- Email: [email protected]
Talk the Talk: Implementing a Communication Curriculum for Surgical Residents
ORIGINAL REPORTS
Talk the Talk: Implementing a Communication Curriculum for Surgical Residents Anna B. Newcomb, PhD, MSW, LCSW,* Amber W. Trickey, PhD, MS, CPH,† Melissa Porrey, MA, NCC, LPC,* Jeffrey Wright, MPH,† Franco Piscitani, NRP,† Paula Graling, DNP, RN, CNOR, FAAN,† and Jonathan Dort, MD, FACS† *
Division of Trauma, Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia; and Department of Surgery, Advanced Surgical Technology and Education Center, Inova Fairfax Medical Campus, Falls Church, Virginia †
OBJECTIVES: The Accreditation Council for Graduate Medical Education milestones provide a framework of specific interpersonal and communication skills that surgical trainees should aim to master. However, training and assessment of resident nontechnical skills remains challenging. We aimed to develop and implement a curriculum incorporating interactive learning principles such as group discussion and simulation-based scenarios to formalize instruction in patient-centered communication skills, and to identify best practices when building such a program. DESIGN: The curriculum is presented in quarterly modules
over a 2-year cycle. Using our surgical simulation center for the training, we focused on proven strategies for interacting with patients and other providers. We trained and used former patients as standardized participants (SPs) in communication scenarios. SETTING: Surgical simulation center in a 900-bed tertiary
care hospital. PARTICIPANTS: Program learners were general surgery residents (postgraduate year 1-5). Trauma Survivors Network volunteers served as SPs in simulation scenarios. RESULTS: We identified several important lessons: (1) designing and implementing a new curriculum is a challenging process with multiple barriers and complexities; (2) several readily available facilitators can ease the implementation process; (3) with the right approach, learners, faculty, and colleagues are enthusiastic and engaged participants; (4) learners increasingly agree that communication skills can be
Correspondence: Inquiries to Anna B. Newcomb, PhD, MSW, LCSW, Division of Trauma, Department of Surgery, Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA 22042; fax: (703) 776-2338; e-mail: [email protected], [email protected]
improved with practice and appreciate the curriculum value; (5) patient SPs can be valuable members of the team; and importantly (6) the culture of patient-physician communication appears to shift with the implementation of such a curriculum. CONCLUSIONS: Our approach using Trauma Survivors
Network volunteers as SPs could be reproduced in other institutions with similar programs. Faculty enthusiasm and support is strong, and learner participation is active. Continued focus on patient and family communication skills would enhance patient care for institutions providing such education as well as for institutions where residents continue on in fellowships or begin their surgical practice. ( J Surg Ed C ]:]]]-]]]. J 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: general surgery, residency, interpersonal and communication skills, curriculum implementation, resident educators COMPETENCIES: Interpersonal and Communication Skills,
Professionalism, Patient Care, Practice-Based Learning and Improvement
INTRODUCTION Communication skills are essential to providing patientcentered care that is customized and adapted to patients’ individual values, needs, and preferences.1 Clear and compassionate communication is critical in surgical practice where communication needs vary in complexity, from setting patient expectations and assessing adherence, to eliciting patient perspectives and concerns, managing family conflicts and patient counseling.2 Physician communication
Journal of Surgical Education & 2016 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.09.009
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proficiency is related to important outcomes such as treatment compliance, accurate information exchange, and patient experience.3-5 The Accreditation Council for Graduate Medical Education (ACGME) milestones specify that surgical trainees should develop interpersonal and communication skills in 3 practice domains—care for diseases and conditions, coordination of care, and performance of operations and procedures.6 Communication skill development has traditionally received relatively light emphasis in graduate medical education given the packed curriculum and assessment difficulties7,8; general surgery trainees often hone their “soft skills” at the bedside and through modeling of mentor attending surgeons.9-11 As approaches to identifying, measuring, and improving communication behavior have become well established in social science literature, surgical trainees have the opportunity to be familiarized with these contemporary skills and assessment methods.12-17 Simulation and role-play have advantages in surgical education including sharpening skills before speaking with patients, video-recording for learner assessment, and professionally mediated feedback during debriefing.18-21 As the need for a specific and thoroughly assessed communications curriculum became apparent at our institution, challenges of program development arose, such as finding protected educational time and resources for simulation, developing scenarios and training actors, and standardizing implementation and assessment techniques. The purpose of this report is to describe our experience designing and implementing a patient-centered communication curriculum for general surgery residents, and to offer guidance for training programs developing similar curricula in the future.
MATERIALS AND METHODS
Inova Fairfax Medical Campus is a level 1 trauma center, and a tertiary care referral center in all surgical specialties. Faculty are a hybrid of private practice and hospitalemployed surgeons. Until the introduction of ACGME milestones, our residency program faculty made assessments without uniform criteria as part of the standard service rotation evaluations. As with most surgical training programs, residents’ communication skills have only recently been formally assessed as part of the introduction of milestone evaluations. Approach After a needs assessment and gap analysis identified opportunities to formalize instruction in patient-centered communication skills, we developed a curriculum incorporating interactive learning principles such as group discussion and simulation-based scenarios. The course was designed to increase residents’ skills of compassionate, effective communication with patients and their family members using simulated encounters, facilitated discussion, and afteraction debriefing. Although brief lectures introduced the topics, we focused on developing a cooperative learning climate that actively engaged the learner.22 The curriculum is presented in quarterly modules over a 2-year cycle and involves a variety of disciplines providing subject matter expertise—social work, risk management, patient experience, palliative care, and social science researchers. We sought to expose trainees to proven strategies for interacting with patients and other providers, encourage residents to practice and sharpen communication skills, increase skills confidence, and develop residents’ competency in interpersonal and communication skills as well as systems-based practice.6
Setting
Resources
The Surgical Residency Program at Inova Fairfax Medical Campus was initially accredited for 2 residency positions in 2002 and has grown to the current complement of 5 residents per postgraduate year (PGY). The entire breadth of training is available to the residents at the campus, as
In our assessment of available resources to develop our curriculum, we noted several resources available to all (Table 1). Universally accessible resources include the MedEd Portal https://www.mededportal.org/, a free publication service promoting educational scholarship and
TABLE 1. Curriculum Development and Implementation Resources Resources Institution specific
Universal
2
Passionate patient volunteers previously trained as hospital volunteers Simulation center with staff dedicated to coordinating activities, training, preparation, and technical management Multidisciplinary team involved in resident training program: physicians, nurses, mental health professionals, qualitative and quantitative researchers, and simulation experts MedEd Portal simulation scenarios Validated assessment tools ACGME milestones and literature providing rationale Multiple teams invested in communication success in system: patient relations/patient engagement departments, social work, palliative care, risk management, and administration
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collaboration and providing access to a variety of family and patient-focused scenarios. The scenarios aligned with each of our communication objectives and came with instructions for the standardized participant (SP), the instructor, “confederates,” and trainers. Validated tools are similarly available in the literature, which are appropriate to assess communication skills, self-perceived emotional traits, and behaviors associated with effective communications during “difficult” patient and family conversations.23-25 Finally, every hospital comprises departments specifically focused on enhancing the patient experience, such as patient relations and patient engagement, risk management, administration, social work, and palliative care. Professionals from these departments appreciate the opportunity to collaborate on patient-focused initiatives and have valuable training in communication, patient experience metrics, crisis management, and compassionate caring. Clinical colleagues from throughout the hospital are available as confederates during a team simulation exercise. Resources specific to our site enhanced our capacity to initiate the program without additional funding sources: (1) Our 640 m2 surgical simulation center provided space and materials for training scenarios, including a classroom, 2 operating rooms, and several recovery rooms; (2) simulation champions—professionals routinely involved in simulation work—offered guidance and feedback during role-plays and team simulations, and simulation center staff coordinated activities and provided technical management; and (3) our multidisciplinary team involved in the resident training program included staff from nursing, surgery and trauma, research, and mental health backgrounds. Among our most unique resources was the Trauma Survivors Network (TSN),26 established over 20 years as a program supporting and connecting patients, families, and providers affected by traumatic injury. TSN volunteers, themselves trauma survivors and family members, provide peer support in the hospital and community under the supervision of the TSN Coordinator, a mental health professional with trauma-specific expertise. TSN volunteers receive extensive training as hospital volunteers and as peer mentors; the TSN Coordinator provides ongoing support, counseling, and guidance throughout their work in the hospital. We chose to engage these volunteers as SPs in the communication curriculum, recognizing that their passion for patient-centered care, compassionate communication, and helping the “next generation” of patients receive the best care possible made them committed and engaged partners in the process.
