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Physician Communication Practices: Analysis Using Simulation-based Case Content
By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh. Dr. Hoffman reports no financial relationship to this field of study. This article originally appeared in the March issue of Critical Care Alert. At that time it was peer reviewed by William Thompson, MD, Associate Professor of Medicine, University of Washington, Seattle. Dr. Thompson reports no financial relationship to this field of study.
Synopsis: An encounter with a critically ill simulated "patient" was used successfully to analyze the communication skills of experienced physicians and identify areas for improving communication behaviors.
Source: Mohan D, et al. Communication practices in physician decision-making for an unstable critically ill patient with end-stage cancer. J Palliat Med 2010;13:949-956.
Successful shared decision-making requires three key elements: identifying patient preferences, clearly explaining pertinent medical information, and developing consensus around a treatment plan. Although many physicians have developed skills that incorporate these elements, others experience difficulty supporting and incorporating patient preferences in the plan of care. This study was conducted to evaluate the potential of using a standardized coding process to analyze the communication behaviors, communication skills, and treatment decisions of physicians in the setting of end-of-life decision-making for a critically ill patient.
Subjects were 27 physicians, with a mean age of 41 years, who had been practicing for a mean of 15 years since graduation from medical school. All were employed in an academic setting and had clinical practice responsibilities. Of these, 13 (48%) were hospitalists, eight (30%) intensivists, and six (22%) emergency physicians. The physicians were introduced to the 78-year old "patient" in a simulation room that resembled a monitored acute care unit. The patient, who had widely metastatic gastrointestinal cancer (CT scan), was recently discharged from the hospital and now admitted with sudden onset of life-threatening hypoxemia. A spiral CT was negative for pulmonary embolism. The chart did not include an advanced care plan; however, if probed, the patient and wife revealed a long-standing preference for avoiding intubation and ICU readmission and for comfort-based treatment.
Most physicians (81%) tried to elicit the patient's preferences, values, and goals, and asked if the patient or wife had questions about the proposed treatment plan (70%). However, few (7%) used behaviors considered best practices for shared decision-making. Eight physicians elected to admit the patient to the ICU and 16 initiated palliation. There was no relationship between physician characteristics (years since graduation, race, gender, specialty) and scores for communication skills.
Typically, simulation is used to perfect complex skills or develop competence in skills that are critical in a life-threatening situation, but may be rarely encountered, e.g., intubation with a difficult airway. Trained simulated patients also are used to perfect skills of medical students in differential diagnosis and treatment planning. This study used simulation facilities in combination with a trained standardized patient to create a setting that required high level communication skills to elicit and confirm patient preferences in the setting of a sudden deterioration in status. The patient had previously indicated a strong preference for avoiding aggressive treatment, but this was not clear without probing.
Today, one in five U.S. citizens dies using ICU services, despite evidence that many Americans prefer less aggressive treatment. Many studies have analyzed the content and topics addressed in ICU family conferences directed toward clarifying end-of-life preferences. Findings suggest that there is room for improvement in clinician ability to elicit preferences and support decision-making. Part of the problem likely results from the situation: Such discussions are inherently difficult and there is no good way to gain expertise aside from observing experts, which is not always possible.
The scenario tested in this study represents a novel way of promoting the development of expert communication skills in such difficult situations. Using simulation, one can record the interaction, debrief those involved, and offer expert guidance to improve communication skills. As with use of simulation to develop other complex skills, scenarios of this type offer the opportunity to perfect skills that are difficult to attain, but frequently required in critical care practice.