Palliative Improv: Improving Critical Communication Skills with CME
Steve Singer, ACCME Vice President for Education and Outreach, interviews Roxanne Bollinger, CME Manager, Lancaster General Hospital, about addressing physician communication issues with CME.
>>SINGER: I'm Steve Singer, I'm the Vice President for Education and Outreach at the Accreditation Council for Continuing Medical Education. My guest today is Roxanne Bolinger from Lancaster General Health and we're going to talk about addressing physician communication issues in a very interesting example.
>>BOLINGER: Thank you for having me.
>>SINGER: We're going to talk today about a very interesting CME activity that you created to address communication issues and I'd like for our conversation to frame it around one of our new accreditation with commendation criteria that rewards providers who address helping physicians and others to improve their communication skills. So, give us a little bit of background about the problem and why you started on this route.
>>BOLINGER: Palliative health has always been an issue recently at our hospital. I'm assuming at a lot of other hospitals. Physicians are struggling on how to have a difficult conversation with their patient. We've done a lot of CME events and other educational events to try to get that conversation going, but have really struggled with that.
>>SINGER: Okay, and when you talk about palliative health just so that I understand, palliative care is care provided at the end of life?
>>BOLINGER: Right. We've done a variety of different education and we had a lot of conversation about the competence aspect as far as teaching physicians what it means to have advanced care planning and various aspects of that. And the feedback we got from the physicians were, yes, they understood the concept but when it came to a department of medicine grand rounds, we realized that they understood the concept but they did not want to have that conversation with their patients.
>>SINGER: Okay. So just for my information, are there... I know that palliative medicine is a discipline. I'm assuming that there are standards of care or guidelines or things that guide what physicians and members of the healthcare team should do or the conversations they should have. Is that what you meant by knowledge that...
>>SINGER: They understand the concepts?
>>BOLINGER: Right. Absolutely.
>>SINGER: But this is an implementation problem.
>>BOLINGER: This is an implementation issue. We have a palliative medicine team at our hospital, and I think there may be four or five physicians on that team. And what was happening is, our other physicians, our hospitals, and other specialties were referring a lot to these physicians because they did not want to have a final conversation about advanced care planning and some difficult conversations that were upsetting. So that was either leading to readmissions for extra care or having extra procedures that really shouldn't be done. So we were seeing a spike in that.
>>SINGER: Okay. Are these conversations between the patient and the physician? Or these patient and family?
>>BOLINGER: Yeah, it could be a variety.
>>SINGER: Or both?
>>BOLINGER: They're really both, but what we were focusing on was the conversation that the physician was having with the family or patient.
>>SINGER: Okay, and it's interesting you remarked that this was data driven as well.
>>SINGER: So that you see readmissions and other sort of outcome issues that are related to the care as that sort of procedure.
>>BOLINGER: Right. Because the physician potentially didn't want to have that conversation that really there is an end of life in sight. So the patient was asking for extra procedures, or often the family asking for extra procedures that really weren't going to provide a quality of life issuance, and so they were doing redundant things or procedures that really didn't need to be done.
>>SINGER: Okay, so that's the problem.
>>BOLINGER: That's the problem.
>>SINGER Now, tell us a little bit about the role that you have and where are you and have you discussed where we came to this?
>>SINGER: How did it find this way to you?
>>BOLINGER: Well, being the CME manager at Lancaster General Health, we're now part of the Penn Medicine system. I was involved in some of the earlier planning with some of the other events that we had, but the course director was more taking the lead on it. The event that sparked this event was a department of medicine grand rounds where I saw that this conversation was occurring towards the end of the event where physicians were saying, "But I don't want to talk to the patient about that." So the course director and I, Dr. Jason Scott, sat down and said, "You know, I think the problem really is, it's the performance. They understand what they're supposed to do, they don't want to do it."
>>BOLINGER: So that's where all the idea started percolating.
>>SINGER: Okay. And I'm assuming that you have to either generate the courage and the strategy to have that or lower some barriers that are the obstacles standing between what they currently do, and which you would like them to do or what they should be doing.
>>BOLINGER: Right. Yeah, and that was... We had a planning meeting with the palliative medicine physicians, some other physicians, and we really discussed what are the barriers, and what can we do to help these other physicians provide this conversation in order to avoid some of these unnecessary readmissions.
>>SINGER: Okay. So I mean it's great to hear that as the CME person as the educator that I think you realize that part of the role that you took is a problem solver to say, "How are we going to help use education as a way to get through these issues and help these folks?" So what came next?
