The Feasibility of Virtual VitalTalk Workshops in Japanese: Can Faculty Members in the US Effectively Teach Communication Skills Virtually to Learners in Japan?

Bringing competency-based communication training to scale: A multi-institutional virtual simulation-based mastery learning curriculum for Emergency Medicine residents

PURPOSE

Serious illness communication skills are essential for physicians, yet competency-based training is lacking. We address scalability barriers to competency-based communication skills training by assessing the feasibility of a multi-center, virtual simulation-based mastery learning (vSBML) curriculum on breaking bad news (BBN).

METHODS

First-year emergency medicine residents at three academic medical centers participated in the virtual curriculum. Participants completed a pretest with a standardized patient (SP), a workshop with didactics and small group roleplay with SPs, a posttest with an SP, and additional deliberate practice sessions if needed to achieve the minimum passing standard (MPS). Participants were assessed using a previously published BBN assessment tool that included a checklist and scaled items. Authors compared pre- and posttests to evaluate the impact of the curriculum.

RESULTS

Twenty-eight (90%) of 31 eligible residents completed the curriculum. Eighty-nine percent of participants did not meet the MPS at pretest. Post-intervention, there was a statistically significant improvement in checklist performance (Median= 93% vs. 53%, p < 0.001) and on all scaled items assessing quality of communication. All participants ultimately achieved the MPS.

CONCLUSIONS

A multi-site vSBML curriculum brought all participants to mastery in the core communication skill of BBN and represents a feasible, scalable model to incorporate competency-based communication skills education in a widespread manner.

Enduring Positive Impact of a Virtual Communication Skills Workshop of VitalTalk Pedagogy in a Non-U.S. Setting

CONTEXT

While in-person workshops on serious illness communication skills using VitalTalk pedagogy have been shown to have a long-lasting impact, whether changing the format into virtual would maintain its enduring impact is unknown. Objectives. To examine long-term impacts of a virtual VitalTalk communication workshop.

METHODS

Physicians in Japan who participated in our virtual VitalTalk workshop were asked to complete a self-assessment survey at 3 time points: before, immediately after, and 2 months after the workshop. We examined self-reported preparedness in 11 communication skills on a 5-point Likert scale at 3 time points, as well as self-reported frequency of practice on 5 communication skills at the pre- and 2-month time points.

RESULTS

Between January 2021 and June 2022, 117 physicians from 73 institutions across Japan completed our workshop. Seventy-four participants returned the survey at all the 3 time points. Their skill preparedness significantly improved upon the completion of the workshop in all 11 skills (P < .001 for all items). The improvement remained at the same level at 2 months in 7 skills. In 4 of the 11 skills, there was further improvement at the 2-month point. The frequency of self-directed skill practice also increased significantly in the 2-month survey for all 5 skills.

CONCLUSION

A virtual workshop of VitalTalk pedagogy improved self-reported preparedness of communication skills, and the impact was long-lasting in a non-U.S. setting as it likely induced self-practice of skills. Our findings encourage the use of a virtual format in any geographical location considering its enduring impact and easy accessibility.

Culturally Acceptable Emotional Expressions Perceived by Non-U.S. Physicians Undergoing U.S.-Based Serious Illness Communication Skills Training: A Cross-Sectional Study

CONTEXT

Responding to emotions is a key feature of U.S.-based serious illness communication skills training, VitalTalk®, of which trained actors portraying seriously ill patients is a component. The cultural appropriateness and perceived utility of the actors' emotional expressions remain to be empirically evaluated outside of the U.S.

OBJECTIVES

To determine the cultural appropriateness and educational utility of VitalTalk® actors' emotional expressions, as perceived by clinicians.

METHODS

From January 2021-April 2022, we conducted a cross-sectional study of physicians in Japan attending virtual VitalTalk® training in Japanese, each session focusing on: responding to emotions (#1) and discussing goals of care (#2), respectively. We examined their perceived authenticity and utility of the actively and passively intense emotional expressions portrayed by actors in VitalTalk® role-plays.

RESULTS

Physicians (N = 100, 94% response rate) from across Japan voluntarily attended two-session workshops and completed post-session surveys. Eighty-eight participants (88%) responded that both actively and passively intense emotions portrayed by the actors provided useful learning experiences. For session #1, the participants found actively intense emotional expressions to be more clinically authentic, compared to passively intense ones (4.21 vs 4.06 out of a 5-point Likert scale, PP= .02). For session #2, no such difference was observed (4.16 vs 4.08 of a 5-point Likert scale, P = .24).

