ANN P. GUILLOT MD FAAP

JERRY G. LARRABEE MD FAAP

DAN SHUMER MD

VANESSA GOODWIN

APPD

SAN ANTONIO

SPRING 2012

Learning to Do it Better:

Improving Professionalism and Communication Around

Difficult Topics by Using Standardized Patients

Disclosures

� None of the presenters has any corporate sponsorship to declare

� We will not be discussing any drug use � on or off label

During this session we will:

� Review the use of standardized patients in undergraduate and graduate medical education

� Describe the PRELUDE curriculum developed at University of Vermont Pediatric Residency Program � Pediatric Resident Experiential Learning Using Dramatic

Encounters

� Have a Break-out Session to Practice Development of Scenarios

� Discuss Applicability to Your Own Institution

Objectives

� By the end of this session, you will be able to:� Develop a program outline that will fit your institution

� Choose topics that are appropriate for residents to work on in Standardized Patient sessions

� Design scenarios for the resident and for the SP

� Understand and overcome some of the logistic challenges

� Design a formative feedback structure that fits your scenarios

ANN GUILLOT

Background

ACGME Core Competencies

� Medical Knowledge

� Patient Care

� Professionalism

� Interpersonal Skills and Communication

� Practice Based Learning and Improvement

� Systems Based Practice

Professionalism and Communication

� Difficult to teach!

� Difficult to evaluate!

� Yet,� Directly correlated to health care quality

� Inversely correlated with risk of malpractice claims

� Named as two of the ACGME Core Competencies

� And should be really conducive to coaching� In the moment

� Focused and linked to performance in the moment

Definitions…

� Professionalism – pruh-fesh-uh-nl-iz-uhm� Compassion, sensitivity, integrity, respect for others and

accountability and commitment to patients, society, colleagues, self, and the profession

� Thus the ABP/APPD Program Director’s Guide

� Interpersonal Skills – in-ter-pur-suh-nl skilz� Create and sustain a therapeutic and ethically sound

relationship with patients

� Communication – kuh-myoo-ni-key-shuhn� Use effective listening skills and elicit and provide information

using effective nonverbal, explanatory, questioning, and writing skills

Professionalism and CommunicationTeaching and Evaluation

� Teaching / Learning� Role modeling

� Challenging in frenetic healthcare world

� Self-directed

� Limited by one’s self-awareness

� Practice with Patients

� Real Time

� Videotaped

� Evaluation� Self-assessment

� Limited by one’s self-awareness

� Observation with Feedback

� Success depends on the perception of the observer

� Patient feedback becomes the key

� Milestones

� Feedback: Summative vs. Formative

~~Curriculum around Standardized Patients is Ideal for This!~~

Standardized Patients

� First used in the 1960s to assess medical students’ clinical skills� “Programmed patients” – at UVM initially were recruits

from our own children, spouses and staff

� Greatly expanded use in undergraduate medical education in the 1990s� Standardized patients: “people, either real patients or

laypersons, who have been carefully coached and trained to portray a patient in a standardized manner”

� Early use for formative feedback re: History taking and PE skills

� ECFMG – high stakes exam / summative evaluation

� USMLE – Step 2 CS high stakes exam / summative eval

Growing Use of SPs in Graduate Medical Education

� A newer phenomenon� As many articles since 2009 as in all years leading up to

2009

� Across nearly every specialty

� Can be used for specific clinical skills, but especially for communication and professionalism� Ideal for formative feedback…

� Can give immediate feedback, and allow for repeats, tweaking, trials of different methods

� More like coaching, less like the “final score”

JERRY LARRABEE

PRELUDE Curriculum

Pediatric Resident Experiential Learning Using Dramatic Encounters (PRELUDE)

� Initiated in 2010 as a pilot project

� First use of standardized patients in resident education at Fletcher Allen� Scenarios based on “giving bad news” module that had been in

use with med students� Designed to serve residents at a different level of experience� Moderated by Ethicist (who is a pediatrician as well)� Small groups mentored by physicians chosen by the residents

� Later adapted specifically to address communication issues for a specific resident � Embedded into ILP� Scenarios developed to address situations that had been a

particular challenge

Pediatric Resident Experiential Learning Using Dramatic Encounters (PRELUDE)

� Pilot Program� Designed to include all pediatric residents

� 18 Residents

� Obtained commitment from Simulation Center and SP program

� Size and layout of rooms (including two-way mirrors)

� Web-based video capture system – immediate and delayed video playback

� Support from the DIO

� Had interest in expanding to other departments beyond peds

� 3 sessions per resident spread across the training year

� Emphasis on Safe Environment

� Residents assured that this is Formative Feedback (aka Coaching)