including bad news delivery, medical error apology, team communication, postoperative education, crisis communication, facilitating patient self-care, and end-of-life discussions (Table 2). A longer “assessment day” was scheduled at the start of the 2-year curriculum to capture baseline data from new interns and update our skills assessment with returning residents. Each module included a short didactic classroom presentation, simulation-based skills training with SPs and confederate colleagues, and moderated debriefing sessions. In addition, a variety of assessment tools captured learners’ confidence levels, competence, content understanding, and appraisal of the module.
We designed a 2-year cycle for our curriculum, with 2 to 3 hours of dedicated classroom and practice time every quarter. Modules focused on patient-centered communication in a variety of settings addressing a variety of situations,
Assessment Day Before initiating our first training session, we sought to introduce the new curriculum and assess resident communication skill levels. We divided our 21 residents into 2 groups: one group met first with a Patient Experience Representative who reviewed the Hospital Consumer Assessment of Healthcare Providers and Systems, whereas the other group engaged in a simulation exercise with SPs. The Hospital Consumer Assessment of Healthcare Providers and Systems lecture included a handout detailing the most frequent complaint topics received by the hospital regarding provider communication, reframed as “positive behaviors” in practice (Appendix A). The groups then switched places to allow each resident access to both the practice and didactic information. The simulation exercise involved a 10-minute “bad news delivery” scenario chosen from MedEdPortal.org.25 One “learner” resident engaged a family member, played by our TSN SP, whereas a second resident observed and rated the “learner” resident based on a behavior checklist that had been included in the scenario download bundle. Residents in the observing role rotated into the physician “learner” role for second round of simulation. All simulation exercises were videotaped. Skill levels were assessed using 3 methods—by the SP, the observing resident, and a trained observer who watched the videotaped interactions. SPs used the Communication Assessment Tool (CAT) to provide their assessment of each resident’s communication proficiency during their roleplay,23 whereas the observing resident and trained observer used the behavior rating scale provided with the scenario.25 To enable each resident an opportunity to perform as “learners” and as “observers,” we arranged 6 concurrent scenarios to be run 4 times, following a rigid time schedule (Appendix B). Recognizing the intense emotional content of the scenario, we scheduled each of 8 SPs to have at least one break from the role-play activity during the session, and arranged to have food and drink for these volunteers. Staff members and faculty provided leadership as timekeepers and station managers, and each resident and SP wore a lanyard detailing their schedule and role for the exercise (Appendix C).
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Design and Implementation
TABLE 2. Curriculum Outline Module Assessment Day
Module 1: Effective communication basics
Module 2: Communicating in health care teams
Module 3: Educating the stressed and complex family Assessment Day Module 4: Communicating with the patient/ family in crisis Module 5: Helping patients understand their conditions and its management Module 6: Grief work: Communicating with the grieving family
Objectives Practice patient-centered communication Assess/debrief communication skills Assess peer communication skills Identify goals/means of communication
Scenario
Assessment Tools
Bad news delivery 4 days post-op
CAT: SPs, peers, and trained observers Confidence assessments Course evaluation Confidence assessment
Apology for retained sponge
Describe benefits of effective and costs of poor communication Practice managing patient's response to receiving bad news Outline process of apology and disclosure after a medical error or unanticipated outcome Outline importance of communication in the health care team leadership and collaboration Describe role of communication in team decision-making and situation assessment Demonstrate effective teamwork skills
Course evaluation
Trauma team training
Identify and manage conflict; demonstrate effective interdisciplinary communication Demonstrate professional behavior when interacting with the care team and patient Modules 3-6: In development Understand family perspective/barriers to selfPostoperative clinic care visit Recognize opportunities to facilitate healing Practice engaging patient/family with goal of adjustment to illness See Assessment 1 (repeat and reassessment with new scenario) Outline basic techniques for communicating Critical injury after with the patient/family in crisis MVC and resuscitation Identify situations when you should ask for help Describe compassion fatigue; develop plan for self-care Identify how teaching patients/families is Pulmonary emboli different from other educational environments Articulate challenges patients/families face in Complication hospital environment regarding understanding condition and its management Outline the psychological effect of terminal Transplant/end of illness on the family life Identify the range and type of grief Describe the physicians role in the adjustment to terminal diagnosis and loss
Confidence assessments Trauma team evaluation (T-NOTECHS) Emotional assessment tool (TEIQue) Course evaluation
Confidence assessments Course evaluation
Confidence assessments Course evaluation Confidence assessments Course evaluation Confidence assessments Course evaluation
MVC, motor vehicle crashes.
Module 1: Medical Error Disclosure The first training module focused on a surgical error disclosure and apology. Residents engaged in a 20-minute group discussion identifying empathetic, patient-centered communication behaviors, followed by a 20-minute didactic presentation from risk management on state apology laws and institutional policies. A 1-page summary of hospital disclosure/apology policies and recommendations was provided to resident learners (Appendix D), offering concrete guidance on steps to take during a disclosure and apology. Following this handout, chief residents began an interactive
scenario disclosing a retained sponge to a patient and her family member.27 During the 30-minute scenario, PGY-4 and PGY-3 residents were selected to rotate as communicators in the scenario to maximize participation. Logistical arrangements were simpler for this module. Two scenarios ran concurrently, each requiring a set of SPs —1 “patient” and 1 “family member.” We placed observing residents inside the simulation rooms rather than allowing them to watch the scenario from the video monitor in the lecture room, anticipating they would more closely experience the demands of an apology discussion while close to
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the physician and family system. As expected, this scenario was challenging for the residents who felt distinctly illprepared to manage the family’s response and their own reactions. Residents were not formally assessed on their performances; instead, an extensive debriefing discussion led by the Program Director enabled residents to process the experience, receive feedback from faculty and SPs, and provide feedback to the course developers regarding their learning experience.
Use of Trauma Survivors as SP Our TSN volunteers added a unique flavor to the curriculum. Several residents had been exposed to professional actor SPs from previous training, but none had worked with a team of former patients and family members trained as SPs. The trauma survivors easily drew from their personal experiences in their roles as distraught or confused patients and families, adding a sense of reality to the scenarios and raising the level of engagement of all involved. We were mindful, however, that such exercises could trigger posttraumatic stress responses in our former trauma patients, and took extra time after role-play scenarios to debrief the experience. TSN SPs had been chosen for their history of either personal for familial injury as well as their evidence of emotional recovery in their work with the TSN Coordinator; some had been TSN volunteers and mentors in the inpatient trauma setting for several years. Compared to professional SPs with experience portraying a variety of patient communication styles and responses, the TSN SPs required some extra preparation for their roles. Before the Assessment Day, we practiced the scenarios in 2 separate training sessions, with surgical faculty playing the roles of residents. Surgical faculty performed multiple runthroughs of the scenarios to simulate the range of potential resident communication styles. We provided specific training on the completion of the CAT, including specific examples of “poor,” “good,” and “excellent” assessments of physician communication. SPs indicated that they needed only a single practice for subsequent modules.
