Online Data Supplement Communication Skills Training Curriculum for Pulmonary and Critical Care Fellows Jennifer W. McCallister, MD, Jillian Gustin, MD, Sharla Wells-Di Gregorio, PhD, David P. Way, MEd, John G. Mastronarde, MSc, MD
Appendix E1: Educational Experience and Attitudes Questionnaire Part I: Background A. Gender: Female Male B. Age: C. Please indicate your plans for after completion of fellowship by placing a check in the box next to each setting, area of interest, and specialty (Check all that apply): Academic Medical Center Critical Care ONLY Community Hospital Setting Pulmonary ONLY Outpatient Clinic Critical Care AND Pulmonary Involvement in Education Area of interest: Involvement in Research Other subspecialty: Further fellowship training Other plans: Part II: Educational/Professional Experience and Attitudes YES NO A. Did you complete a palliative care and/or hospice rotation in medical school? B. Did you complete a palliative care and/or hospice rotation in residency? C. During your residency, did you had any contact with clinicians (i.e. in the context of caring for patients) who specialize in palliative care? D. 1) From the list below, please check the venues or activities in which you received communication skills training during residency. 2) For each identified venue, please rate its effectiveness in teaching you communication skills by circling the rating that matches your opinion. Use the following scale: NH= Not Helpful; MH= Minimally Helpful; H= Helpful; VH= Very Helpful NH MH H VH Lecture series Small group discussions Role play &/or standardized patient Other: Modeling during clinical care rotations. If checked, please indicate below who did the modeling (Check & rate all that apply) Other residents Fellows Attendings Others: E2
E. During your residency, were you explicitly taught: Yes No How to prepare for a family meeting How to lead/facilitate a family meeting How to elicit patient and/or family perceptions of illness How to deliver bad news How to facilitate a DNR discussion How to assess patient/family concerns (e.g. spiritual, psychological, social) How to discuss uncertainty in illness trajectory How to attend to emotion How to foster shared decision-making How to document a family meeting in the medical record F. During your residency, were you exposed to the following communication concepts/ techniques: Yes No Ask-tell-ask 1 Tell me more 1 SPIKES protocol for breaking bad news 2 VALUE protocol for facilitating a family meeting 3 NURSE mnemonic for attending to emotion 4 Hope/worry technique for managing uncertainty 5 Active listening 6 Reflective questioning 6 Patient-centered communication 7 G. How adequate was your residency training curriculum in teaching you the skills to manage challenging goals of care discussions with patients and families? o More than adequate o Adequate o Inadequate o Extremely inadequate H. How important is it to have instruction in goals of care discussions during fellowship training? o Extremely important o Fairly important o Fairly unimportant o Not at all important I. What do you think about the value of didactic (e.g. lectures, small group seminars) as opposed to experiential teaching exercises (e.g. use of standardized patients, MICU family meeting checklist) in teaching goals of care communication skills? o Didactic more valuable than experiential o Didactic and experiential exercises equally valuable o Experiential more valuable than didactic E3
Appendix E2: Family Meeting Behavioral Skills Checklist 31 items used for self-assessment by fellows and assessment by psychologists after simulated family meetings Behavior performed 1. Prepare for family meeting Yes No n/a Greeted pt/family members and asked for introductions 2. Assess/Understand family and patient perception Yes No n/a Expressed interest in patient as a person, prior to illness Asked pt/family to share perspective on patient s illness i.e. 3 levels of understanding 3. Elicit pt/family preferences for communication Yes No n/a Asked pt/family who the team should contact regarding patient condition Asked pt/family about amount of detail that would be helpful re: clinical condition Explored pt/family s decision-making preferences 4. Exchange/Share clinical information with pt/family Yes No n/a Clearly stated the patient s clinical condition with avoidance of medical jargon Asked if the family understood the information conveyed i.e. ask-tell-ask Gave warning of difficult news with time for preparation Provided information in short chunks Provided level of detail to match family s desired level of detail 5. Assessing/Attending to patient and family reactions Yes No n/a Explored pt/family s psychosocial and emotional concerns i.e. tell me more Explored pt/family s spiritual and cultural concerns Acknowledged/accurately reflected family s distress i.e. named emotion Validated pt/family reaction i.e. empathic statement 6. Manage uncertainty Yes No n/a Assessed prognostic awareness i.e. current understanding, future hope and worry Identified uncertainty of patient s clinical trajectory i.e. hope/worry technique Promoted normative coping i.e. hope for best/prepare for worst, denial/acceptance 7. Share decision-making Yes No n/a Achieved common understanding of patient s clinical condition Focused discussion on patient values/goals prior to discussion of specific interventions Discussed treatment options based on patient s goals/values Offered recommendations when in keeping with family s decision-making preferences 8. Summarize/Plan Yes No n/a Summarized discussion Suggested next steps including future contact between family and care team Prepared family for the unexpected Provided necessary resources/contact information to help support family 9. General approach Yes No n/a Used reflective questioning Invited pt/family questions throughout meeting Listened without interruption Allowed silence Demonstrated non-verbal cues of empathy/engagement E4
