Are Interns Too Green for End-of-Life Talks?

Nick Mulcahy

December 03, 2013

In discussing end-of-life care with patients, young clinicians might have to learn by doing rather than by special schooling, suggest the results of a first-of-its-kind randomized trial.

Doctors and nurses in residency and fellowship programs who practiced end-of-life talks in simulated training sessions did not subsequently communicate with their patients any better than their counterparts who received usual education.

Worse yet, depression scores were significantly higher in patients counseled by trainees than by those who received usual education, report the authors, led by J. Randall Curtis, MD, MPH, from the University of Washington in Seattle.

First-year residents (i.e., interns) fared especially poorly in the study, having a number of worse outcomes than the more senior clinicians.

The study, which is the first-ever to measure patient opinions of providers trained in such simulations, was published in the December 4 issue of JAMA.

The results are "unexpected," write Jeffrey Chi, MD, and Abraham Verghese, MD, in an accompanying editorial. Both are from the Stanford University School of Medicine in California.

The "hope" for such simulation-based training is that it will be a "valuable adjunct to experience with real patients," they write.

The study had a "worthy goal" because communicating clearly with patients at the end of life has been proven to be "profoundly beneficial when done correctly," the pair argue.

The investigators adapted their 4-day program from a workshop originally designed to teach medical oncology fellows how to deliver bad news.

Study participants (internal medicine and nurse practitioner trainees at the University of Washington and the Medical University of South Carolina) were randomized to the communication skills intervention (n = 232) or usual education (n = 240).

The subsequent interaction between patients and healthcare providers took place up to 10 months after the training or usual education.

The researchers received 1866 patient evaluations completed by 1717 patients evaluating 345 of the trainees, and 936 surveys completed by 898 family respondents evaluating 295 trainees.

The training intervention was not associated with improvement in the study's primary outcome of patient-reported quality of communication (QOC).

There was also no difference between the 2 study groups for the secondary outcomes of patient-reported quality of end-of-life care (QEOLC) and family-reported QOC and QEOLC.

The healthcare professionals from the Medical University of South Carolina received better scores on the QOC questionnaire than those from the University of Washington.

"I think it has to do with Southern 'politeness' of the patients and family members when they are rating communication skills," Dr. Curtis told Medscape Medical News in an email.

In addition, QOC scores were significantly lower for interns (first-year residents) than for other, more senior trainees.

Maybe More Senior Physicians Should Tackle This Stuff

Mean depression score was significantly higher in patients treated by trainees (10.0; 95% confidence interval [CI], 9.1 - 10.8) than by those who received usual education (8.8; 95% CI, 8.4 - 9.2). An adjusted model showed an intervention effect of 2.2 (95% CI, 0.6 - 3.8; P = .006).

Depression scores were also higher in the patients of interns than in the patients of more senior trainees. The editorialists call this specific finding "intriguing."

"Perhaps in the world of a busy intern, with many tasks competing for time and attention, and with work-hour restrictions, it is a challenge to reproduce what was learned in the setting of a controlled workshop," the pair write.

End-of-life conversations should be left to more senior physicians.

"One conclusion from the study might be that end-of-life conversations should be left to more senior physicians," opine Drs. Chi and Verghese.

Dr. Curtis and colleagues also ruminate about this depression-related finding.

"Patients could experience depressive symptoms or feelings of sadness as a result of discussion about end-of-life care," they write, adding that increasing awareness of prognosis "may trigger negative experiences."

Ultimately, the investigators argue that some clinical experience counts for a lot at the end of life.

They suggest that the increase in the depressive symptoms score associated with first-year residents "might be associated with the skill level of the clinician having the discussion."

The study was funded by the National Institute of Nursing Research of the National Institutes of Health. The study authors, Dr. Chi, and Dr. Verghese have disclosed no relevant financial relationships.

JAMA. 2013;310:2257-2258, 2271-2281. Editorial, Abstract


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