Module 2: Team Communication The focus of the second training module centered on team communication among health care providers; we selected a trauma code resuscitation of a highly animated patient following a motor vehicle collision.27 The module opened with a 30-minute lecture led by a trauma surgeon and an interactive discussion identifying positive and negative examples of nontechnical skills in trauma resuscitation.28 The scenario included simulation confederates (multidisciplinary team members) playing somewhat disruptive roles, which the PGY-4 learner (team leader) was required to manage. Two independent teams completed back-to-back scenarios to allow PGY-3 and 4 learners to lead 1 resuscitation simulation. A junior resident (PGY-2) learner was also assigned as a member of each team, along with a simulation facilitator (surgeon faculty) and simulation confederates: emergency medicine fellow, trauma nurse, anesthesia provider, student observer, trauma recorder, and SP patient voice. The patient voice was played by 2 emergency care providers with previous simulation experience: an emergency medical technician fire fighter and a critical care fellow. The simulation exercise concluded with a largegroup debriefing including residents, faculty, and confederates discussing their experiences and the influences on their behaviors during the scenario. During the lecture and interactive discussion, faculty emphasized how nontechnical communication behaviors have been associated with significant reduction in disposition time, an essential trauma quality indicator.29 Residents reflected on the legitimacy of this assertion during the debriefing, noting how maintaining order during the chaos of the resuscitation was critical to their coordinating timely care. For instance, several residents “lost” their anesthesiologist when they failed to insist on their continued presence in the trauma bay, a failure that resulted in poor outcomes when the patient needed to be intubated. Others artfully relocated an emergency department attending who had been blocking the junior resident’s attempts to insert a chest tube without antagonizing the clinician. This module required the important resources of a “trauma man” mannequin operated by the simulation center technicians and 2 teams of volunteer clinicians from throughout the hospital. Two “dry run” training simulations were arranged to ensure adequate preparation and to accommodate the many provider schedules.
Measuring Resident Skills and Capacity Resident communication skills are evaluated annually in a standardized scenario using the SP-CAT.23 The CAT consists of 14 physician-specific items written at a fourthgrade literacy level, and it has been field tested across numerous physician specialties, demonstrating high internal consistency, content, and construct validity for patient interactions.23 The ACGME Advisory Committee recommended the CAT for inclusion in the 2009 ACGME Toolbox.30 Assessment Day scenarios were also evaluated using a communication behavior checklist,25 completed by residents during live observations of their peers and by a trained observer during video review. The Trait Emotional Intelligence Questionnaire Short Form (TEIQue)24 was completed by all learners in module 2. The TEIQue was developed to assess trait emotional selfefficacy and is considered a more robust measurement than the early conceptions of emotional “intelligence.” Additional opportunities to assess resident skills were employed in other course modules, though they were not standardized for all residents (e.g., the Trauma NOTECHS assessment was used in module 2 for PGY-3 and PGY-4 resuscitation code leaders).28
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Assessment of Program
Course Assessment Course evaluations are provided by residents after each module. The learners report pre- and post-module confidence levels in specific skills based on the objectives of each module, as well as feedback on what worked well or how the module could be improved with an overall module grade and open-ended responses. In addition to written course assessments, we collect qualitative data on learners’ experience of the curriculum and their assessment of their own skill gaps and expertise. We present these “debriefing notes” to them in subsequent modules to remind them of their learning goals, and to guide the development of our materials each session (Table 3). Multidisciplinary debriefings with learners, SPs, and other simulation confederates occur after each module, providing additional valuable qualitative feedback.
RESULTS In reporting the results of our efforts to develop and implement a patient-centered communication curriculum for general surgery residents, we focus on the feedback we TABLE 3. Examples of Resident Debrief Responses What I feel competent doing Setting the stage Introducing myself Assessing the situation (medically) Nonverbal communication Making eye contact Sitting down/leaning forward Emotional communication Identifying emotions/empathy Knowing not to say “I know how you feel” Making a plan What I need more help with Getting the story Figuring out the relationship of family to patient Managing the flow of the conversation Dealing with chatty patient and family members Managing expectations Gentle extrications Dealing with angry patients Communicating content Being clear/frank (not equivocating) Discussing end-of-life decisions Plain speak about graphic or technical stuff Dealing with patients who “don't get it” Nonverbal signals (concluding sentences with confirming sounds) Challenging situations Dealing with the unknown stuff/unknowable Saying “I don't know” Sharing difficult information over the phone Team leadership Balancing providing direction with overmanagement Being assertive without being offensive Clarifying team members' roles in chaotic situation 6
received from the learners and partners in the exercises, the challenges and facilitators we encountered in the process, and the important lessons learned that may provide guidance to other institutions. Faculty and colleagues were committed partners in the exercises. Clinical staff brought students, fellows, and residents from their disciplines to participate, and other institutional residency programs have begun to mimic our curriculum and methods. Our residents’ active participation during presimulation discussion and especially postsimulation debriefing has been notable and lively; course feedback has been positive. Most learners commended the course and reported higher self-confidence in communication skills following each module (Table 4).31 The most significant challenge we encountered in our curriculum development and implementation was the coordination of the many team members’ schedules: faculty and staff were drawn from multiple disciplines from several departments in the hospital. In addition, we struggled to carve out dedicated resident lecture and practice time given the various competing clinical and educational interests in their schedules. Designing each module, including identifying and tailoring the scenario to our learning objectives, required significant time commitments for the developers who themselves had full schedules. Finally, choosing to use patient volunteers as SPs instead of paid actors meant additional coordination challenges due to the extra training and debriefing sessions. A number of facilitators, highlighted above as “resources,” eased the burden of implementation. Importantly, the enthusiasm of the TSN volunteers was energizing, infusing the team with a sense of purpose and increased motivation. Additionally, our simulation center professionals were excited about this unique use of the equipment and space, and provided significant resources in time and training expertise. Our curriculum development team included mental health professionals and social science researchers in addition to physicians, nurses, and simulation experts, enabling us to draw upon a variety of connections and relationships within the hospital. The readily available scenarios and assessment tools available online eased the burden of curriculum development, and the clear ACGME mandate to teach and evaluate communication skills provided a justification for us to mandate resident participation and carve out dedicated time in the residents’ classroom schedule. Finally, it was important to have a team of curriculum developers driving the design and implementation of the new modules and the surgical program director’s commitment to and focus on the success of the course. Ultimately, it was this commitment to the curriculum that enabled us to secure dedicated resident education time each quarter, with mandated attendance. Our TSN SPs were critical members of the team. Their presence as invested, articulate, and experienced patients brought a sense of meaning and dignity to the work. And finally, the participation of the range of professionals, Journal of Surgical Education Volume ]/Number ] ] 2016
TABLE 4. Learner Skills Confidence and Course Evaluations Pre-Module Mean (SD) or N (%)
Module Confidence in communication skills Average CAT skills rating (range: 1-5) Assessment Identify effective communication behaviors that enable Module 1 patients/families to feel understood Understand the psychological, sociological, institutional, Module 1 legal, and clinical issues involved in medical errors Demonstrate an approach to disclosure and apology for Module 1 medical errors Demonstrate good teamwork skills, both as a team leader Module 2 and as a team player Manage conflict and demonstrate effective Module 2 interdisciplinary communication Demonstrate the ability to act in a professional manner in Module 2 a setting of interpersonal conflict that poses a threat to the safety of the patient Agreement with the statement: “Communication skills can be learned Average agreement rating (range: 1-5) Assessment “Strongly Agree” Assessment Course grade A/Aþ Assessment A/Aþ Module 1 A/Aþ Module 2
1
Post-Module Mean (SD) or N (%)
4.27 (0.5) 4.10 (0.8)
4.55 (0.5) 4.43 (0.7)
0.020 0.005
3.43 (0.8)
3.95 (0.8)
o0.001
3.52 (0.81)
4.19 (0.8)
o0.001
3.81 (0.7)
4.10 (0.6)
0.030
3.71 (0.6)
4.05 (0.6)
0.031
4.00 (0.6)
4.10 (0.6)
0.58
and improved with practice” 1 4.50 (0.6) 4.71 (0.5) 1 10 (56%) 15 (71%) 1
Paired p Value*
— — —
19 (90%) 15 (79%) 20 (95%)
0.082 0.157 — — —
SD, standard deviation. *p Values derived from nonparametric paired Wilcoxon signed-rank tests.
