1. ® Introduction Using Visual Technology in Advance Care Planning Education Craig M. Klugman PhD, Jonathan Gelfond MD PhD, Kristy Kosub MD, Diane Ferguson RN BSN The University of Texas Health Science Center at San Antonio Conclusions Over the last 20 years, many publications have reported the need for training medical students in advance care planning (ACP). 1-8 Challenges to an effective curriculum range from lack of physician knowledge and skill, discomfort with such conversations, and lack of practice opportunities. Several innovative programs have been tried. Torke et. al developed a half-day workshop after which students reported increased skills in breaking bad news, discussing advance directives, and managing pain. 9 Gallagher et. al administered a 70-minute curriculum consisting of a short lecture followed by 2 standardized patient (SP) sessions. SPs and student self- assessments were recorded. The data suggests the program may be helpful. 10 Mueller et. al taught a 10-hour bioethics course that included advance directives. One month after the course, students self-reported feeling more knowledgeable and confident about advance care planning. 11 The only control group study was conducted by Green & Levi. In a required ethics course, students were assigned to either a pen-paper packet or a computer-based tool. The results of pre/post tests show that students in the computer group learned more factual knowledge and had increased confidence. 12 Materials and Methods At the UT Health Science Center San Antonio School of Medicine, every third-year medical student (n=220) takes part in a 2-hour ethics session during his/her internal medicine (IM) clerkship. The session consists of: (a) 1-hour conversation about ethical and professional issues the students have encountered or observed; (b) 15-minute viewing of award-winning Advance Directives video; (c) 45-minute discussion of video and advance care planning. All students complete an objective structured clinical examination (OSCE) using standardized patients (SPs) during the IM clerkship. One OSCE encounter requires the student to discuss advance directives with a SP in the role of patient. All encounters are video-taped. Two-third of the students have the OSCE 1 to 2 months after the ethics session (experimental group) and one-third have the OSCE 1 month before the ethics session (control group). Both groups have access to an article about having advance care planning conversations with their patients. SPs complete an evaluation of the students’ skills and students complete a self-assessment of their comfort with end- of-life conversations. We looked at video and assessment results for one calendar year March 2011-March 2012, covering parts of two medical school classes. Every third video (by alphabetical order) was reviewed and coded for body language, terminology, behavior, and knowledge content. These 73 interviews were coded by a single rater. Every fifth video was viewed by a second rater and their answers compared. Any discrepancies were discussed and the video provided final arbitration. We analyzed the self-assessment, standardized patient scores, and coded elements for correlation, Chi-Square, and Fischer Exact Test using R Statistics (ver 2.15.1). Although other teaching sessions have used more time, this data shows that even a short 2-hour advance care planning session in the MS3 year during a clinical rotation can have an affect on the student’s skills. In particular students are more likely to use a questioning, rather than lecture, style and to have follow up plans that provide patients with further resources. Students also are more likely to have increased comfort in end-of-life conversations which is evident to patients through tone of voice, hand gestures, using lay language, and asking questions about the patient’s experience with advance directives. We propose that more teaching hours and experiences would lead to a greater affect. This study had several limitations. The sample size of 47 is very small and the two groups were not evenly divided (66% intervention vs. 34% control). Even though many of the results show borderline significance, all of the results trend in the direction of the intervention having a positive influence. In addition, this study was at 1 school, taking place over part of 2 separate class years. 1.Billings JA, Bock S (1997). Palliative care in undergraduate medical education: status report and future directions. JAMA 278: 733-738; 2.Field MJ, Cassell CK (1997). Approaching death: Improving care and the end of life. Institute of Medicine Report. Washington DC: National Academy Press. 3.Sullivan AM, Lakoma MD, Block SD (2003). The status of medical education in end-of-life care: A national report. J Gen Intern Med 18:685-695. 4.Barnard D, Quill T, Hafferty FW, Arnold R, Plumb J, Bulger R, Field M (1999) Preparing the ground: contributions of the preclinical years to medical education for care near the end of life. Working Group on the Pre-clinical Years of the National 5.Consensus Conference on Medical Education for Care Near the End of Life. Acad Med 74:499– 505 6.Schonwetter RS, Robinson BE (1994) Educational objectives for medical training in the care of the terminally ill. Acad Med 69:688–690 7.Sullivan AM, Lakoma MD, Billings JA, Peters AS, Block SD, Faculty PC (2005) Teaching and learning end-of-life care: evaluation of a faculty development program in palliative care. Acad Med 80:657–668 8.Sullivan AM, Lakoma MD, Block SD (2003) The status of medical education in end-of-life care: a national report. J Gen Intern Med 18:685–695 9.Torke AM, Quest TE, Kinlaw K, ELey JW, Branch WT (2004). A workshop to teach medical students communication skills and clinical knowledge about end-of-life care. J Gen Intern med 19: 540-544. 10.Gallagher TH, Pantilat SZ, Lo B, Papadakis MA (1999). Teaching medical students to discuss advance directives: A standardized patient curriculum. Teaching & Learning in Medicine 11(3): 142-147. 11.Mueller PS, Litin SC, Hook CC, Creagan ET, Cha SS, Backman TJ (2010). A novel advance directives course provides a transformative learning experience for medical students. 22(2): 137- 141. 12.Green MJ, Levi BH (2011). Teaching advance care planning to medical students with a computer- based decision aid. J Canc Edu 26: 82-91 ACKNOWLEDGEMENTS: The authors wish to acknowledge Alvand Sehat and Nicole Manley for their assistance in this project. Results 73 SP encounters reviewed (47=intervention group, 26=control group) Statistical or correlative significance found for positive increase in Body language o Head nodding o Using hand gestures Vocal Communication o Displaying vocal confidence o Use of lay language instead of medical Professional Approach o Affirming patient choice to have advance care planning conversations o Using questions instead of lecturing in speaking with patient o Asking if patient has a living will or advance directive o Closing the interview with plans for follow up and providing further resources Other o SP score directly correlated to time spent in session o Students self report more comfort in ACP Filming of family debate in Advance Directives film (2010) Suggestive Impacts on Video Analysis Data References