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Original Article |
Department of Surgery, Brown Medical School, Rhode Island Hospital, APC Room 437, 593 Eddy Street, Providence, Rhode Island 02903, USA
Correspondence: Address correspondence and reprint requests to: Thomas J. Miner, MD; E-mail: tminer{at}usasurg.org
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ABSTRACT |
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Methods: A pilot curriculum in palliative surgical care designed for residents was presented in three 1-hour sessions. Sessions included group discussion, role-playing exercises, and instruction in advanced clinical decision making. Residents completed pretest, posttest, and 3-month follow-up surveys designed to measure the program’s success.
Results: Forty-seven general surgery residents from Brown University participated. Most residents (94%) had "discussed palliative care with a patient or patient’s family" in the past. Initially, 57% of residents felt "comfortable speaking to patients and patients’ families about end-of-life issues," whereas at posttest and at 3-month intervals, 80% and 84%, respectively, felt comfortable (P < .01). Few residents at pretest (9%) thought that they had "received adequate training in palliation during residency," but at posttest and at 3-month follow-up, 86% and 84% of residents agreed with this statement (P < .01). All residents believed that "managing end-of-life issues is a valuable skill for surgeons." Ninety-two percent of residents at 3-month follow-up "had been able to use the information learned in clinical practice."
Conclusions: With a reasonable time commitment, surgical residents are capable of learning about palliative and end-of-life care. Surgical residents think that understanding palliative care is a useful part of their training, a sentiment that is still evident 3 months later.
Key Words: Palliation • Surgical education • End-of-life care • Palliative care
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INTRODUCTION |
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The surgical community has been placing increased emphasis on improved education in the field of palliative care. In 1998 the American College of Surgeons (ACS) made palliation and end-of life care a priority with their Principles Guiding End of Life Care.4 This was followed by the creation of the ACS Palliative Care Task Force, whose goals included investigating the current state of palliative care in surgery, disseminating information about palliation and end-of-life care, and fostering educational opportunities for students, residents, and surgeons in the community. Members of the task force participated in a symposium on palliative care at the 2003 ACS Clinical Congress, stressing the need for improved education among surgeons at all levels of training.5 The American Board of Surgery (ABS) specifically mentions palliation in its definition of the specialty of general surgery. Along with the expectation that a general surgeon will be able to manage an airway and perform basic laparoscopic surgery, is an expectation that he or she will have a working knowledge of palliative care and end-of-life issues.6 Lacking from the online literature of the ABS, ACS, and even the Association of Surgical Educators is a specific curriculum for teaching palliative and end-of-life care to surgical residents.7
As the mandate to provide effective palliative care is increasingly realized on a national and societal level, the need to develop efficient and effective ways of teaching surgical house officers these important skills becomes greater. Recognizing the existing deficiency, we designed a curriculum to teach surgical residents about palliative care and end-of-life issues. Our pilot project attempts to answer three questions: (1) Are palliative and end-of-life care important topics for surgical residents? (2) Do surgical residents think that they are adequately trained to confront these issues? (3) Is it possible to teach surgical residents about palliative and end-of-life care in a way that they would find meaningful and immediately useful?
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METHODS |
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Once a week for 3 weeks, residents were asked to attend 1-hour sessions in place of a routinely scheduled basic science conference. Surgeons carefully designed the course specifically for surgical residents, combining hands-on role-playing exercises with review of the most current palliative care literature. A fellowship-trained surgical oncologist with experience and special training in palliative and end-of-life care moderated sessions and facilitated discussion (Table 1
). Sessions focused on defining palliation and end-of-life terms by using didactics, literature reviews, and group discussion.1,3,8–10 Group discussions continued onto topics such as barriers to conducting good palliation research and the expectations of surgeons, patients, and patient families during end-of-life care.11–13 Role-playing exercises allowed residents to work through difficult palliative care scenarios with constructive feedback offered by staff and residents alike. Strategies for improving surgeon-patient interactions, including the CLASS and SPIKES methods for breaking bad news to patients at times of need, were introduced.14 Discussions on outcomes data and complications of palliative procedures were followed by dialogue on the concepts of "overall survival" versus "quality of life."
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Statistical analysis was performed by analysis of variance, Wilcoxon test, and paired t-test as appropriate. A P value of < .05 was considered statistically significant.
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RESULTS |
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).
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Three questions focused on adequacy of and need for surgical training in palliative and end-of-life care. Initially, only three residents (9%) agreed that they had "received adequate training in residency about palliative care and end-of-life issues." A statistically significant difference (P < .001) was found at post-test and at 3-month follow-up, with 25 (58%) and 32 (74%) residents, respectively, agreeing that they had received adequate residency training in palliative and end-of-life care. All 34 residents thought that "managing palliative care and end-of-life issues is a valuable skill for general surgeons" at pretest evaluation, whereas 42 residents (98%) at posttest and 41 residents (95%) at 3-month survey agreed with the statement. Thirty-two residents (97%) at pretest survey agreed that "all surgical training programs should include a course on palliation and end-of-life issues," whereas 41 residents (95%) at both posttest and 3-month follow-up agreed that training programs should teach palliative and end-of-life care.
The next three questions tested the resident’s situational comfort with certain palliative and end-of-life care issues. Initially, 31 residents (91%) agreed that they "had been in clinical situations where [they were] expected to discuss palliative care and/or end-of-life issues with a patient or patient’s family." Similar results were found at posttest and at 3-month follow-up: 42 residents (98%) and 38 residents (88%), respectively, agreed with the statement. At pretest, 20 residents (59%) agreed that they "[felt] comfortable speaking to patients and patients’ families about end-of-life and palliative care issues," but at posttest and at 3-month review, a statistically different (P < .001) 35 (81%) and 36 (84%) residents could say that they felt comfortable discussing palliative and end-of-life issues with patients and their families. When asked whether residents "felt comfortable breaking bad news to patients and/or patients’ families," 25 residents (74%) initially agreed, at posttest 35 (81%) agreed, and at 3-month follow-up 34 residents (79%) agreed. Male residents felt more comfortable initially than female residents breaking bad news to patients and their families (P = .023), but no differences were noticed by posttest and 3-month follow-up.