CONCLUSIONS

Even in a culture where patients may express emotions passively, any intense and authentic emotional expressions by actors can be perceived as facilitating learning. Most participants perceived both the Name, Understand, Respect, Support, and Explore '(NURSE)' statements and Reframe, Expect emotion, Map out patient goals Align with goals and Propose a plan '(REMAP)' frameworks as useful in routine clinical practice in Japan.

Futility and Shared Decision-Making

Medical futility is an ancient and yet consistent challenge in clinical medicine. The means of balancing conflicting priorities and stakeholders' preferences has changed as much as the science that powers the understanding and treatment of disease. The introduction of patient self-determination and choice in medical decision-making shifted the locus of power in the physician-patient relationship but did not obviate the physician's responsibilities to provide benefit and prevent harm. As we have refined the process in time, new paradigms, specialists, and tools have been developed to help navigate the ever-changing landscape.

Communication Training and Code Status Conversation Patterns Reported by Emergency Clinicians

CONTEXT

During acute health decompensations for seriously ill patients, emergency clinicians often determine the intensity end-of-life care. Little is known about how emergency clinicians conduct these conversations, especially among those who have received serious illness communication training.

OBJECTIVES

To determine the self-reported practice patterns of code status conversations by emergency clinicians with and without serious illness communication training.

METHODS

A cross-sectional survey was conducted among emergency clinicians with and without a recent evidence-based, serious illness communication training tailored for emergency clinicians. Emergency clinicians were included from two academic medical centers. A five-point Likert scale ("very unlikely" to "very likely" to ask) was used to assess the self-reported likelihood of asking about patients' preferences for medical procedures and patients' values and goals.

RESULTS

Among 161 respondents (71% response rate), 77 (48%) received the training. A total of 70% of emergency clinicians reported asking about procedure-based questions, and only 38% reported asking about patient's values regarding end-of-life care. For value-based questions, statistically significant differences were observed between emergency clinicians who underwent the training and those who did not in four of the seven questions asked (e.g., the higher odds of exploring the patient's life priorities [adjusted OR = 4.34, 95% CI = 1.95-9.65, P-value < 0.001]). No difference was observed in the self-reported rates of all procedure-based questions between the two groups.

CONCLUSION

Most emergency clinicians reported asking about procedure-based questions, and some asked about patient's value-based questions. Clinicians with recent serious illness communication training may ask more about some values and priorities.

Serious Illness Conversation Training for Inpatient Medical Oncology Advanced Practice Providers: A Quality Improvement Project

Background

Hospitalized advanced cancer patients and their families are inadequately informed about their cancer diagnosis and prognosis, which limits educated and reasonable decision-making for their care and end-of-life planning.

Objectives

The primary objective of this evidence-based project was to enhance serious illness conversations (SICs) with advanced cancer patients by providing advanced practice providers (APP) training and to increase the frequency of SIC documentation in the electronic medical record (EMR).

Methods

SIC training included a 45-minute Zoom video recording and 30-minute discussion groups. Advanced practice providers' beliefs and self-efficacy were measured pre- and post-training via a survey. Prior training was queried in the pre-survey. Data from APP discussion groups were summarized and themes identified. Serious illness conversation documentation frequency was measured. Pre- and post-survey differences were assessed using Wilcoxon rank sum tests.

Findings

19 inpatient medical oncology nurse practitioners and 6 physician assistants participated. Many reported little formal training yet are engaging in SICs regularly. Scores on both the belief and self-efficacy survey sections were high prior to training and did not significantly change following training. Despite the high pre-survey scores, many of the APPs verbalized the need for more training to improve their confidence and to learn SIC communication skills. Training significantly improved the APP's ability to manage their own emotions and be present. This indicates a trend toward improved APP comfort with SICs. Accessible documentation in the EMR increased with training.

Primary palliative care recommendations for critical care clinicians

Palliative care is an interdisciplinary care to optimize physical, psychosocial, and spiritual symptoms of patients and their families whose quality of life is impaired by serious, life-limiting illness. In 2021, the importance of providing palliative care in the intensive care unit (ICU) is well recognized by various studies to alleviate physical symptoms due to invasive treatments, to set patient-centered goals of care, and to provide end-of-life care. This paper summarizes the evidence known to date on primary palliative care delivered in the ICU settings. We will then discuss the potential benefits and harms of primary palliative care so that critical care clinicians are better equipped to decide what services might best improve the palliative care needs in their ICUs.