especially attending physicians from a variety of medical specialties, appears to be heightening the awareness of these faculty, their students, and their colleagues to the central importance of effective patient-centered communication to the well-being of our patients and their families.
We developed and implemented a successful simulationbased curriculum in patient-centered communication skills for general surgery residents. Several important lessons learned in the implementation of this curriculum are notable: (1) designing and implementing a new curriculum is a challenging process with multiple barriers and complexities; (2) several facilitators are likely universal in any program, and, in our program in particular, ease the implementation process; (3) with the right approach, learners, faculty, and colleagues are dedicated and engaged participants, despite the additional time burden; (4) learners increasingly agree that communication skills can be improved with practice; (5) patient SPs can be valuable members of the team; and importantly (6) the culture of patient-physician communication appears to shift with the implementation of such a curriculum.
In response to identified opportunities to formalize instruction in patient-centered communication skills and to assess resident competency and learning needs in this area, we developed a communication curriculum for our general surgery residents. Our approach was interactive, using simulated encounters and facilitated discussion in a cooperative learning climate. Designing and implementing a new curriculum is a complex enterprise, requiring the coordination of myriad resources and schedules. Success of the curriculum could be attributed to several factors, including a strong commitment of leadership and curriculum developers, the enthusiastic engagement of patient volunteers as SPs, and a simulation center providing space, equipment, and staff. Most strong learners rated the course highly and reported higher self-confidence in important communication skills after each module. Their recognition of the importance of practicing these nontechnical skills, despite limited classroom time for all surgical skills, was reflected in these course evaluations and comments. Our unique resource, former patients, and family members actively involved in a peer support program in the hospital, added a sense of reality and dignity to the simulation exercises and energized the curriculum development team. However, our use of prior patients as SPs is not unique. Clever et al.32 compared volunteer outpatients
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DISCUSSION
(VOs) to trained SPs in medical students’ communication training in which students interviewed VOs to gather family and social histories. The study’s findings that students rated their learning experiences with VOs significantly higher than with SPs are consistent with the anecdotal evidence we received during simulation debriefing. In contrast to the VO study, however, our learners did not identify the TSN volunteers as comfortable or friendly, because of the emotionally charged simulations central to our training curriculum. Our curriculum is ongoing and our assessment of longitudinal learner skill development is pending. In a previous study, we demonstrated that SP-CAT ratings of resident communication skills were correlated with observed positive communication behaviors as well as residents’ selfefficacy in emotionality as measured by the TEIQue.33 Residents’ significant increase in self-confidence in communication skills in combination with their active engagement in the self-reflective debriefing exercises suggests increased patient-centered communication self-efficacy and proficiency.34 As described by Decker et al., the debriefing process is the most important component of simulationbased learning, and the skills of the debriefer are central to ensuring the best possible learning. Members of our debriefing team have extensive training in this area, with a focus on group identification of best practices.35 In our “team communication” module 2, in which 3 of the 4 residents expressing “complete” confidence in their “ability to act in a professional manner in a setting of interpersonal conflict that poses a threat to the safety of the patient” reduced their confidence postsession, we believe this reflects increased appreciation for the complexity of the communication tasks and interest in self-improvement. The enthusiastic engagement of the faculty and colleagues appears to affect the communication culture. Engaging a wide range of faculty as mentors and teachers of communication skills has been a reminder in their own practice of important techniques that elicit the patient perspective, communicate respect, and provide effective support and education. Based on resident feedback, early lessons learned, and continued interest in identifying successful communication training methods, we have recognized several improvements and updates to our approach. We have begun to (1) adapt our training plans to include repeated simulations to enable residents an increased sense of success; (2) tailor learner roles in simulations according to learning needs and competencies identified in early sessions; and (3) correlate selfconfidence and emotional assessment measures with inpatient and clinic patient assessments of resident communication skills. Plans continue for the remaining modules number 3 to 6, focusing on skills such as communicating postoperative care with a challenging family system and working with a grieving family. This second year of training would focus on tailoring the training to individual resident’s
unique learning needs as evidenced by our first year of assessments.
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CONCLUSION We describe a multiyear curriculum for surgical residents as we strive to meet surgery milestones from the ACGME. Our approach using patient volunteers as SPs is relatively unique in the literature and may be reproducible in other institutions. Faculty enthusiasm and support has been strong, and learner participation is active. We believe that continued focus on patient and family communication skills would enhance patient care at institutions providing such education as well as the institutions where residents practice in the future.
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views of physician communication skills: development and testing of the Communication Assessment Tool. Patient Educ Couns. 2007;67(3):333-342. 24. Petrides KV. Psychometric properties of the Trait
Emotional Intelligence Questionnaire. In: Stough C, Saklofske DH, Parker JD. Advances in the Assessment of Emotional Intelligence. New York: Springer, 2009. 25. Falcone J, Claxton R, Marshall G. The Sensitive
General Surgery Resident: Three “Difficult Conversation” Objective Structured Clinical Examinations. MedEdPORTAL Publications; 2013. Available from: 〈https://www.mededportal.org/publication/9490〉 〈http://dx.doi.org/10.15766/mep_2374-8265.9490〉.
26. Bradford AN, Castillo RC, Carlini AR, Wegener ST,
Teter H, Mackenzie EJ. The Trauma Survivors Network: survive. Connect. Rebuild. J Trauma. 2011;70 (6):1557-1560. 27. Scott DJ, Dunnington GL. The new ACS/APDS skills
curriculum: moving the learning curve out of the operating room. J Gastrointest Surg. 2008;12(2):213-221. 28. Steinemann S, Berg B, DiTullio A, et al. Assessing
teamwork in the trauma bay: introduction of modified “NOTECHS” scale for trauma. Am J Surg. 2012; 203(1):69-75. 29. Puncher PH, Aggarwal R, Batrick N, Jenkins M, Darzi
A. Nontechnical skills performance and care processes in the management of the acute trauma patient. Surgery. 2014;155(5):902-909. 30. Swing SR, Clyman SG, Holmboe ES, Williams RG.