� To allow them to move towards excellence

� Enlisted support of the pediatric faculty

� Serve as mentors

PRELUDE – Pilot Program Scenarios, Mentors, Sessions

� Scenarios� Several topics suggested by residents – 3 chosen by our team

� Breaking bad news� Establishing (and redirecting) goals of care� Anticipatory guidance in the context of extreme prematurity (i.e., “the NICU

talk”)

� Scenarios written by ethicist in collaboration with chief resident and program coordinator

� Mentors� Nominated by residents by virtue of professionalism and

communication skills� Faculty development preceded participation

� Sessions� Safe environment; Formative feedback� 3-4 Residents per session; One resident at a time with others observing� Faculty mentor in the room, remaining quiet, available if asked

PRELUDEAlgorithms: Literature and Home-grown

� SPIKES� Setup: prepare yourself ahead

of time� Perception: what does

patient/family think of medical situation

� Invitation: how much information does patient/family want

� Knowledge: Use language that meets patient/family where they are

� Empathize: Use compassionate statements in response to patient/family emotions

� Summarize: Review clinical information and make a plan for next step

� SOLAR

� Setting the tone

� Owning their role

� Listening intentionally

� Allying with the family

� Reflecting thoughts and emotions

Anatomy of a PRELUDE Session

� Pre-Survey

� Article� Example: “I Learned That No Death Is Routine”: Description of a Death and Bereavement Seminar for Pediatric Residents, Serwint J R, et. al.

� 15-Minute Didactic – by the Ethicist/Mentor� Acronym (e.g., SPIKES, SOLAR)

� Review Session Guideline

� 2 Hour Session

� Feedback and discussion

� Post-Survey (after all 3 sessions)

Scenario Metric Before After p value

Breaking Bad News

(2/3/11; 11 residents)Faculty: Macauley,

Berg, Pfister, Hopkins

I had a comprehensive, structured approach for breaking bad news to patients or families. 2.36 3.27 0.002

I felt comfortable breaking bad news to patients or families. 2.45 2.72 0.08

I rated my ability to break bad news to patients or families in an effective and compassionate way as: 2.56 2.90 0.04

Establishing goals of care

(3/24/11; 8 residents)Faculty: Macauley,

Pfister, Lahiri, Hopkins, Guillot

I had a comprehensive, structured approach to establishing goals of care for a critically ill child. 2.75 3.125 0.35

I felt comfortable establishing goals of care for a critically ill child. 2.125 2.75 0.05

I rated my ability to establish goals of care for a critically ill child. 2 2.75 0.002

“NICU talk” (4/3/11; 9 residents)Faculty: Macauley,

Berg, Salerno, Pfister, Green, Young (fellow)

I had a comprehensive, structured approach to preparing parents for the delivery of an extremely premature infant. 2.75 3.25 0.03

I felt comfortable providing anticipatory guidance and establishing a plan of care for an extremely premature infant. 2.63 3.125 0.03

I rated my ability to prepare patients for the delivery of an extremely premature infant as: 2.63 3.125 0.03

PRELUDE Pre and Post-Survey Results2010-11 Pilot Year

0

1

2

3

4

5

6

7

Strongly Disag reeDisagree

Neutral

Agree

Strongly Agree

Positively influence clinical practice…

0

1

2

3

4

5

6

7

Poor

Fair

Good

Excellent

Outst anding

Overall educational experience…

DAN SHUMER

PRELUDE Scenario

PRELUDE Scenario – an example…

� Disclosure of Medical Error – Dealing with angry parents

� Context: Hospital room, two days after admission.

� Doctor (Resident Background):

An infant was admitted for rule-out-sepsis, and even though the order was written correctly, the child received 10 times the appropriate dose of Gentamicin. As a result, the child’s renal function has worsened, although this is likely to be temporary. You wrote the order correctly, yet a mistake was made. Your task is to communicate the error to the family, explain that there is kidney insult (likely temporary), that the patient’s hearing will need to be monitored, and (if necessary) address issues of payment (as the family will not be charged for this admission) but family/insurance will be charged for hearing screens in the future.

� Goals of the ward resident:� Clearly explain what happened

� Apologize for the error

� Solicit and empathize with the parent’s concerns

� Appropriately answer questions and admit to uncertainty if appropriate

� Parent (SP Background):

You didn’t see what the big deal was. Your two-month-old had a fever, but she was eating okay and didn’t look too bad. But your doctor felt strongly that you should take her to ER, and from there everything happened so fast. People talked about what could happen if she had a serious infection, and you consented to what they said would likely be a couple of days of antibiotics, just to be on the safe side. You’re expecting the doctors to come in and update you on lab tests for infection, anticipating you will go home.

