA, USA
| | | | - Jeffrey D Kerby
- Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bellal A Joseph
- Department of Surgery, University of Arizona Health Sciences, Tucson, AZ, USA
| | - M J Mohler
- Department of Surgery, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Joseph Cuschieri
- Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Mary E Paulk
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Akpofure P Ekeh
- Department of Surgery, Wright State University, Dayton, OH, USA
| | - Tarik D Madni
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Luis R Taveras
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Jonathan B Imran
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
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9
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Marterre B, Clayville K. Navigating the Murky Waters of Hope, Fear, and Spiritual Suffering: An Expert Co-Captain's Guide. Surg Clin North Am 2019; 99:991-1018. [PMID: 31446923 DOI: 10.1016/j.suc.2019.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
How can surgeons deliver compassionate, holistic care to patients who are beyond cure? Interacting emotionally and understanding hope, fear, and spiritual suffering is key. Responsibly reframing hope to underlying meanings, and away from specific outcomes, is critical. Facilitating moves from cure to comfort to a peaceful dying process requires some retooling of the surgical toolbox. Surgeons possess a unique set of skills, including imagination and an undying sense of hope. Surgeons who have the courage to delve into their emotions and sustain realistic hope for their patients, all the way to the end, will reap deep personal and professional rewards.
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Affiliation(s)
- Buddy Marterre
- Surgical Palliative Care, Department of General Surgery, Wake Forest Baptist Health, 5th Floor, Watlington Hall, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
| | - Kristel Clayville
- Zygon Center for Religion and Science, MacLean Center for Clinical Medical Ethics, 1100 East 55th Street, Chicago, IL 60615, USA
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10
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Surgical education research: How to move beyond the survey. Surgery 2019; 167:269-272. [PMID: 31253415 DOI: 10.1016/j.surg.2019.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 05/15/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Surgical education serves as the foundation for high-quality, efficient patient care. Because clinical knowledge is gained and newer surgical techniques developed, this material is incorporated into the curricula of surgical trainees. Methods for studying this integration vary widely, however, providing data that, at times, is challenging to interpret in the context of patient care and outcomes. METHODS A review of the literature was conducted to evaluate current practices in surgical education research, as well as topics areas of focus. RESULTS Several techniques in surgical education research currently exist, including surveys, knowledge assessments, tests of skill, and single-arm educational interventions, which may or may not include a prepost design with assessments administered both before and immediately following the intervention. The applicability of these measures to patient outcomes is variable. CONCLUSION Research in surgical education represents a field of great interest, with opportunity for novel investigations among a broad collection of topic areas. Educational research should be approached in a methodologically rigorous fashion with high investigational standards in order to advance the education of surgical trainees and the care of surgical patients.
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11
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Lee CW, Vitous CA, Silveira MJ, Forman J, Dossett LA, Mody L, Dimick JB, Suwanabol PA. Delays in Palliative Care Referral Among Surgical Patients: Perspectives of Surgical Residents Across the State of Michigan. J Pain Symptom Manage 2019; 57:1080-1088.e1. [PMID: 30742891 PMCID: PMC9077765 DOI: 10.1016/j.jpainsymman.2019.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
CONTEXT Palliative care services (PCS) are underutilized and frequently delayed among surgical patients. Surgical residents often serve at the forefront for patient issues, including conducting conversations regarding prognosis and goals of care. OBJECTIVES This qualitative study identifies critical barriers to palliative care referral among seriously ill surgical patients from the perspective of surgical residents. METHODS We conducted semistructured interviews with surgical residents (n = 18) across the state of Michigan, which focused on experiences with seriously ill surgical patients and PCS. Inductive thematic analysis was used to establish themes based on the research objectives and data collected. RESULTS Four dominant themes of resident-perceived barriers to palliative care referral were identified: 1) challenges with prognostication, 2) communication barriers, 3) respect for the surgical hierarchy, and 4) surgeon mentality. Residents consistently expressed challenges in predicting patient outcomes, and verbalizing this to both attendings and families augmented this uncertainty in seeking PCS. Communicative challenges included managing discordant provider opinions and the stigma associated with PCS. Finally, residents perceived that an attending surgeon's decisive authority and mentality negatively influenced the delivery of PCS. CONCLUSIONS Among resident trainees, unpredictable patient outcomes led to uncertainty in the timing and appropriateness of palliative care referral and further complicated communicating plans of care. Residents perceived and relied on the attending surgeon as the ultimate decision maker, wherein the surgeon's sense of responsibility to the patient was identified as a significant barrier to PCS referral. Further studies are needed to test surgeon-specific interventions to improve access to and delivery of PCS.