Advancing resident assessment in graduate medical education. J Grad Med Educ. 2009;1(2):278-286. 31. Trickey AW, Newcomb AB, Wright J, et al. Patient-
Emotion and Response in Surgery (HEARS): a simulation-based curriculum for communication skills, systems-based practice, and professionalism in surgical residency training. J Am Coll Surg. 2010;211(2): 285-292.
Centered Communication for Surgical Residents: A Simulation-Based Curriculum. Paper presented at: 9th Annual American College of Surgeons Accredited Education Institutes Consortium Meeting; March 78, 2016; Chicago, IL. 32. Clever SL, Dudas RA, Solomon BS, et al. Medical student and faculty perceptions of volunteer outpatients versus simulated patients in communication skills training. Acad Med. 2011;86(11): 1437-1442.
21. Yedidia M, Gillespie CC, Kachur E, Schwartz MD,
33. Trickey AW, Newcomb AB, Porrey M, et al. Assess-
Ockene J, Chepaitis AE. Effect of communications
ment of surgery residents’ interpersonal communication
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19. Hotchberg MS, Kalet A, Zabar S, Kachur E, Gillespie
C, Berman RS. Can professionalism be taught? Encouraging evidence. Am J Surg. 2010;199(1):86-93. 20. Larkin AC, Cahan MA, Whalen G, et al. Human
skills: validation evidence for the Communication Assessment Tool in a simulation environment. J Surg Educ. 2016. http://dx.doi.org/10.1016/j.jsurg.2016.04.016. 34. Ammentorp J, Sabroe S, Kofoed PE, Mainz J. The
effect of training in communication skills on medical
doctors’ and nurses’ self-efficacy: a randomized controlled trial. Patient Educ Couns. 2007;66(3):270-277. 35. Decker S, Fey M, Sideras S, et al. Standards of best
practice: simulation standard VI: the debriefing process. Clin Simulation Nurs. 2013;9(6):S26-S29.
SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jsurg. 2016.09.009.
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Talk the Talk: Implementing a Communication Curriculum for Surgical Residents Anna B. Newcomb, PhD, MSW, LCSW,* Amber W. Trickey, PhD, MS, CPH,† Melissa Porrey, MA, NCC, LPC,* Jeffrey Wright, MPH,† Franco Piscitani, NRP,† Paula Graling, DNP, RN, CNOR, FAAN,† and Jonathan Dort, MD, FACS† *
Division of Trauma, Department of Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia; and Department of Surgery, Advanced Surgical Technology and Education Center, Inova Fairfax Medical Campus, Falls Church, Virginia †
OBJECTIVES: The Accreditation Council for Graduate Medical Education milestones provide a framework of specific interpersonal and communication skills that surgical trainees should aim to master. However, training and assessment of resident nontechnical skills remains challenging. We aimed to develop and implement a curriculum incorporating interactive learning principles such as group discussion and simulation-based scenarios to formalize instruction in patient-centered communication skills, and to identify best practices when building such a program. DESIGN: The curriculum is presented in quarterly modules
over a 2-year cycle. Using our surgical simulation center for the training, we focused on proven strategies for interacting with patients and other providers. We trained and used former patients as standardized participants (SPs) in communication scenarios. SETTING: Surgical simulation center in a 900-bed tertiary
care hospital. PARTICIPANTS: Program learners were general surgery residents (postgraduate year 1-5). Trauma Survivors Network volunteers served as SPs in simulation scenarios. RESULTS: We identified several important lessons: (1) designing and implementing a new curriculum is a challenging process with multiple barriers and complexities; (2) several readily available facilitators can ease the implementation process; (3) with the right approach, learners, faculty, and colleagues are enthusiastic and engaged participants; (4) learners increasingly agree that communication skills can be
Correspondence: Inquiries to Anna B. Newcomb, PhD, MSW, LCSW, Division of Trauma, Department of Surgery, Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA 22042; fax: (703) 776-2338; e-mail: [email protected], [email protected]
improved with practice and appreciate the curriculum value; (5) patient SPs can be valuable members of the team; and importantly (6) the culture of patient-physician communication appears to shift with the implementation of such a curriculum. CONCLUSIONS: Our approach using Trauma Survivors
Network volunteers as SPs could be reproduced in other institutions with similar programs. Faculty enthusiasm and support is strong, and learner participation is active. Continued focus on patient and family communication skills would enhance patient care for institutions providing such education as well as for institutions where residents continue on in fellowships or begin their surgical practice. ( J Surg Ed C ]:]]]-]]]. J 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: general surgery, residency, interpersonal and communication skills, curriculum implementation, resident educators COMPETENCIES: Interpersonal and Communication Skills,
Professionalism, Patient Care, Practice-Based Learning and Improvement
INTRODUCTION Communication skills are essential to providing patientcentered care that is customized and adapted to patients’ individual values, needs, and preferences.1 Clear and compassionate communication is critical in surgical practice where communication needs vary in complexity, from setting patient expectations and assessing adherence, to eliciting patient perspectives and concerns, managing family conflicts and patient counseling.2 Physician communication
Journal of Surgical Education & 2016 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.09.009
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proficiency is related to important outcomes such as treatment compliance, accurate information exchange, and patient experience.3-5 The Accreditation Council for Graduate Medical Education (ACGME) milestones specify that surgical trainees should develop interpersonal and communication skills in 3 practice domains—care for diseases and conditions, coordination of care, and performance of operations and procedures.6 Communication skill development has traditionally received relatively light emphasis in graduate medical education given the packed curriculum and assessment difficulties7,8; general surgery trainees often hone their “soft skills” at the bedside and through modeling of mentor attending surgeons.9-11 As approaches to identifying, measuring, and improving communication behavior have become well established in social science literature, surgical trainees have the opportunity to be familiarized with these contemporary skills and assessment methods.12-17 Simulation and role-play have advantages in surgical education including sharpening skills before speaking with patients, video-recording for learner assessment, and professionally mediated feedback during debriefing.18-21 As the need for a specific and thoroughly assessed communications curriculum became apparent at our institution, challenges of program development arose, such as finding protected educational time and resources for simulation, developing scenarios and training actors, and standardizing implementation and assessment techniques. The purpose of this report is to describe our experience designing and implementing a patient-centered communication curriculum for general surgery residents, and to offer guidance for training programs developing similar curricula in the future.