Appendix E3: Self-Confidence for Communication Skills Survey We would like to assess your level of confidence in performing goals of care discussions during family meetings. For each question below, please rate your current confidence level for each of the communication skills. Use the key below: 1 = No confidence at all (i.e. I do not have ability to effectively perform the skill) 2 = Minimal confidence (i.e. I need expert guidance to effectively perform the skill) 3 = Moderate confidence (i.e. I can effectively perform the skill with some expert guidance) 4 = Very confident (i.e. I can effectively perform the skill independently) Communication Skills Confidence Level 1. Preparing care team for a family meeting 1 2 3 4 2. Leading/facilitating a family meeting 1 2 3 4 3. Eliciting family/patient perceptions of illness 1 2 3 4 4. Exploring family preferences for communication 1 2 3 4 5. Sharing clinical information with family 1 2 3 4 6. Specifically: a) delivering bad news 1 2 3 4 b) providing prognostic information 1 2 3 4 7. Assessing patient and family concerns 1 2 3 4 8. Specifically: a) psychosocial and emotional concerns 1 2 3 4 b) spiritual and cultural concerns 1 2 3 4 9. Managing conflict among family members and/or care providers 1 2 3 4 10. Eliciting patient s value/goals from family s perspective 1 2 3 4 11. Managing uncertainty in illness trajectory 1 2 3 4 12. Providing decision-making support 1 2 3 4 Specifically: a) discussing treatment options based on goals 1 2 3 4 b) offering recommendations for plan of care 1 2 3 4 c) discussing code status 1 2 3 4 13. Summarizing plan of care to family 1 2 3 4 14. Documenting family meeting in the chart 1 2 3 4 15. Using silence 1 2 3 4 16. Using reflective questioning i.e. I hear you saying 1 2 3 4 How well prepared do you feel to teach others (i.e. residents and medical students) to perform goals of care discussions with patients and families? o o o Extremely prepared (i.e. have all the necessary skills) Fairly prepared (i.e. have adequate skills but may benefit from more training) Fairly unprepared (i.e. require more training to improve skills) o Not at all prepared (i.e. require extensive training to gain skills) E5
Appendix E4: Family Meeting Behavioral Skills Checklist for formative feedback used for identification of learning goals before and self-reflection/formative feedback after family meetings in the Medical Intensive Care Unit A. Educational Goals of the Family Meeting for the trainee: 1. List the potential challenge(s) for you in this encounter. 2. Identify at least 1-2 skills that you want to work on during this encounter. B. Behavioral skills checklist Behavior performed 1. Prepare for family meeting Yes No n/a Identified members of care team to be involved in meeting Reviewed medical issues with care team Discussed goals of family meeting with care team Minimized distractions i.e. arranged private location, turned off pagers/phones Greeted pt/family members and asked for introductions 2. Assess/Understand family and patient perception Yes No n/a Expressed interest in patient as a person, prior to illness Asked pt/family to share perspective on patient s illness i.e. 3 levels of understanding 3. Elicit pt/family preferences for communication Yes No n/a Asked pt/family who the team should contact regarding patient condition Asked pt/family about amount of detail that would be helpful re: clinical condition Explored pt/family s decision-making preferences 4. Exchange/Share clinical information with pt/family Yes No n/a Clearly stated the patient s clinical condition with avoidance of medical jargon Asked if the family understood the information conveyed i.e. ask-tell-ask Gave warning of difficult news with time for preparation Provided information in short chunks Provided level of detail to match family s desired level of detail 5. Assessing/Attending to patient and family reactions Yes No n/a Explored pt/family s psychosocial and emotional concerns i.e. tell me more Explored pt/family s spiritual and cultural concerns Acknowledged/accurately reflected family s distress i.e. named emotion Validated pt/family reaction i.e. empathic statement 6. Manage uncertainty Yes No n/a Assessed prognostic awareness i.e. current understanding, future hope and worry Identified uncertainty of patient s clinical trajectory i.e. hope/worry technique Promoted normative coping i.e. hope for best/prepare for worst, denial/acceptance 7. Share decision-making Yes No n/a Achieved common understanding of patient s clinical condition Focused discussion on patient values/goals prior to discussion of specific interventions Discussed treatment options based on patient s goals/values Offered recommendations when in keeping with family s decision-making preferences 8. Summarize/Plan Yes No n/a Summarized discussion Suggested next steps including future contact between family and care team Prepared family for the unexpected Provided necessary resources/contact information to help support family 9. General approach Yes No n/a Used reflective questioning Invited pt/family questions throughout meeting E6
