Impact of a Novel Goals-of-Care Communication Skills Coaching Intervention for Practicing Oncologists.

Background: Oncologists routinely have opportunities for goals-of-care (GoC) discussions with patients. GoC discussions increase the likelihood that patients receive care consistent with their values. However, oncologists often feel ill-equipped to discuss end-of-life care. Objective: To assess the impact of a communication training and coaching intervention (INT) for oncologists during GoC discussions. Design: We randomized oncologists to usual care (UC) or a communication skills training INT, which consisted of an interactive training session and four joint visits with communication coaches. Setting/Subjects: Solid tumor oncologists seeing advanced cancer patients at four hospitals in New York and Connecticut. Measurements: Three blinded coders evaluated recorded encounters before and after INT using a validated tool to assess skill attainment. Results: Oncologists (n = 22) were 32% female and averaged 46 years of age. In baseline visits, INT oncologists (n = 11) and UC oncologists (n = 11) had no difference in the number of mean skills employed out of 8 GoC skills (INT 3.5, UC 2.4; p = 0.18). Post-INT, INT oncologists were significantly more likely to elicit patient values (55% vs. 0%; p = 0.01). There was no significant difference in overall mean skills employed (INT 3.4, UC 2.2; p = 0.14). Assessing for understanding, offering "I wish" statements, and providing prognosis were the least utilized skills among all oncologists. Conclusion: Our real-time communication skills coaching INT resulted in a significant increase in oncologists' ability to elicit patient values during GoC discussions, suggesting that skill acquisition can occur in the face of less intensive training. Future studies can highlight gaps leading to the lack of differences in utilization of other skills.

Development and Validation of the ACP-CAT for Assessing the Quality of Advance Care Planning Communication.

CONTEXT: High-quality advance care planning (ACP) discussions are important to ensure patient receipt of goal-concordant care; however, there is no existing tool for assessing ACP communication quality. OBJECTIVES: The objective of this study was to develop and validate a novel instrument that can be used to assess ACP communication skills of clinicians and trainees. METHODS: We developed a 20-item ACP Communication Assessment Tool (ACP-CAT) plus two summative items. Randomized rater pairs assessed residents' performances in video-recorded standardized patient encounters before and after an ACP training program using the ACP-CAT. We tested the tool for its 1) discriminating ability, 2) interrater reliability, 3) concurrent validity, 4) feasibility, and 5) raters' satisfaction. RESULTS: Fifty-eight pre/post-training video recordings from 29 first-year internal medicine residents at Mount Sinai Hospital were evaluated. ACP-CAT reliably discriminated performance before and after training (median score 6 vs. 11, P < 0.001). For both pre/post-training encounters, interrater reliability was high for ACP-CAT total scores (intraclass correlation coefficient or ICC = 0.83 and 0.82) and the summative items Overall impression of ACP communication skills (ICC = 0.73 and 0.80) and Overall ability to respond to emotion (ICC = 0.83 and 0.82). Concurrent validity was shown by the strong correlation between ACP-CAT total score and both summative items. Raters spent an average of 4.8 minutes to complete the ACP-CAT, found it feasible, and were satisfied with its use. CONCLUSION: ACP-CAT provides a validated measure of ACP communication quality for assessing video-recorded encounters and can be further studied for its applicability with clinicians in different clinical contexts.

Goals of Care Ambulatory Resident Education: Training Residents in Advance Care Planning Conversations in the Outpatient Setting.

BACKGROUND: Advance care planning (ACP) discussions often occur in the inpatient setting when patients are too ill to participate in decision making. Although the outpatient setting is the preferred time to begin these discussions, few physicians do so in practice. Many internal medicine (IM) residents report inadequate training as a barrier to having outpatient ACP discussions. OBJECTIVE: To assess whether a novel curriculum entitled Goals of Care Ambulatory Resident Education (GOCARE) improved resident physicians' understanding of and preparedness for conducting ACP discussions in the outpatient setting. DESIGN: The curriculum was delivered over four weekly three-hour small group sessions to IM residents. Each session included didactics, a demonstration of skills, and a simulated patient communication laboratory that emphasized deliberate practice. SETTING/SUBJECTS: IM residents from an urban, academic ambulatory care practice. MEASUREMENTS: Impact of the intervention was evaluated using a retrospective pre-post design. Residents completed surveys immediately after the course and six months later. RESULTS: Forty-two residents participated in the curriculum and 95% completed the postcourse survey. Residents' self-rated level of preparedness increased for ACP discussions overall (4.0 pre vs. 5.2 post on 7-point Likert scale) and for communication steps involved in ACP (p < 0.001). Fifty-nine percent of participants completed the six-month follow-up survey. Residents' self-rated preparedness to engage in outpatient ACP discussions remained high (4.5 pre vs. 5.5 post at six months p < 0.001). Residents also reported increased use of ACP communication skills (p < 0.001) six months later. CONCLUSIONS: The GOCARE curriculum provides an alternative model of communication training that can be integrated into residency training and improve residents' skills in outpatient ACP discussions.

Food allergy as a risk factor for asthma morbidity in adults.

BACKGROUND: The objective of this study was to evaluate the relationship between food allergy and asthma morbidity in adults. METHODS: We interviewed a cohort of persistent asthmatics from an inner-city clinic. Allergies to food were assessed by patient report of convincing symptoms of acute allergic reactions. Outcome variables included health resource utilization and medication use. RESULTS: The prevalence of allergy to fish, peanut, tree-nut, shellfish, and seed allergies were 3%, 3%, 3%, 13%, and 1%. Patients with allergies to > 1 food had increased asthma hospitalizations, ED visits, and use of oral steroids (p < 0.05 for all comparisons). Specifically, allergy to fish was associated with a greater risk of health resource utilization and increased frequency of oral steroid use (p < or = 0.03 for all comparisons). CONCLUSIONS: Self-reported allergy to foods was associated with worse outcomes, suggesting that food allergy may be a risk factor for increased asthma morbidity in adults.