1. Simulated Patients Improve Medical Student Comfort Level with Breaking Bad News and End of Life Issues Skotti Church, MD Carl J Fichtenbaum, MD, FACP University of Cincinnati Academic Health Center Cincinnati, OH Introduction: Training for end-of-life (EOL) care discussions and how to “break bad news” are an important aspects of medical education. Paucity of published data on effective teaching methods No standardized curriculum Nationally, there is a large variation in the timing, length and content of palliative care courses or education regarding EOL communication skills. 1 Medical Education is undergoing a transformation to more integrated curricula that spans clinical course work. 2 Student perceptions concerning with EOL care: 2 Worry and anxiety reported with EOL discussions Feelings of being unprepared for family discussions Feelings of lack of support from residents and attendings More than 40% of internal medicine residents reported no formal training for discussions of prognosis, bad news or family meetings. 90% reported formal training for DNR/DNI orders and advance directives. 3 Residents who were more confident in breaking bad news reported higher skill levels in caring for dying patients. 3 More clinical experience was associated with improved comfort levels and perceived abilities in communication at the end of life. 3 Medical Education for End of Life Care: Prior to 2006, End of Life Course Consisted of: 6 contact hours in the 1 st year Didactic lectures Small group discussion sessions Major Course Content Experiences with gross anatomy Personal comfort level and experiences with death Cultural differences Coping with loss (Loss exercise) Case-based small group discussions EOL Course Redesign New course structure: 12 contact hrs near beginning of 3 rd year clerkship experiences Two simulated patient encounters and role play. Immediate feedback from simulated patients to students. Students completed their own living wills, healthcare proxy forms and health care value worksheets. Major Course Content: Emphasis on communication skills building. Medical student roles and reactions to bad news. Discussions of fixed and modifiable patient characteristics, legal/ethical concerns, pain control and hope. Methods: Survey of graduating medical students before and after curriculum change. A 17-item anonymous questionnaire Administered at end of 4 th year clinical experiences Self-reported comfort level and experiences (Likert scale) Survey administered to three graduating classes: One class prior to course changes (2007) Two classes after course changes (2008 and 2010) Data was analyzed using SAS 9.1.3. Comparisons of proportions using standard methods Medical Student Demographics: 200720082010 Number Graduating142155157 Mean Age2827.828 Gender Male Female 56% 44% 57% 43% 59% 41% Race/Ethnicity Black White Asian Hispanic Other Unknown 5% 75% 18% 2% - 7% 68% 20% 2% 3% - 5% 67% 19% 1% 2% Residency Choice Medicine Surgery Pediatrics Obstetrics Emergency Psychiatry FP/Med-Peds Other 20% 24% 14% 7% 8% 7% 12% 8% 26% 21% 8% 5% 16% 5% 11% 8% 20% 33% 15% 7% 6% 4% 8% 7% Number Surveyed143163159 Surveys Completed*60% (N=86) 82% (N=133) 81% (N=129) *P<0.001 comparing 2007 vs. 2008 and 2007 vs. 2010 Student Experiences on the Ward: More students had experience with a patient receiving bad news on the wards during later years of graduation: 2007 – 78% (P=0.004 vs. 2010) 2008 – 80% (P=0.01 vs. 2010) 2010 – 91% There was a trend towards more students having experience with a patient dying while on the wards in more recent year of graduation: 2007 – 71% (P=0.06 vs. 2008) 2008 – 82% 2010 – Data not available Comfort with Breaking Bad News: “How comfortable are you telling a patient they have a life threatening disease?” “How comfortable are you speaking with family members about a patient’s terminal prognosis?” Life threatening disease PrognosisLife threatening disease to family members Prognosis to family members 200786%88%75%84% 200893% 83%87% 201090% 82%89% “How comfortable are you discussing end of life issues (e.g. hospice, palliative care) with patients?” “How comfortable are you discussing advance directives (e.g. living will, healthcare power of attorney) with a patient’s family members?” End of lifeAdvance directivesEnd of life with family members Advance directives with family members 200794%90%93%90% 200891% 93% 201089%93%92%94% Importance of mentorship, peers and other courses on student comfort levels: “Please describe the importance of each experience below in terms of helping you become more comfortable dealing with issues of death and dying with your patients.” Attending physicians Resident Physicians Ward RotationsMedical Student Peers Ethics Course 2007 94%95%98%70%60% 2008 90%91%98%54%*64% 2010 96%94%98%54%*71% Value of Redesigned End of Life Course: Summary: Medical students are increasingly exposed to experiences involving end of life care and breaking bad news. Medical students reported that the utility and importance of the end of life course was improved with the addition of an emphasis on skill building and the use of standardized simulated patients. Experiences on the wards and interactions with mentors remained important in their comfort level in addressing end of life issues. Conclusions/Implications: Standardized patients are a unique educational tool to enhance skill and comfort levels of medical students delivering bad news and dealing with end of life care. Comfort level and confidence are likely as important as knowledge-base when discussing end of life issues. Standardized patients should be used to further improve skills of medical students and residents in effective communication techniques. Continued research is needed to optimize curricula that emphasize end of life communication skills and determine how these enhancements affect patient and family satisfaction. Limitations: The number of completed surveys was significantly lower in the year prior to the changes in curriculum Survey results were anonymous, therefore, performance data with standardized patients could not be linked to self-reported comfort levels. P= NS for all comparisons *P=0.03 compared to 2007 P= NS for all comparisons Rated Utility/Importance of EOL course on reported comfort levels for breaking bad news *P=0.02 versus 2010 † P=0.05 versus 2010 1 Bicket-Swenson, J Palliative Med, 2007;10:229-235. 2 Wear, Acad Med, 2002;77:271-277. 3 Ury et al, Acad Med 2003;78:530-537.