Key Physician Behaviors that Predict Prudent, Preference Concordant Decisions at the End of Life

Eye on the Prize: Patient Outcomes Research in Medical Education

The overarching goal of medical education is to train clinicians who achieve and maintain competence in patient care. Although the field of medical education research has acknowledged the importance of education on clinical practices and outcomes, most research endeavors continue to focus on learner-centered outcomes, such as knowledge and attitudes. The absence of clinical and patient-centered outcomes in pulmonary and critical care medicine medical education research has been attributed to barriers at multiple levels, including financial, methodological, and practical considerations. This Perspective explores clinical outcomes relevant to pulmonary and critical care medicine educational research and offers strategies and solutions that educators can use to accomplish what many consider the "prize" of medical education research: an understanding of how our educational initiatives impact the health of patients.

Cultures of Practice: Specialty-Specific Differences in End-of-Life Conversations

Importance: Goals of care discussions at the end of life give opportunity to affirm the autonomy and humanity of dying patients. Best practices exist for communication around goals of care, but there is no research on differences in approach taken by different specialties engaging these conversations. Objective: To describe the communication practices of internal medicine (IM), emergency medicine (EM), and critical care (CC) physicians in a high-fidelity simulation of a terminally ill patient with stable and defined end-of-life preferences. Design, Setting, and Participants: Mixed-methods secondary analysis of transcripts obtained from a multicenter study simulating high stakes, time-limited end-of-life decision making in a cohort of 88 volunteer physicians (27 IM, 22 EM, and 39 CC) who were called to evaluate a standardized patient in extremis. The patient had clear comfort-oriented goals of care that the physician needed to elicit and use to inform treatment decisions. Discussions were coded at the level of the sentence for semantic content. Exposures: Data were analyzed by physician specialty. Main Outcome Measure: Occurrence of content codes indicative of prudent (right outcome by the right means) goals of care conversations. Data were analyzed both for number of occurrences of the code in a simulated conversation and for presence or absence of the code within a conversation. Results: There was no difference between physician types in intubation rates or intensive care unit admissions. Codes for "comfort as a goal of care," "noncurative goals of care," and "oblique references to death" emerged as significantly different between physician types. Conclusions and Relevance: This experiment shows demonstrable differences in practice patterns between physician specialties when addressing end-of-life decision making. Some of the variation likely arose from differences in setting, but these data suggest that training in goals of care conversations may benefit if it is adapted to the distinct needs and culture of each specialty.