Video of a PRELUDE Scenario

VANESSA GOODWIN

Curriculum Logistics

Curriculum Logistics

� 18 residents� 3 sessions each� Attempting to avoid conflicts with other rotation obligations� Coordination of faculty members participating in the session

� Scheduling � Ensuring a mix of resident training levels at each session� Attempt to have different residents scheduled at each session� Conflicts with vacation, rotations, other training sessions

� Personnel costs� SP cost $100/hour for 2 Standardized Patients� Currently Faculty time is on a volunteer/“work into their already busy

schedules” basis (Importance of needing strong faculty commitment)

Curriculum Logistics

� Fun and challenges� Faculty are honored to be nominated and want to play

� need enough advance notice to be able to participate as mentors

� Residents like the sessions and want to participate

� Pulling them off a service was challenging for them to switch gears

� Tough for us to cross cover

THE WHOLE TEAM

Breakout Session

Breakout Session

� Discuss potential scenarios that would be applicable to your current residents

� Work together on one idea and write up a scenario using the worksheet provided – Have Fun!

� We will reconvene and discuss the nuances and challenges of writing up a scenario

� A volunteer group will report back on their scenario including the content and the specific components of professionalism and communication at which they are taking aim

� The worksheets will be collected, collated, and distributed to all participants after the conference

Potential topics

� Breaking bad news

� Establishing goals of care

� Advanced care planning

� Code status or establishing goals of care

� Responding to emotion

� Informed consent

� Disclosure of error

� Impaired colleagues

� Possible medical outcomes (benefits and burdens)

ANN GUILLOT

Wrap-Up

Future possibilities

� Integrated sessions across department lines

� Dedicated time (residents on elective)

� Dedicated retreats

� Use for Individualized Learning Plan

� Use for remediation

� More structured faculty development

� Interweave with milestones

Milestones – Some useful examples…

2. Demonstrate the insight and understanding into emotion and human response to emotion that allow one to appropriately develop and manage human interactions

Primary Author: Bradley Benson, MD

� Does not accurately anticipate or read others’ emot ions in verbal and nonverbal communication. Is unaware of one’s own emotional and behavioral cues and may transmit emotions in communication (e.g., anxiety, exuberance, and anger) that can precipitate unintended emotional responses in others. Does not effectively manage strong emotions in oneself or others.

� Begins to use past experiences to anticipate and read (in real time) the emotional responses in herself and others across a limited range of medical communication scenarios, but does not yet have the ability or insight to moderat e her behavior to effectively manage the emotions . Strong emotions in oneself and others may still bec ome overwhelming .

� Anticipates, reads, and reacts to emotions in real time with appropriate and professional behavior in nearly all typical medical communication scenarios , including those evoking very strong emotions . Uses these abilities to gain and maintain therapeutic alliances with others.

� Perceives, understands, uses, and manages emotions in a broad range of medical communication scenarios and learns from new or unexpected emotional experiences . Effectively manages her own emotions appropriately in all situations . Effectively and consistently uses emotions to gain and maintain therapeutic alli ances with others. Is perceived as a humanistic provider .

� Intuitively perceives, understands, uses, and manag es emotions to improve the health and well-being of others and to foster therapeutic relationships in any and all situations . Is seen as an authentic role model of humanism in medicine.

Milestones – Some useful examples…

7. Demonstrate self-confidence that puts patients, families, and members of the health care team at ease

Primary Author: Ann Burke, MD

� Unaware of how to solve a problem /question. Expected to have little self-confidence given limited experience, and appropriately identifies the need to ask for help.

� Speaks in a confident manner, but still unsure of when and how to clearly articulate his limitations to the family . Exhibits behaviors that reflect some comfort and confidence with his role as a physician, but families would not necessarily feel at ease without reassurance from a more senior colleague or supervisor.

� Starts to self-reflect and navigate the interplay of the complexity of explaining uncertainty to patients and families, while remaining confident with information he knows and understands clinically. Has some insight into when to be confident and when to express uncertainty with situations and diagnoses. Emerging alignment between knowledge/skill and degree of certainty allows families to assess him as effective in placing them at ease in many situations.

� Gaining experience and comfort with uncertainty. Is appropriately self-confident and considered to be trustworthy (skilled, truthful, discerning, and conscientious). The balance between confidence and uncertainty allows families and patients to assess him as quite effective in placing them at ease.

� Master of explaining uncertainty and what is known. Does so with a mature/comforting self-confidence that is easily identified by all, modified to the emotional needs of the family/patie nt . Families and patients identify him as excellent at placing them at ease, even in the face of difficult situations.

Questions & Discussion