Improving Residents' Code Status Discussion Skills: A Randomized Trial

Abstract

Background: Inpatient Code Status Discussions (CSDs) are commonly facilitated by resident physicians, despite inadequate training. We studied the efficacy of a CSD communication skills training intervention for internal medicine residents. Methods: This was a prospective, randomized controlled trial of a multimodality communication skills educational intervention for postgraduate year (PGY) 1 residents. Intervention group residents completed a 2 hour teaching session with deliberate practice of communication skills, online modules, self-reflection, and a booster training session in addition to assigned clinical rotations. Control group residents completed clinical rotations alone. CSD skills of residents in both groups were assessed 2 months after the intervention using an 18 item behavioral checklist during a standardized patient encounter. Average scores for intervention and control group residents were calculated and between-group differences on the CSD skills assessment were evaluated using two-tailed independent sample t tests. Results: Intervention group residents displayed higher overall scores on the simulated CSD (75.1% versus 53.2%, p < 0.0001) than control group residents. The intervention group also displayed a greater number of key CSD communication behaviors and facilitated significantly longer conversations. The training, evaluation, and feedback sessions were rated highly. Conclusion: A focused, multimodality curriculum can improve resident performance of simulated CSDs. Skill improvement lasted for at least 2 months after the intervention. Further studies are needed to assess skill retention and to set minimum performance standards.

Code Status Discussion Skill Retention in Internal Medicine Residents: One-Year Follow-Up

“…9 All residents were graduates of United States medical schools; complete demographic information is available elsewhere. 9 Nineteen residents completed the intervention including small group teaching, on-line modules, and a log of CSDs performed in actual clinical care. 9 Nineteen residents completed clinical training alone and did not participate in the intervention.…”

“…9 Nineteen residents completed the intervention including small group teaching, on-line modules, and a log of CSDs performed in actual clinical care. 9 Nineteen residents completed clinical training alone and did not participate in the intervention. All 38 residents (intervention and control group) completed a CSD clinical skills examination (CSE) with a trained standardized patient in January, 2011.…”

“…CSD skills were assessed via an 18-item behavioral checklist composed of three sections (a) patient-centered interviewing skills, (b) CSD skills, and (c) responding to emotion. 9 Each checklist item was scored dichotomously (done correctly or done incorrectly) and given equal weight. Each item performed correctly received one point and points were summed for a total score.…”

“…8 Earlier research demonstrates that focused interventions improve trainee skill in facilitating end-of-life conversations. 2,9,10 At Northwestern University, internal medicine residents completed a multimodality intervention in CSD skills including small group sessions, deliberate practice, and self-study. 9 Skill was significantly better in intervention group residents than controls, as assessed by performance on a simulated CSD with a standardized patient.…”

“…2,9,10 At Northwestern University, internal medicine residents completed a multimodality intervention in CSD skills including small group sessions, deliberate practice, and self-study. 9 Skill was significantly better in intervention group residents than controls, as assessed by performance on a simulated CSD with a standardized patient. However, post-intervention skills were assessed only at 2 months, 9 similar to short-term follow-up reported in other studies.…”