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Affiliation(s)
- Christina W Lee
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - C Ann Vitous
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Maria J Silveira
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Geriatric Research, Education and Clinical Center (GRECC), Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Jane Forman
- Center for Clinical Management Research, Veterans Affairs Health Services Research & Development, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Lesly A Dossett
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA; Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Geriatric Research, Education and Clinical Center (GRECC), Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA; Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Pasithorn A Suwanabol
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA; Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.
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12
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Vigil. J Gen Intern Med 2019; 34:762-763. [PMID: 30993621 PMCID: PMC6502886 DOI: 10.1007/s11606-019-04890-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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13
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Cunningham HB, Scielzo SA, Nakonezny PA, Bruns BR, Brasel KJ, Inaba K, Brakenridge SC, Kerby JD, Joseph BA, Mohler MJ, Cuschieri J, Paulk ME, Ekeh AP, Madni TD, Taveras LR, Imran JB, Wolf SE, Phelan HA. Trauma Surgeon and Palliative Care Physician Attitudes Regarding Goals-of-Care Delineation for Injured Geriatric Patients. Am J Hosp Palliat Care 2019; 36:669-674. [DOI: 10.1177/1049909118823182] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The value of defining goals of care (GoC) for geriatric patients is well known to the palliative care community but is a newer concept for many trauma surgeons. Palliative care specialists and trauma surgeons were surveyed to elicit the specialties’ attitudes regarding (1) importance of GoC conversations for injured seniors; (2) confidence in their own specialty’s ability to conduct these conversations; and (3) confidence in the ability of the other specialty to do so. Methods: A 13-item survey was developed by the steering committee of a multicenter, palliative care-focused consortium and beta-tested by trauma surgeons and palliative care specialists unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Association for the Surgery of Trauma and American Academy for Hospice and Palliative Medicine. Results: Respondents included 118 trauma surgeons (8.8%) and 244 palliative care specialists (5.7%). Palliative physicians rated being more familiar with GoC, were more likely to report high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to trauma surgeons. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so and favored their own specialty leading team discussions. Conclusions: Both groups believe themselves to conduct GoC discussions for injured seniors better than the other specialty perceived them to do so, which led to disparate views on the optimal leadership of these discussions.
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Affiliation(s)
| | - Shannon A. Scielzo
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Paul A. Nakonezny
- Department of Psychiatry, University of Texas Southwestern, Dallas, TX, USA
| | - Brandon R. Bruns
- Department of Surgery, University of Maryland, College Park, MD, USA
| | - Karen J. Brasel
- Department of Surgery, Oregon Health Science University, Portland, OR, USA
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | | | - Jeffrey D. Kerby
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bellal A. Joseph
- Department of Surgery, University of Arizona Health Sciences, Tucson, AZ, USA
| | - M. J. Mohler
- Department of Surgery, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Joseph Cuschieri
- Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Mary E. Paulk
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | | | - Tarik D. Madni
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Luis R. Taveras
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Jonathan B. Imran
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Steven E. Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Herb A. Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
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Bakke KE, Miranda SP, Castillo-Angeles M, Cauley CE, Lilley EJ, Bernacki R, Bader AM, Urman RD, Cooper Z. Training Surgeons and Anesthesiologists to Facilitate End-of-Life Conversations With Patients and Families: A Systematic Review of Existing Educational Models. JOURNAL OF SURGICAL EDUCATION 2018; 75:702-721. [PMID: 28939306 DOI: 10.1016/j.jsurg.2017.