Feedback questions were included to measure resident responses to the curriculum. When asked on the posttest survey, 31 residents (72%) had "read the articles and prepared for these sessions." One PGY-2 participant commented that "the articles were very helpful and the first session was a good open forum which we needed." Thirty-three residents (77%) had "been able to use the information learned in actual clinical practice" by 3-month follow-up survey. A PGY-1 participant commented that "this symposium helped a lot ... it should be part of the yearly curriculum." Thirty-four residents (79%) at posttest review and 32 residents (77%) at 3-month follow-up agreed that "the role playing was an important and useful part of the curriculum." A PGY-2 participant commented that "the best part was the role playing. Hopefully, I can use some of these tips with my patient contact." A PGY-4 resident reflected that "role playing is key in teaching residents how to break bad news and interact with families. The role playing was great." At posttest and at 3-month follow-up, 39 residents (91%) and 34 residents (79%), respectively, thought that "the group discussions were useful and an important part of the curriculum." One resident (2%) at posttest review and three residents (7%) at 3-month follow-up thought that "these sessions have been a waste of time."
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DISCUSSION |
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We wanted to know whether surgical residents thought that they needed training in palliative and end-of-life care. Before the course began, almost all residents agreed that they "had been in clinical situations where they were expected to discuss palliative and/or end-of-life care with a patient or patient’s family" (pretest, 91% agree); however, little more than half felt "comfortable speaking with patients about end-of-life care" (pretest, 59% agree). Residents universally thought that they had not "received adequate training during residency" before the course (pretest, 9% agree). We conclude that residents are clearly involved in managing patients during the dying process, but are not trained well enough to feel comfortable in that role.
Second, we wanted to know whether residents considered palliative and end-of-life care important subjects for surgeons to be familiar with. Almost all of the residents thought that "managing palliative and end-of-life care is an important skill for a general surgeon" (pretest, 100% agree; posttest, 98%; 3 months, 98%). Similar responses arose when asked whether "surgical training programs should include a course on palliative and end-of-life care" (pretest, 100% agree; posttest, 100%; 3 months, 98%). Clearly residents realize the importance of being able to manage patient care at the end of life.
Finally, we wanted to show that it is possible to teach surgical residents about palliative and end-of-life care in a way that they would find meaningful and useful. Only a minority of residents thought that "these sessions have been a waste of time" (posttest, 3% agree; 3 months, 7%). In addition, 3 hours’ training in end-of-life care was enough for residents to think that they now had "received adequate training during residency" (pretest, 9% vs. posttest, 58%; P < .001). More importantly, at 3-month follow-up, most of the residents had been "able to use the information learned in actual clinical practice" (3 months, 77%). Residents found this curriculum clinically relevant and immediately applicable. Residents seemed to appreciate learning about strategies for dealing with end-of-life situations, and then having the opportunity to practice these strategies during role-playing exercises. Resident comments from the final survey were positive and suggested that this was a constructive part of their learning.
With the introduction of new faculty in the past few years who have stressed palliative and end-of-life care, residents in the Brown University program have been exposed to these issues more than in past years. This may explain why three-quarters of the residents felt comfortable breaking bad news, and most residents (59%) felt comfortable speaking to patients and their families about palliative and end-of-life care before the program even began. This may not be the case for other surgical training programs where faculty may not be as facile with these issues.
This program is not intended to replace the ideal of learning from actual experience. A PGY-2 participant noticed that "these sessions are not a substitute for on the job training. Meaning, we need to be able to watch our attendings give bad news and discuss palliation options, as well as get feedback from our attendings and chiefs when we are not doing well with patient interactions." Because work-hour restrictions lead to fewer on-the-job training opportunities, creative ways of teaching palliative and end-of-life care become necessary. The ideal of trainees watching experienced master surgeons interact with patients and their families is supplemented by lectures and coursework.
Despite the positive feedback from residents, the weekly reminders from staff and senior residents, and the mandatory nature of the course, attendance was not perfect. Forty-seven of the 50 residents in our program attended at least one of the three sessions; however, little more than one-third of residents attended all 3 hours of the curriculum. The unpredictability of surgical training makes scheduling any in-hospital learning session difficult. The importance of this topic and the positive resident response has inspired the creation of a humanities curriculum as part of the standard teaching in the Brown University Surgery program. This program is designed to continue humanities learning for residents as they move through their surgical training. Other surgical training programs will, we hope, also benefit from this experience.
Fluency with end-of-life and palliative care are important aspects of surgical resident education, which are not stressed during standard residency training. It is possible to instruct surgical residents in end-of-life and palliative care in an efficient and positive manner with lasting effects. With a focused, well-planned approach, we were able to accomplish our goals. By creating a curriculum based on current literature with an emphasis on active participation, we were able to effectively teach end-of-life and palliative care in a way that was useful and immediately applicable for surgical residents. If made available to surgical training programs on a national level, a curriculum such as this would satisfy the national mandate for training in palliative and end-of-life care.
Received for publication October 28, 2005. Accepted for publication December 1, 2006.
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This article has been cited by other articles:
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  C. T. Bradley and K. J. Brasel Core Competencies in Palliative Care for Surgeons: Interpersonal and Communication Skills American Journal of Hospice and Palliative Medicine, January 1, 2008; 24(6): 499 - 507. [Abstract] [PDF]
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