Discussing Prognosis and Recommending Hospice: A Resident Observed Structured Clinical Examination (OSCE)

Abstract

1.Develop an observed structured clinical examination (OSCE) to assess and give feedback to residents on their ability to provide prognostic information and recommend hospice as part of an existing required palliative care curriculum in our institution's internal medicine residency program. Over the past decade, late referral to hospice has become an increasing problem in the United States. Barriers to hospice referral are not well understood, but the lack of residency training in essential generalist palliative care competencies, such as giving prognostic information and recommending hospice, is a potential barrier to improving hospice utilization. Using observed structured clinical examinations (OSCEs) to improve trainees' interpersonal and communication skills may address this barrier. The OSCE case was developed by an expert palliative care educator and modified though an iterative process consisting of 22 pilot OSCEs. An extensive literature review informed the development of the OSCE assessment tool, and items were reviewed and revised by six palliative and geriatric medicine experts. The assessment tool was revised in an iterative process over the course of 16 OSCEs with internal medicine residents. One standardizedpatient was used for all OSCEs. The final OSCE assessment tool consists of a 20-item behavior checklist. Preliminary results suggest high interrater reliability (K=0.97). Pilot assessment of 13 internal medicine residents found that the most frequently missed behaviors were assessing a patient's desire for prognostic information, identifying social workers or chaplains as part of the hospice team, and describing the hospice team's role after the patient dies (pronouncement, post-mortem care, and bereavement care). Of participants who evaluated the OSCE, all reported that the exercise was useful and “better than average” compared with other residency educational activities. Common “take home” points for residents included identifying members of the hospice team and asking patientswhat they understand and want to know about their prognosis. Results from an additional 20 OSCEs will be reported using the final assessment tool. This OSCE offers an opportunity for standardized assessment and individualized feedback to improve internal medicine residents' medical knowledge and skills related to the essential generalist palliative care competencies discussing prognosis and recommending hospice. Although originally developed for internal medicine residents, this tool could be readily applied to other specialties. The Discussing Prognosis and Recommending Hospice OSCE is a useful and effective tool for identifying and addressing residents' gaps in knowledge and communication skills around discussing prognosis and recommending hospice.