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 07/17/2017] [Accepted: 08/07/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Despite caring for patients near the end-of-life (EOL), surgeons and anesthesiologists report low confidence in their ability to facilitate EOL conversations. This discrepancy exists despite competency requirements and professional medical society recommendations. The objective of this systematic review is to identify articles describing EOL communication training available to surgeons and anesthesiologists, and to assess their methodological rigor to inform future curricular design and evaluation. METHODS This PRISMA-concordant systematic review identified English-language articles from PubMed, EMBASE, and manual review. Eligible articles included viewpoint pieces, and observational, qualitative, or case studies that featured an educational intervention for surgeons or anesthesiologists on EOL communication skills. Data on the study objective, setting, design, participants, intervention, and results were extracted and analyzed. The Newcastle-Ottawa Scale was used to assess methodological quality. RESULTS Database and manual search returned 2710 articles. A total of 2268 studies were screened by title and abstract, 46 reviewed in full-text, and 16 included in the final analysis. Fifteen studies were conducted exclusively in academic hospitals. Two studies included attending surgeons as participants; all others featured residents, fellows, or a mix thereof. Fifteen studies used simulated role-playing to teach and assess EOL communication skills. Measured outcomes included knowledge, attitudes, confidence, self-rated or observer-rated communication skills, and curriculum feedback; significance of results varied widely. Most studies lacked adequate methodological quality and appropriate control groups to be confident about the significance and applicability of their results. CONCLUSIONS There are few quality studies evaluating EOL communication training for surgeons and anesthesiologists. These programs frequently use role-playing to teach and assess EOL communication skills. More studies are needed to evaluate the effect of these interventions on patient outcomes. However, evaluating the effectiveness of these initiatives poses methodological challenges.
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Affiliation(s)
- Katherine E Bakke
- Department of Surgery, University of Massachusetts Medical School, Massachusetts, USA
| | - Stephen P Miranda
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Manuel Castillo-Angeles
- Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christy E Cauley
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth J Lilley
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Rachelle Bernacki
- Department of Palliative Care and Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Angela M Bader
- Department of Surgery, University of Massachusetts Medical School, Massachusetts, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Center for Perioperative Research, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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Examining racial disparities in the time to withdrawal of life-sustaining treatment in trauma. J Trauma Acute Care Surg 2018; 84:590-597. [DOI: 10.1097/ta.0000000000001775] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Suwanabol PA, Kanters AE, Reichstein AC, Wancata LM, Dossett LA, Rivet EB, Silveira MJ, Morris AM. Characterizing the Role of U.S. Surgeons in the Provision of Palliative Care: A Systematic Review and Mixed-Methods Meta-Synthesis. J Pain Symptom Manage 2018; 55:1196-1215.e5. [PMID: 29221845 DOI: 10.1016/j.jpainsymman.2017.11.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT The provision of palliative care varies appropriately by clinical factors such as patient age and severity of disease and also varies by provider practice and specialty. Surgical patients are persistently less likely to receive palliative care than their medical counterparts for reasons that are not clear. OBJECTIVES We sought to characterize surgeon-specific determinants of palliative care in seriously ill and dying patients. METHODS We performed a systematic review of the literature focused on surgery and palliative care within PubMed, CINAHL, EMBASE, Scopus, and Ovid Medline databases from January 1, 2000 through December 31, 2016 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quantitative and qualitative studies with primary data evaluating surgeons' attitudes, knowledge, and behaviors or experiences in care for seriously ill and dying patients were selected for full review by at least two study team members based on predefined inclusion criteria. Data were extracted based on a predetermined instrument and compared across studies using thematic analysis in a meta-synthesis of qualitative and quantitative findings. RESULTS A total of 2589 abstracts were identified and screened, and 35 articles (26 quantitative and nine qualitative) fulfilled criteria for full review. Among these, 17 articles explored practice and attitudes of surgeons regarding palliative and end-of-life care, 11 articles assessed training in palliative care, five characterized surgical decision making, one described behaviors of surgeons caring for seriously ill and dying patients, and one explicitly identified barriers to use of palliative care. Four major themes across studies affected receipt of palliative care for surgical patients: 1) surgeons' experience and knowledge, 2) surgeons' attitudes, 3) surgeons' preferences and decision making for treatment, and 4) perceived barriers. CONCLUSIONS Among the articles reviewed, surgeons overall demonstrated insight into the benefits of palliative care but reported limited knowledge and comfort as well as a multitude of challenges to introducing palliative care to their patients. These findings indicate a need for wider implementation of strategies that allow optimal integration of palliative care with surgical decision making.
