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SIMULATION-based education can play a key role in helping doctors develop communication skills to engage in end-of-life discussions with patients, but it needs to be accompanied by experiential learning, says the outgoing chair of the AMA Council of Doctors-in-Training, Dr Will Milford.
Dr Milford said the finding of a US study that simulation-based communication training did not improve the patient-reported quality of communication about end-of-life care compared with usual education was disappointing.
The randomised trial of 391 internal medicine and 81 nurse practitioner trainees, published in JAMA, also found that simulation-based training resulted in a small increase in patients’ depressive symptoms. (1)
Dr Milford said the findings might reflect the difficulty in translating skills obtained in a controlled environment to the busy work environment of trainee clinicians.
“[Simulation-based] learning will be one part of a suite of teaching methods which imbue junior doctors with those sort of skills”, Dr Milford told MJA InSight. He said simulation-based teaching may be a good way to introduce junior doctors to the skills needed to deliver bad news, but experiential learning was essential in further growing these skills.
“Apprenticeship-style teaching works very well because you can watch your seniors and then you learn from that yourself”, he said. “I think that probably needs to form a major part of the teaching.”
Dr Yvonne Luxford, CEO of Palliative Care Australia, said simulation-based training would continue to play a role in training clinicians to better communicate with patients in end-of-life care discussions.
“I don’t think you can deliver education to health professionals in this day and age, without including simulation as part of the overall tools in delivering that training”, Dr Luxford told MJA InSight. She agreed that simulation should not be the sole mechanism for training delivery.
Dr Luxford said it was important to evaluate the effectiveness of educational tools and their implementation, but said she would be wary of dismissing the value of simulation-based training on the basis of this study, which had several limitations.
The study authors acknowledged limitations to their study, including the 10-month time lag between intervention and follow-up.
Professor Wendy Hu, professor of medical education at the University of Western Sydney, said the effect of simulation training on real-world practice was an ongoing issue, but questions remained over the best way to determine the effectiveness of training.
“We need to explore different approaches to researching outcomes in medical education”, she said. “Medical education is not necessarily a good fit with biomedical research paradigms as it is impossible to control for all confounding factors — randomised controlled trials are not the be all and end all of scientific proof.”
An accompanying JAMA editorial study noted that the patients of interns were more likely to have increased depression scores than the patients of more senior trainees. (2)
“Perhaps in the world of the busy intern, with many tasks competing for time and attention … it is challenging to reproduce what was learned in the setting of a controlled workshop”, the editorial said. “One conclusion from the study might be that end-of-life conversations should be left to more senior physicians”.
Dr Milford said while senior physicians may sometimes be better placed to deliver bad news, they had also had to learn those skills at some point in their careers.
He said universities were increasingly playing a part in preparing medical graduates with the appropriate communication skills to engage in these difficult discussions, but more focus on communication skills was required in the workplace.
“Graduates are coming through with the tools, but it’s about having the opportunity and the environment in which they can be used properly and the encouragement of the more senior doctors.
“You still hear horror stories of episodes where the consultant walks in, delivers bad news and leaves, and an intern or registrar is left to pick up the pieces”, Dr Milford said. “It’s getting better, but I think there’s still a way to go.”
Is this a surprise? I think not. Simulation is a valuable tool in medical education; one that was rarely employed during my own training. However, for the purpose of teaching about EOLC discussions, the artificial context limits the efficacy and responsiveness. To a large extent such communication skills are intrinsic to the individual. Mentorship also has an important role. When I was a medical student this role was not formally taught but many of the skills were acquired through watching others “do it well”. What’s more, the skills were put into practice very early, from internship, not left to the senior clinician. Really, there are only a few essential requirements – knowledge of the patient’s condition, honesty, empathy and respect. I think we are making it much more diffcult than it really is!