>>BOLINGER: Okay, so then we had sort of a pow wow between the physician, the palliative medicine, and then my course director and we talked about, "Well, how can we make this real? How can we teach performance?" The course director said, "You know, I don't know if it can be too touchy feely because that's really not something that we typically do", so we have to kind of take a baby step into that. So we came up with the idea of palliative improv where we would have one physician act as the doctor and then other physicians act as patients, and then have the audience participate watching these little scenarios. So that was...
>>SINGER: So this is an event that took place at your institution?
>>SINGER: Okay. And then describe the room for me.
>>BOLINGER: Oh, well, I'm sorry I should take a step back.
>>SINGER: No. Sure.
>>BOLINGER: It happened at an outside facility where we planned it.
>>SINGER: Sure, sure.
>>BOLINGER: But yeah. So what we did was the course director assigned the roles of the patients who were actually physicians. We had four different scenarios. We had like a lung cancer, cystic fibrosis patient... There are four scenarios, and the physicians that were the actors playing the patients came dressed very interestingly and enjoyed that part of it. And then the other physicians, they're palliative care medicine physicians and others played the part of the physician counseling these patients.
>>SINGER: So it's interesting, both in the needs assessment and planning, you're depending on these experts, the palliative medicine physicians.
>>SINGER: And then in your activity, they are serving as sort of as presenters or actors. And I'm guessing. Tell me if I'm right.
>>BOLINGER: No, that's right.
>>SINGER: Because they could model the right way to do the... You mentioned performance to have the conversation in the right way or the right way to respond.
>>BOLINGER: Right, right, that's how it unfolded. And the physicians that were playing the patients were not given much information other than what their condition was. So they just played their condition. But the physician that was acting as a physician understood the scenario very well. And so, we had the palliative medicine physician be the emcee of it and mold in. So we had about five minutes for each scenario, and then we would step back and talk to the audience and say, "How could this conversation have been improved? What could we do? What would be the better way to do it? Or what were things that we thought were done very well?" So we got a lot of audience participation in that aspect of it.
>>SINGER: Great. So how did it go?
>>BOLINGER: It went very well. We had a sold-out crowd. We capped it at 100 attendees which for... We're not a very big organization so for us, that was an astronomical number.
>>SINGER: Yeah, that engagement.
>>BOLINGER: We had people wanting to come. Yeah, that was a lot of engagement. Physicians were very excited to be either the patient or the physician role. We had little awards at the end of the event, who was best...
>>SINGER: The daytime Emmy for…
>>BOLINGER: Everyone got an award but you're right. There was a lot of teamwork building, just a lot of excitement building up.
>>SINGER: Okay. So for the audience, so that we don't minimize those aspects of it, I'm drawing back to where you started, which is to say this is a difficult conversation, these are hard issues for the patient, for the family, for the care team. And here, you through a number of ways, including giving awards found a way to have it not only be engaging for folks, but to have it be fun. It sounds funny to say that.
>>SINGER: But to have it be a good experience and also be a learning experience.
>>BOLINGER: Right, right.
>>SINGER: Okay, so one of the core requirements that we have for accredited CME is that we're looking at what is the activity changing or what impact are you having? So I don't know if it's too early to tell, but do you have some sense to what the impact of the activity was on these performance issues?
>>BOLINGER: That's a good point. We did go back and measure and we did notice that of the attendees that attended we did notice that they were implementing the strategies that they described and we noticed that they were not as frequently referring or readmitting a patient so we felt that it was a big success in that way, but we are in the Plan-Do-Study-Act model. We're going back and constantly looking at what we can do, what's the next step, what are the next options for us.
>>SINGER: Oh, that's great. As you talk through this video to your colleagues around the country, are there things that you learn from doing this? Like, what were things that you’d do differently or things to avoid or things that you found that were really useful?
>>BOLINGER: A lot of the pros to it were the team building, the engagement. Our course director actually read an excerpt from the New England Journal of Medicine from Dr. McMahon saying we are changing the way we're doing CME, we're going to get away from the didactic. So that was wonderful. A con I would say is just, it took a lot of planning. As you can imagine, there are lot of parts involved instead of somebody standing up in front of a PowerPoint. But we felt that the benefits so outweighed that that we're going to do it again really. Really, it was a big success.
>>SINGER: That's great. And I'm sure that your leadership or the folks have noticed that and understood that the education takes investment so that's great.
>>SINGER: Thanks again for joining us.
>>BOLINGER: Thank you very much.