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Affiliation(s)
| | - Arielle E Kanters
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ari C Reichstein
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Lauren M Wancata
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily B Rivet
- Department of Surgery and Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Maria J Silveira
- Department of Surgery, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Arden M Morris
- S-SPIRE Center and Department of Surgery, Stanford University, Stanford, California, USA
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Suwanabol PA, Reichstein AC, Suzer-Gurtekin ZT, Forman J, Silveira MJ, Mody L, Morris AM. Surgeons' Perceived Barriers to Palliative and End-of-Life Care: A Mixed Methods Study of a Surgical Society. J Palliat Med 2018; 21:780-788. [PMID: 29649396 DOI: 10.1089/jpm.2017.0470] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Nearly 20% of colorectal cancer (CRC) patients present with potentially incurable (Stage IV) disease, yet their physicians do not integrate cancer treatment with palliative care. Compared with patients treated by primary providers, surgical patients with terminal diseases are significantly less likely to receive palliative or end-of-life care. OBJECTIVE To describe surgeon perspectives on palliative and end-of-life care for patients with Stage IV CRCs. DESIGN This is a convergent mixed methods study using a validated survey instrument from the Critical Care Peer Workgroup of the Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care Project with additional qualitative questions. SETTINGS Participants were all current, nonretired members of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES Surgeon-perceived barriers to palliative and end-of-life care for patients with Stage IV CRCs were identified. RESULTS Among 131 Internet survey respondents (response rate 16.5%), 76.1% reported no formal education in palliative care, and specifically noted inadequate training in techniques to forgo life-sustaining measures (37.9%) and communication (42.7%). Over half (61.8%) of surgeons cited unrealistic expectations among patients and families as a barrier to care, which also limited discussion of palliation. At the system level, absence of documentation, appropriate processes, and culture hindered the initiation of palliative care. Thematic analysis of open-ended questions confirmed and extended these findings through the following major barriers to palliative and end-of-life care: (1) surgeon knowledge and training; (2) communication challenges; (3) difficulty with prognostication; (4) patient and family factors encompassing unrealistic expectations and discordant preferences; and (5) systemic issues including culture and lack of documentation and appropriate resources. LIMITATIONS Generalizability is limited by the small sample size inherent to Internet surveys, which may contribute to selection bias. CONCLUSIONS Surgeons valued palliative and end-of-life care but reported multilevel barriers to its provision. These data will inform strategies to reduce these perceived barriers.
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Affiliation(s)
- Pasithorn A Suwanabol
- 1 Division of Colorectal Surgery, Department of Surgery, University of Michigan , Ann Arbor, Michigan
| | - Ari C Reichstein
- 2 Division of Colorectal Surgery, Department of Surgery, Allegheny Health Network , Pittsburgh, Pennsylvania
| | | | - Jane Forman
- 4 Center for Clinical Management Research , Veterans Affairs Health Services Research & Development, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Maria J Silveira
- 5 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan.,6 Geriatric Research, Education and Clinical Center (GRECC) , Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Lona Mody
- 5 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan.,6 Geriatric Research, Education and Clinical Center (GRECC) , Veterans Affairs Health Affairs, VA Ann Arbor Health Care System, Ann Arbor, Michigan
| | - Arden M Morris
- 7 Department of Surgery, S-SPIRE Center, Stanford University , Stanford, California
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Lamba S, Tyrie LS, Bryczkowski S, Nagurka R. Teaching Surgery Residents the Skills to Communicate Difficult News to Patient and Family Members: A Literature Review. J Palliat Med 2016; 19:101-7. [DOI: 10.1089/jpm.2015.0292] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sangeeta Lamba
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Leslie S. Tyrie
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sarah Bryczkowski