Listened without interruption Allowed silence Demonstrated non-verbal cues of empathy/engagement 10. Documentation Yes No n/a Documented date and time of meeting in the chart Documented members present for meeting Summarized content of meeting accurately in chart Documented family understanding of patient condition Documented decision-making and subsequent plan Documented and coordinated care to meet family support needs Documented challenges including resolution and/or ongoing issues C. Reflection on communication skills during Family Meeting: 1. Did you perform the skills identified above (Section A)? Yes No 2. What went smoothly for you during this encounter? 3. What was most challenging for you about this encounter? 4. What do you take away from this encounter (i.e. take-home point)? 5. What skill would you like to work on during the next family meeting? E7
Appendix E5. Instructional objectives and educational strategies for PCCM Fellows Communication Curriculum Instructional Objectives 1. Knowledge a) Describe importance of effective communication in MICU b) Explain five elements of patientcentered communication c) Recite techniques to foster patientcentered communication 2. Attitudes a) Reflect on one s competence to facilitate family meetings b) Identify barriers to effective communication in MICU 3. Skills a) Identify observable behavioral skills that enhance communication b) Employ cognitive & behavioral frameworks for discussions regarding goals of care c) Demonstrate proficiency in utilizing five key elements of patientcentered communication d) Perform self-assessment of communication skills after each family meeting Educational Strategies 1. Simulated family meeting to aid in the identification of areas for improvement in communication skills by comparing self-evaluation and evaluation by behavioral psychologist using a Family Meeting Behavioral Skills Checklist. 2. Three hour communication skills training workshop to introduce knowledge concepts interspersed with small group discussion and practice through role- play 3. Additional supervised practice: a. Structured observation of Palliative Care provider utilizing the Family Meeting Behavioral Skills Checklist (FMBSC) b. Supervised facilitation of family meeting with subsequent feedback using the FMBSC (minimum of two required per fellow per month in MICU) 4. One-hour group and self-reflection on experiences facilitating family meetings in conjunction with internal medicine residents at end of month rotation PCCM = Pulmonary & Critical Care Medicine Fellow; MICU = Medical intensive care unit; FMBSC = Family Meeting Behavioral Skills Checklist E8
Appendix E6. Summary of PCCM Fellows Communication Curriculum Evaluation Evaluation Methods MICU rotations Preintervention Postintervention Control Group Self-report Measures: Educational experience & attitudes* Clinical Communication Skills Self- Confidence survey Observational Measures: Simulate family meeting experience using FMBSC - includes self-evaluation and evaluation by behavioral psychologists Faculty formative feedback after family meetings using FMBSC PCCM=Pulmonary and Critical Care Medicine; MICU=Medical Intensive Care Unit; FMBSC=Family Meeting Behavioral Skills Checklist; * See Appendix E1; See Appendix E2; See Appendix E3; See Appendix E4. E9
Appendix E7. Summary of types and perceived value of prior communication skills education reported by 15 PCCM fellows during residency training prior to fellowship. Type of communication skills training N Mea n Std Dev Not Helpful Freq (%) Minimally Helpful Freq (%) Helpful Freq (%) Very Helpful Freq (%) Lectures 14 2.57 0.85 1 (7.1) 6 (42.9) 5 (35.7) 2 (14.3) Small group discussions 13 2.85 0.80 1 (7.7) 2 (15.4) 8 (61.5) 2 (15.4) Simulated encounters with peers (role play) or standardized patients 12 2.67 1.07 2 (16.7) 3 (25.0) 4 (33.3) 3 (25.0) Modeling by other residents 12 2.75 0.75 1 (8.3) 2 (16.7) 8 (66.7) 1 (8.3) Modeling by fellows 11 3.00 0.89 1 (9.1) 1 (9.1) 6 (54.5) 3 (27.3) Modeling by attendings 13 3.31 0.85 1 (7.7) 0 (0) 6 (46.2) 6 (46.2) PCCM=Pulmonary and Critical Care Medicine; Std Dev=Standard Deviation; Freq=Frequency E10
Appendix E8. Summary of communication skills, concepts, and/or techniques experienced by 15 PCCM fellows during residency training prior to fellowship. During your residency, were you explicitly taught how to: Frequency % deliver bad news 12 80.0 discuss uncertainty in illness trajectory 11 73.3 facilitate a DNR discussion 11 73.3 assess patient and/or family concerns (e.g. spiritual, psychological, social) 10 66.7 document a family meeting in the medical record 10 66.7 lead/facilitate a family meeting 10 66.7 elicit patient and/or perceptions of illness 9 60.0 prepare for a family meeting 7 46.7 foster shared decision-making 7 46.7 attend to emotion 6 40.0 During your residency, which of these communication techniques did you learn? Freqs Pct Active listening 13 86.7 Tell me more 13 86.7 Patient-centered communication 12 80.0 Reflective questioning 9 60.0 Ask-tell-ask 8 53.3 Hope/worry technique for managing uncertainty 4 26.7 SPIKES mnemonic for breaking bad news 2 13.3 NURSE mnemonic for attending to emotion 1 6.7 VALUE mnemonic for facilitating a family meeting 1 6.7 PCCM=Pulmonary and Critical Care Medicine; DNR=Do Not Resuscitate E11
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