MATERIALS AND METHODS
Inova Fairfax Medical Campus is a level 1 trauma center, and a tertiary care referral center in all surgical specialties. Faculty are a hybrid of private practice and hospitalemployed surgeons. Until the introduction of ACGME milestones, our residency program faculty made assessments without uniform criteria as part of the standard service rotation evaluations. As with most surgical training programs, residents’ communication skills have only recently been formally assessed as part of the introduction of milestone evaluations. Approach After a needs assessment and gap analysis identified opportunities to formalize instruction in patient-centered communication skills, we developed a curriculum incorporating interactive learning principles such as group discussion and simulation-based scenarios. The course was designed to increase residents’ skills of compassionate, effective communication with patients and their family members using simulated encounters, facilitated discussion, and afteraction debriefing. Although brief lectures introduced the topics, we focused on developing a cooperative learning climate that actively engaged the learner.22 The curriculum is presented in quarterly modules over a 2-year cycle and involves a variety of disciplines providing subject matter expertise—social work, risk management, patient experience, palliative care, and social science researchers. We sought to expose trainees to proven strategies for interacting with patients and other providers, encourage residents to practice and sharpen communication skills, increase skills confidence, and develop residents’ competency in interpersonal and communication skills as well as systems-based practice.6
Setting
Resources
The Surgical Residency Program at Inova Fairfax Medical Campus was initially accredited for 2 residency positions in 2002 and has grown to the current complement of 5 residents per postgraduate year (PGY). The entire breadth of training is available to the residents at the campus, as
In our assessment of available resources to develop our curriculum, we noted several resources available to all (Table 1). Universally accessible resources include the MedEd Portal https://www.mededportal.org/, a free publication service promoting educational scholarship and
TABLE 1. Curriculum Development and Implementation Resources Resources Institution specific
Universal
2
Passionate patient volunteers previously trained as hospital volunteers Simulation center with staff dedicated to coordinating activities, training, preparation, and technical management Multidisciplinary team involved in resident training program: physicians, nurses, mental health professionals, qualitative and quantitative researchers, and simulation experts MedEd Portal simulation scenarios Validated assessment tools ACGME milestones and literature providing rationale Multiple teams invested in communication success in system: patient relations/patient engagement departments, social work, palliative care, risk management, and administration
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collaboration and providing access to a variety of family and patient-focused scenarios. The scenarios aligned with each of our communication objectives and came with instructions for the standardized participant (SP), the instructor, “confederates,” and trainers. Validated tools are similarly available in the literature, which are appropriate to assess communication skills, self-perceived emotional traits, and behaviors associated with effective communications during “difficult” patient and family conversations.23-25 Finally, every hospital comprises departments specifically focused on enhancing the patient experience, such as patient relations and patient engagement, risk management, administration, social work, and palliative care. Professionals from these departments appreciate the opportunity to collaborate on patient-focused initiatives and have valuable training in communication, patient experience metrics, crisis management, and compassionate caring. Clinical colleagues from throughout the hospital are available as confederates during a team simulation exercise. Resources specific to our site enhanced our capacity to initiate the program without additional funding sources: (1) Our 640 m2 surgical simulation center provided space and materials for training scenarios, including a classroom, 2 operating rooms, and several recovery rooms; (2) simulation champions—professionals routinely involved in simulation work—offered guidance and feedback during role-plays and team simulations, and simulation center staff coordinated activities and provided technical management; and (3) our multidisciplinary team involved in the resident training program included staff from nursing, surgery and trauma, research, and mental health backgrounds. Among our most unique resources was the Trauma Survivors Network (TSN),26 established over 20 years as a program supporting and connecting patients, families, and providers affected by traumatic injury. TSN volunteers, themselves trauma survivors and family members, provide peer support in the hospital and community under the supervision of the TSN Coordinator, a mental health professional with trauma-specific expertise. TSN volunteers receive extensive training as hospital volunteers and as peer mentors; the TSN Coordinator provides ongoing support, counseling, and guidance throughout their work in the hospital. We chose to engage these volunteers as SPs in the communication curriculum, recognizing that their passion for patient-centered care, compassionate communication, and helping the “next generation” of patients receive the best care possible made them committed and engaged partners in the process.
including bad news delivery, medical error apology, team communication, postoperative education, crisis communication, facilitating patient self-care, and end-of-life discussions (Table 2). A longer “assessment day” was scheduled at the start of the 2-year curriculum to capture baseline data from new interns and update our skills assessment with returning residents. Each module included a short didactic classroom presentation, simulation-based skills training with SPs and confederate colleagues, and moderated debriefing sessions. In addition, a variety of assessment tools captured learners’ confidence levels, competence, content understanding, and appraisal of the module.
We designed a 2-year cycle for our curriculum, with 2 to 3 hours of dedicated classroom and practice time every quarter. Modules focused on patient-centered communication in a variety of settings addressing a variety of situations,
Assessment Day Before initiating our first training session, we sought to introduce the new curriculum and assess resident communication skill levels. We divided our 21 residents into 2 groups: one group met first with a Patient Experience Representative who reviewed the Hospital Consumer Assessment of Healthcare Providers and Systems, whereas the other group engaged in a simulation exercise with SPs. The Hospital Consumer Assessment of Healthcare Providers and Systems lecture included a handout detailing the most frequent complaint topics received by the hospital regarding provider communication, reframed as “positive behaviors” in practice (Appendix A). The groups then switched places to allow each resident access to both the practice and didactic information. The simulation exercise involved a 10-minute “bad news delivery” scenario chosen from MedEdPortal.org.25 One “learner” resident engaged a family member, played by our TSN SP, whereas a second resident observed and rated the “learner” resident based on a behavior checklist that had been included in the scenario download bundle. Residents in the observing role rotated into the physician “learner” role for second round of simulation. All simulation exercises were videotaped. Skill levels were assessed using 3 methods—by the SP, the observing resident, and a trained observer who watched the videotaped interactions. SPs used the Communication Assessment Tool (CAT) to provide their assessment of each resident’s communication proficiency during their roleplay,23 whereas the observing resident and trained observer used the behavior rating scale provided with the scenario.25 To enable each resident an opportunity to perform as “learners” and as “observers,” we arranged 6 concurrent scenarios to be run 4 times, following a rigid time schedule (Appendix B). Recognizing the intense emotional content of the scenario, we scheduled each of 8 SPs to have at least one break from the role-play activity during the session, and arranged to have food and drink for these volunteers. Staff members and faculty provided leadership as timekeepers and station managers, and each resident and SP wore a lanyard detailing their schedule and role for the exercise (Appendix C).
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Design and Implementation
TABLE 2. Curriculum Outline Module Assessment Day
Module 1: Effective communication basics
Module 2: Communicating in health care teams
Module 3: Educating the stressed and complex family Assessment Day Module 4: Communicating with the patient/ family in crisis Module 5: Helping patients understand their conditions and its management Module 6: Grief work: Communicating with the grieving family
Objectives Practice patient-centered communication Assess/debrief communication skills Assess peer communication skills Identify goals/means of communication
Scenario
Assessment Tools
Bad news delivery 4 days post-op
CAT: SPs, peers, and trained observers Confidence assessments Course evaluation Confidence assessment
Apology for retained sponge
Describe benefits of effective and costs of poor communication Practice managing patient's response to receiving bad news Outline process of apology and disclosure after a medical error or unanticipated outcome Outline importance of communication in the health care team leadership and collaboration Describe role of communication in team decision-making and situation assessment Demonstrate effective teamwork skills
Course evaluation
Trauma team training
Identify and manage conflict; demonstrate effective interdisciplinary communication Demonstrate professional behavior when interacting with the care team and patient Modules 3-6: In development Understand family perspective/barriers to selfPostoperative clinic care visit Recognize opportunities to facilitate healing Practice engaging patient/family with goal of adjustment to illness See Assessment 1 (repeat and reassessment with new scenario) Outline basic techniques for communicating Critical injury after with the patient/family in crisis MVC and resuscitation Identify situations when you should ask for help Describe compassion fatigue; develop plan for self-care Identify how teaching patients/families is Pulmonary emboli different from other educational environments Articulate challenges patients/families face in Complication hospital environment regarding understanding condition and its management Outline the psychological effect of terminal Transplant/end of illness on the family life Identify the range and type of grief Describe the physicians role in the adjustment to terminal diagnosis and loss
Confidence assessments Trauma team evaluation (T-NOTECHS) Emotional assessment tool (TEIQue) Course evaluation
Confidence assessments Course evaluation
Confidence assessments Course evaluation Confidence assessments Course evaluation Confidence assessments Course evaluation
MVC, motor vehicle crashes.