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Roxanne Nagurka
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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Tam B, Salib M, Fox-Robichaud A. The effect of rapid response teams on end-of-life care: a retrospective chart review. Can Respir J 2014; 21:302-6. [PMID: 25299222 PMCID: PMC4198233 DOI: 10.1155/2014/393807] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND A subset of critically ill patients have end-of-life (EOL) goals that are unclear. Rapid response teams (RRTs) may aid in the identification of these patients and the delivery of their EOL care. OBJECTIVES To characterize the impact of RRT discussion on EOL care, and to examine how a preprinted order (PPO) set for EOL care influenced EOL discussions and outcomes. METHODS A single-centre retrospective chart review of all RRT calls (January 2009 to December 2010) was performed. The effect of RRT EOL discussions and the effect of a hospital-wide PPO set on EOL care was examined. Charts were from the Ontario Ministry of Health and Long-Term Care Critical Care Information Systemic database, and were interrogated by two reviewers. RESULTS In patients whose EOL status changed following RRT EOL discussion, there were fewer intensive care unit (ICU) transfers (8.4% versus 17%; P<0.001), decreased ICU length of stay (5.8 days versus 20 days; P=0.08), increased palliative care consultations (34% versus 5.3%; P<0.001) and an increased proportion who died within 24 h of consultation (25% versus 8.3%; P<0.001). More patients experienced a change in EOL status following the introduction of an EOL PPO, from 20% (before) to 31% (after) (P<0.05). CONCLUSIONS A change in EOL status following RRT-led EOL discussion was associated with reduced ICU transfers and enhanced access to palliative care services. Further study is required to identify and deconstruct barriers impairing timely and appropriate EOL discussions.
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Affiliation(s)
- Benjamin Tam
- Department of Medicine, Division of General Internal Medicine, McMaster University, Hamilton, Ontario
| | - Mary Salib
- Department of Medicine, Division of General Internal Medicine, McMaster University, Hamilton, Ontario
| | - Alison Fox-Robichaud
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, Ontario
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Yarger JB, James TA, Ashikaga T, Hayanga AJ, Takyi V, Lum Y, Kaiser H, Mammen J. Characteristics in response rates for surveys administered to surgery residents. Surgery 2013; 154:38-45. [PMID: 23809484 DOI: 10.1016/j.surg.2013.04.060] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 04/26/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Surveys are important research tools that permit the accumulation of information from large samples that would otherwise be impractical to collect. Resident surveys have been used frequently to monitor the quality of postgraduate training. Low response rates threaten the utility of this research tool. The purpose of this study was to determine the standard response rate of surveys administered to surgery residents and identify characteristics associated with achieving greater response rates. METHODS A search of peer-reviewed literature published between September 2003 and June 2011 was performed with the use of PubMed with Medical Subject Headings: "internship and residency," "surgery," "data collection," and "questionnaires." For inclusion, articles must have described a survey given to active surgery residents within the United States. Surveys were evaluated based on the following criteria: population size, response rate, incentive use, follow-up use, survey format (online vs paper), and institution versus national. RESULTS Of 433 initial results, 47 met inclusion criteria with a mean response rate of 65.3%. Surveys administered in paper format had a greater response rate compared with those given electronically (mean 78.6% vs 36.4%, respectively, P < .001). Greatest mean response rates were seen for institutional surveys compared with those given nationally (83.1% vs 42% respectively, P < .001). CONCLUSION Our review demonstrated that paper surveys administered at the institutional level and during assemblies integrated into residents' schedules demonstrated enhanced response rates. The validity and generalizability of data collected through such surveys will improve as the aspects which dictate response rate are better understood and implemented.
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Affiliation(s)
- John B Yarger
- University of Vermont College of Medicine, Burlington, VT, USA.
