Curriculum Innovations: Enhancing Skills in Serious Illness Communication in Neurology Residents Using Simulation: A Pilot Study.

Abstract

Patients with acute ischemic stroke are faced with prognostic uncertainty, progressive decline, and early mortality. Many neurologists report a lack of education and experience in providing palliative care. We developed a simulation-based curriculum to improve residents' confidence and comfort with conducting late-stage goals of care (GOC) conversations. To assess and improve neurology residents' self-reported confidence and comfort around GOC discussions, prognostication, and hospice; encourage neurology residents to conduct GOC conversations early in the illness; introduce neurology residents to a structured framework for conducting GOC conversations; facilitate the residents to build rapport and convey a mindful presence during GOC conversations; provide direct, real-time feedback and an opportunity for redo and practice; and identify gaps for education. The 3-hour experience included a didactic session followed by an interactive simulation and debriefing. The residents' objectives were to deliver difficult news, discuss prognosis, explore goals, navigate treatment options, and discuss end-of-life care including hospice. The faculty observed each interaction and called time-outs to allow the residents to self-assess and obtain feedback. Residents and faculty debriefed to identify take-home points and to reflect on their emotions, self-care, and sense of purpose in medicine. Twenty-six neurology residents filled out an anonymous presurvey to self-assess their confidence and comfort surrounding GOC conversations. More than 50% of residents reported being confident in conducting GOC discussions, whereas only 42% reported adequate prior training. Postsession, more than 90% of residents reported that training was relevant, helpful, organized, and clear. Faculty identified that residents had difficulty addressing prognosis, assessing goals, planning treatment, and using silence, responding to emotion, and displaying empathy. Fifteen residents filled out a postsurvey that revealed improved comfort with delivering prognosis, discussing hospice, and initiating early GOC discussions. Our project uniquely focuses on late-stage GOC conversations and builds on existing literature that supports a structured program with both didactic and simulation components to improve residents' abilities to effectively navigate GOC conversations with patients and families. Future work will focus on reinforcement and reassessment of communication skills.