Module 1: Medical Error Disclosure The first training module focused on a surgical error disclosure and apology. Residents engaged in a 20-minute group discussion identifying empathetic, patient-centered communication behaviors, followed by a 20-minute didactic presentation from risk management on state apology laws and institutional policies. A 1-page summary of hospital disclosure/apology policies and recommendations was provided to resident learners (Appendix D), offering concrete guidance on steps to take during a disclosure and apology. Following this handout, chief residents began an interactive
scenario disclosing a retained sponge to a patient and her family member.27 During the 30-minute scenario, PGY-4 and PGY-3 residents were selected to rotate as communicators in the scenario to maximize participation. Logistical arrangements were simpler for this module. Two scenarios ran concurrently, each requiring a set of SPs —1 “patient” and 1 “family member.” We placed observing residents inside the simulation rooms rather than allowing them to watch the scenario from the video monitor in the lecture room, anticipating they would more closely experience the demands of an apology discussion while close to
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the physician and family system. As expected, this scenario was challenging for the residents who felt distinctly illprepared to manage the family’s response and their own reactions. Residents were not formally assessed on their performances; instead, an extensive debriefing discussion led by the Program Director enabled residents to process the experience, receive feedback from faculty and SPs, and provide feedback to the course developers regarding their learning experience.
Use of Trauma Survivors as SP Our TSN volunteers added a unique flavor to the curriculum. Several residents had been exposed to professional actor SPs from previous training, but none had worked with a team of former patients and family members trained as SPs. The trauma survivors easily drew from their personal experiences in their roles as distraught or confused patients and families, adding a sense of reality to the scenarios and raising the level of engagement of all involved. We were mindful, however, that such exercises could trigger posttraumatic stress responses in our former trauma patients, and took extra time after role-play scenarios to debrief the experience. TSN SPs had been chosen for their history of either personal for familial injury as well as their evidence of emotional recovery in their work with the TSN Coordinator; some had been TSN volunteers and mentors in the inpatient trauma setting for several years. Compared to professional SPs with experience portraying a variety of patient communication styles and responses, the TSN SPs required some extra preparation for their roles. Before the Assessment Day, we practiced the scenarios in 2 separate training sessions, with surgical faculty playing the roles of residents. Surgical faculty performed multiple runthroughs of the scenarios to simulate the range of potential resident communication styles. We provided specific training on the completion of the CAT, including specific examples of “poor,” “good,” and “excellent” assessments of physician communication. SPs indicated that they needed only a single practice for subsequent modules.
Module 2: Team Communication The focus of the second training module centered on team communication among health care providers; we selected a trauma code resuscitation of a highly animated patient following a motor vehicle collision.27 The module opened with a 30-minute lecture led by a trauma surgeon and an interactive discussion identifying positive and negative examples of nontechnical skills in trauma resuscitation.28 The scenario included simulation confederates (multidisciplinary team members) playing somewhat disruptive roles, which the PGY-4 learner (team leader) was required to manage. Two independent teams completed back-to-back scenarios to allow PGY-3 and 4 learners to lead 1 resuscitation simulation. A junior resident (PGY-2) learner was also assigned as a member of each team, along with a simulation facilitator (surgeon faculty) and simulation confederates: emergency medicine fellow, trauma nurse, anesthesia provider, student observer, trauma recorder, and SP patient voice. The patient voice was played by 2 emergency care providers with previous simulation experience: an emergency medical technician fire fighter and a critical care fellow. The simulation exercise concluded with a largegroup debriefing including residents, faculty, and confederates discussing their experiences and the influences on their behaviors during the scenario. During the lecture and interactive discussion, faculty emphasized how nontechnical communication behaviors have been associated with significant reduction in disposition time, an essential trauma quality indicator.29 Residents reflected on the legitimacy of this assertion during the debriefing, noting how maintaining order during the chaos of the resuscitation was critical to their coordinating timely care. For instance, several residents “lost” their anesthesiologist when they failed to insist on their continued presence in the trauma bay, a failure that resulted in poor outcomes when the patient needed to be intubated. Others artfully relocated an emergency department attending who had been blocking the junior resident’s attempts to insert a chest tube without antagonizing the clinician. This module required the important resources of a “trauma man” mannequin operated by the simulation center technicians and 2 teams of volunteer clinicians from throughout the hospital. Two “dry run” training simulations were arranged to ensure adequate preparation and to accommodate the many provider schedules.
Measuring Resident Skills and Capacity Resident communication skills are evaluated annually in a standardized scenario using the SP-CAT.23 The CAT consists of 14 physician-specific items written at a fourthgrade literacy level, and it has been field tested across numerous physician specialties, demonstrating high internal consistency, content, and construct validity for patient interactions.23 The ACGME Advisory Committee recommended the CAT for inclusion in the 2009 ACGME Toolbox.30 Assessment Day scenarios were also evaluated using a communication behavior checklist,25 completed by residents during live observations of their peers and by a trained observer during video review. The Trait Emotional Intelligence Questionnaire Short Form (TEIQue)24 was completed by all learners in module 2. The TEIQue was developed to assess trait emotional selfefficacy and is considered a more robust measurement than the early conceptions of emotional “intelligence.” Additional opportunities to assess resident skills were employed in other course modules, though they were not standardized for all residents (e.g., the Trauma NOTECHS assessment was used in module 2 for PGY-3 and PGY-4 resuscitation code leaders).28
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Assessment of Program
Course Assessment Course evaluations are provided by residents after each module. The learners report pre- and post-module confidence levels in specific skills based on the objectives of each module, as well as feedback on what worked well or how the module could be improved with an overall module grade and open-ended responses. In addition to written course assessments, we collect qualitative data on learners’ experience of the curriculum and their assessment of their own skill gaps and expertise. We present these “debriefing notes” to them in subsequent modules to remind them of their learning goals, and to guide the development of our materials each session (Table 3). Multidisciplinary debriefings with learners, SPs, and other simulation confederates occur after each module, providing additional valuable qualitative feedback.