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Moon JY, Lee HY, Lim CM, Koh Y. Medical Residents' Perception and Emotional Stress on Withdrawing Life-Sustaining Therapy. Korean J Crit Care Med 2012. [DOI: 10.4266/kjccm.2012.27.1.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jae Young Moon
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Young Lee
- National Health Insurance Corporation Research Fellow, Seoul, Korea
| | - Chae-Man Lim
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Medical Humanities and Social Sciences, University of Ulsan College of Medicine, Seoul, Korea
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Feasibility and impact of a case-based palliative care workshop for general surgery residents. J Am Coll Surg 2011; 214:231-6. [PMID: 22169003 DOI: 10.1016/j.jamcollsurg.2011.11.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 11/03/2011] [Accepted: 11/03/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND The American Board of Surgery has emphasized that palliative care education should be included in surgical training. The few formal curricula for teaching palliative care, although effective, are time-intensive and have low longitudinal participation rates. The aim of this project was to design a feasible and effective palliative care intervention for general surgery residency training. STUDY DESIGN A multidisciplinary group developed a 2-hour case-based palliative care workshop including a brief introductory didactic, 4 case-based scenarios, and role-playing exercises. Program effectiveness was assessed using pre- and 3 weeks post-workshop surveys to measure attitudes toward and knowledge of palliative care. Fisher's exact test was used for data analysis; statistical significance was accepted at p < 0.05. RESULTS Twenty-two (88%) residents attended the workshop and completed the baseline survey; 16 (72.7%) completed the post-workshop survey. The workshop changed residents' attitudes to be more consistent with accepted palliative care principles. Statistically significant shifts were seen in attitudes about the use of total parenteral nutrition for malignant small bowel obstruction (31.8% disagree with use pre- vs 68.8% post-workshop; p < 0.0001); the use of surgical therapy for malignant small bowel obstruction (45.5% disagree pre- vs 68.8% post-workshop; p = 0.002); and that depression is normal in terminal illness (22.7% disagree pre- vs 43.8% post-workshop; p = 0.002). Residents also performed considerably better on knowledge questions about CPR, patient autonomy, and withdrawal of life-sustaining therapy. CONCLUSIONS A brief, interactive workshop is effective in changing general surgery residents' attitudes toward and knowledge of palliative care. The results demonstrate that a single teaching session is a useful intervention.
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Abstract
The traditional action-oriented surgical personality, although essential in the service of solving emergent operative dilemmas, may serve as a barrier to introspection. Certainly, challenges of the twenty-first century practice environment, including time constraints, also distract from self-reflection. Without engaging in moments of introspection, surgeons risk not only abandoning dying patients in their time of need, but leave the surgeons themselves at risk for burnout and its consequences. The increase in the number of women surgeons, as well as the less heroic image of surgeons performing laparoscopic operations, may reorient traditional extroverted behavior toward a persona of professional grace.
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Affiliation(s)
- David W Page
- Department of Surgery, Tufts University School of Medicine, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA.
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Duane TM, Fan L, Bohannon A, Han J, Wolfe L, Mayglothling J, Whelan J, Aboutanos M, Malhotra A, Ivatury RR. Geriatric Education for Surgical Residents: Identifying a Major Need. Am Surg 2011. [DOI: 10.1177/000313481107700714] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated a program designed to test and enhance residents’ knowledge of geriatrics. A 2-year prospective interventional trial was conducted. Surgical residents underwent pretesting (pre) in three areas: polypharmacy, delirium, and end of life. They then received educational materials and completed a posttest within 1 month and a patient simulation examination graded by a physician observer and the patient on his or her satisfaction. Forty-nine residents (51% interns, 55% general surgery residents) participated. Seventy per cent had no prior geriatrics education. Test scores significantly improved from pretest to posttest (12.9 ± 3.1 vs 13.78 ± 3.12, P = 0.01). The scores were consistently better on poly topics and consistently worse on end-of-life topics: pretest per cent correct: polypharmacy 60, end of life 46, P = 0.007; posttest percent correct: polypharmacy 63, end of life 49, P = 0.0014. By Pearson correlation, the pretest and posttest scores did not correlate with either the observer ( R = -0.16, P = 0.27 pre, R = -0.08, P = 0.59 post) or subscores ( R = -0.27, P = 0.11 pre, R = -0.13, P = 0.45 post), although the observer and subscore correlated with each other ( R = 0.35, P = 0.036). Performance was poor and did not correlate with better patient care by simulation. Other options for geriatric education need to be considered and evaluated.
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Affiliation(s)
- TherÈSe M. Duane
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Lingbo Fan
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Arline Bohannon
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Jinfeng Han
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Luke Wolfe
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Julie Mayglothling
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - James Whelan
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Michael Aboutanos
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Ajai Malhotra
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Rao R. Ivatury
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
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