MedicalResearch.com Interview with:
J. Randall Curtis, MD, MPH
Professor of Medicine
Director, UW Palliative Care Center of Excellence
Section Head, Pulmonary and Critical Care Medicine, Harborview Medical CenterA. Bruce Montgomery, M.D. – American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA 98104
MedicalResearch.com: What are the main findings of the study?
Dr. Curtis: We examined the effect of a communication-skills intervention for internal medicine and nurse practitioner trainees on patient- and family-reported outcomes. The study was funded by the National Institutes of Nursing Research of the National Institutes of Heatlh. We conducted a randomized trial with 391 internal medicine and 81 nurse practitioner trainees at two universities. Participants were randomized to either an 8-session simulation-based, communication-skills intervention or to usual education. We collected outcome data from a large number of patients with life-limiting illness and their families, including 1866 patient ratings and 936 family ratings. The primary outcome was patient-reported quality of communication and, overall, this outcome did not change with the intervention. However, when we restricted our analyses to only patients who reported their own health status as poor, the intervention was associated with increased communication ratings. Much to our surprise, the intervention was associated with a small but significant increase in depression scores among post-intervention patients. Overall, this study demonstrates that among internal medicine and nurse practitioner trainees, simulation-based communication training compared with usual education improved communication skills acquisition, but did not improve quality of communication about end-of-life care for all patients. However, the intervention was associated with improved patient ratings of communication for the sickest patients. Furthermore, the intervention was associated with a small increase in patients’ depressive symptoms, and this appeared most marked among patients of the first-year residents.
MedicalResearch.com: Were any of the findings unexpected?
Dr. Curtis: Yes, the finding of increased depressive symptoms among patients of trainees who had received the intervention was a surprise. Although statistically significant, it is important to point out that this change was small and is less than the “minimal clinically important difference” on this scale. Nonetheless, it is possible that patients could experience depressive symptoms or feelings of sadness as a result of discussion about end-of-life care. Our finding that the increase in patients’ depressive symptoms was significantly greater for first-year residents suggests this increase might be associated with the skill level of the clinician having the discussion. Future studies should explore the effect of discussing end-of-life care on patients’ psychological symptoms and satisfaction with care and consider ways to mitigate negative effects while achieving the positive effects of these discussions.
MedicalResearch.com: What should clinicians and patients take away from your report?
Dr. Curtis: We showed that simulation training improves communication skills, but we were not able to convincingly show the benefits with patient-reported outcomes. Our study suggests that patients and their families may not be sensitive raters of clinician communication because they don’t know what to expect from clinicians and suggests that some prompting or training may be necessary if patients and family members are to be able to identify improved communication.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Curtis: In an editorial about this article Drs. Jeffrey Chi and Abraham Verghese from Stanford University comment that this study “provides an important lesson in the nature of pedagogy in medicine: new and innovative ways are needed to teach skills, and continued measurement, reassessment, and validation are needed to determine if those teaching methods have been successful.” I agree with this assessment and believe this is an important area for future research.
Curtis J, Back AL, Ford DW, et al. Effect of Communication Skills Training for Residents and Nurse Practitioners on Quality of Communication With Patients With Serious Illness: A Randomized Trial. JAMA. 2013;310(21):2271-2281. doi:10.1001/jama.2013.282081.