RESULTS In reporting the results of our efforts to develop and implement a patient-centered communication curriculum for general surgery residents, we focus on the feedback we TABLE 3. Examples of Resident Debrief Responses What I feel competent doing Setting the stage Introducing myself Assessing the situation (medically) Nonverbal communication Making eye contact Sitting down/leaning forward Emotional communication Identifying emotions/empathy Knowing not to say “I know how you feel” Making a plan What I need more help with Getting the story Figuring out the relationship of family to patient Managing the flow of the conversation Dealing with chatty patient and family members Managing expectations Gentle extrications Dealing with angry patients Communicating content Being clear/frank (not equivocating) Discussing end-of-life decisions Plain speak about graphic or technical stuff Dealing with patients who “don't get it” Nonverbal signals (concluding sentences with confirming sounds) Challenging situations Dealing with the unknown stuff/unknowable Saying “I don't know” Sharing difficult information over the phone Team leadership Balancing providing direction with overmanagement Being assertive without being offensive Clarifying team members' roles in chaotic situation 6
received from the learners and partners in the exercises, the challenges and facilitators we encountered in the process, and the important lessons learned that may provide guidance to other institutions. Faculty and colleagues were committed partners in the exercises. Clinical staff brought students, fellows, and residents from their disciplines to participate, and other institutional residency programs have begun to mimic our curriculum and methods. Our residents’ active participation during presimulation discussion and especially postsimulation debriefing has been notable and lively; course feedback has been positive. Most learners commended the course and reported higher self-confidence in communication skills following each module (Table 4).31 The most significant challenge we encountered in our curriculum development and implementation was the coordination of the many team members’ schedules: faculty and staff were drawn from multiple disciplines from several departments in the hospital. In addition, we struggled to carve out dedicated resident lecture and practice time given the various competing clinical and educational interests in their schedules. Designing each module, including identifying and tailoring the scenario to our learning objectives, required significant time commitments for the developers who themselves had full schedules. Finally, choosing to use patient volunteers as SPs instead of paid actors meant additional coordination challenges due to the extra training and debriefing sessions. A number of facilitators, highlighted above as “resources,” eased the burden of implementation. Importantly, the enthusiasm of the TSN volunteers was energizing, infusing the team with a sense of purpose and increased motivation. Additionally, our simulation center professionals were excited about this unique use of the equipment and space, and provided significant resources in time and training expertise. Our curriculum development team included mental health professionals and social science researchers in addition to physicians, nurses, and simulation experts, enabling us to draw upon a variety of connections and relationships within the hospital. The readily available scenarios and assessment tools available online eased the burden of curriculum development, and the clear ACGME mandate to teach and evaluate communication skills provided a justification for us to mandate resident participation and carve out dedicated time in the residents’ classroom schedule. Finally, it was important to have a team of curriculum developers driving the design and implementation of the new modules and the surgical program director’s commitment to and focus on the success of the course. Ultimately, it was this commitment to the curriculum that enabled us to secure dedicated resident education time each quarter, with mandated attendance. Our TSN SPs were critical members of the team. Their presence as invested, articulate, and experienced patients brought a sense of meaning and dignity to the work. And finally, the participation of the range of professionals, Journal of Surgical Education Volume ]/Number ] ] 2016
TABLE 4. Learner Skills Confidence and Course Evaluations Pre-Module Mean (SD) or N (%)
Module Confidence in communication skills Average CAT skills rating (range: 1-5) Assessment Identify effective communication behaviors that enable Module 1 patients/families to feel understood Understand the psychological, sociological, institutional, Module 1 legal, and clinical issues involved in medical errors Demonstrate an approach to disclosure and apology for Module 1 medical errors Demonstrate good teamwork skills, both as a team leader Module 2 and as a team player Manage conflict and demonstrate effective Module 2 interdisciplinary communication Demonstrate the ability to act in a professional manner in Module 2 a setting of interpersonal conflict that poses a threat to the safety of the patient Agreement with the statement: “Communication skills can be learned Average agreement rating (range: 1-5) Assessment “Strongly Agree” Assessment Course grade A/Aþ Assessment A/Aþ Module 1 A/Aþ Module 2
1
Post-Module Mean (SD) or N (%)
4.27 (0.5) 4.10 (0.8)
4.55 (0.5) 4.43 (0.7)
0.020 0.005
3.43 (0.8)
3.95 (0.8)
o0.001
3.52 (0.81)
4.19 (0.8)
o0.001
3.81 (0.7)
4.10 (0.6)
0.030
3.71 (0.6)
4.05 (0.6)
0.031
4.00 (0.6)
4.10 (0.6)
0.58
and improved with practice” 1 4.50 (0.6) 4.71 (0.5) 1 10 (56%) 15 (71%) 1
Paired p Value*
— — —
19 (90%) 15 (79%) 20 (95%)
0.082 0.157 — — —
SD, standard deviation. *p Values derived from nonparametric paired Wilcoxon signed-rank tests.
especially attending physicians from a variety of medical specialties, appears to be heightening the awareness of these faculty, their students, and their colleagues to the central importance of effective patient-centered communication to the well-being of our patients and their families.
We developed and implemented a successful simulationbased curriculum in patient-centered communication skills for general surgery residents. Several important lessons learned in the implementation of this curriculum are notable: (1) designing and implementing a new curriculum is a challenging process with multiple barriers and complexities; (2) several facilitators are likely universal in any program, and, in our program in particular, ease the implementation process; (3) with the right approach, learners, faculty, and colleagues are dedicated and engaged participants, despite the additional time burden; (4) learners increasingly agree that communication skills can be improved with practice; (5) patient SPs can be valuable members of the team; and importantly (6) the culture of patient-physician communication appears to shift with the implementation of such a curriculum.
In response to identified opportunities to formalize instruction in patient-centered communication skills and to assess resident competency and learning needs in this area, we developed a communication curriculum for our general surgery residents. Our approach was interactive, using simulated encounters and facilitated discussion in a cooperative learning climate. Designing and implementing a new curriculum is a complex enterprise, requiring the coordination of myriad resources and schedules. Success of the curriculum could be attributed to several factors, including a strong commitment of leadership and curriculum developers, the enthusiastic engagement of patient volunteers as SPs, and a simulation center providing space, equipment, and staff. Most strong learners rated the course highly and reported higher self-confidence in important communication skills after each module. Their recognition of the importance of practicing these nontechnical skills, despite limited classroom time for all surgical skills, was reflected in these course evaluations and comments. Our unique resource, former patients, and family members actively involved in a peer support program in the hospital, added a sense of reality and dignity to the simulation exercises and energized the curriculum development team. However, our use of prior patients as SPs is not unique. Clever et al.32 compared volunteer outpatients
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DISCUSSION
(VOs) to trained SPs in medical students’ communication training in which students interviewed VOs to gather family and social histories. The study’s findings that students rated their learning experiences with VOs significantly higher than with SPs are consistent with the anecdotal evidence we received during simulation debriefing. In contrast to the VO study, however, our learners did not identify the TSN volunteers as comfortable or friendly, because of the emotionally charged simulations central to our training curriculum. Our curriculum is ongoing and our assessment of longitudinal learner skill development is pending. In a previous study, we demonstrated that SP-CAT ratings of resident communication skills were correlated with observed positive communication behaviors as well as residents’ selfefficacy in emotionality as measured by the TEIQue.33 Residents’ significant increase in self-confidence in communication skills in combination with their active engagement in the self-reflective debriefing exercises suggests increased patient-centered communication self-efficacy and proficiency.34 As described by Decker et al., the debriefing process is the most important component of simulationbased learning, and the skills of the debriefer are central to ensuring the best possible learning. Members of our debriefing team have extensive training in this area, with a focus on group identification of best practices.35 In our “team communication” module 2, in which 3 of the 4 residents expressing “complete” confidence in their “ability to act in a professional manner in a setting of interpersonal conflict that poses a threat to the safety of the patient” reduced their confidence postsession, we believe this reflects increased appreciation for the complexity of the communication tasks and interest in self-improvement. The enthusiastic engagement of the faculty and colleagues appears to affect the communication culture. Engaging a wide range of faculty as mentors and teachers of communication skills has been a reminder in their own practice of important techniques that elicit the patient perspective, communicate respect, and provide effective support and education. Based on resident feedback, early lessons learned, and continued interest in identifying successful communication training methods, we have recognized several improvements and updates to our approach. We have begun to (1) adapt our training plans to include repeated simulations to enable residents an increased sense of success; (2) tailor learner roles in simulations according to learning needs and competencies identified in early sessions; and (3) correlate selfconfidence and emotional assessment measures with inpatient and clinic patient assessments of resident communication skills. Plans continue for the remaining modules number 3 to 6, focusing on skills such as communicating postoperative care with a challenging family system and working with a grieving family. This second year of training would focus on tailoring the training to individual resident’s
unique learning needs as evidenced by our first year of assessments.
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CONCLUSION We describe a multiyear curriculum for surgical residents as we strive to meet surgery milestones from the ACGME. Our approach using patient volunteers as SPs is relatively unique in the literature and may be reproducible in other institutions. Faculty enthusiasm and support has been strong, and learner participation is active. We believe that continued focus on patient and family communication skills would enhance patient care at institutions providing such education as well as the institutions where residents practice in the future.
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SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jsurg. 2016.09.009.
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