Abstract
Background
As palliative medicine concepts emerge as essential surgical education, there has been a resulting spike in surgical palliative care research. Historic surgical dogma viewed mortality and comfort-focused care as a failure of the providers’ endurance, knowledge base, or technical skill. Therefore, many providers avoided consultation to a palliative medicine service until it became evident a patient could not survive or was actively dying. As the need for surgical palliative care grows, the identification of deficits in surgical providers’ understanding of the scope of palliative medicine is necessary to direct further training and development efforts.
Method
A ten-question survey was emailed to all residents, physician assistants, nurse practitioners, and attending physicians in the general surgery and subspecialty surgical departments within the Einstein Healthcare Network.
Results
30 non-trainees (attending surgeons, nurse practitioners, and physician assistants) and 26 trainees (PGY-1 to PGY-5) completed the survey. Less than half of participants reported training in conversations regarding withdrawal of life-prolonging treatments in the setting of expected poor outcomes, 55% reported receiving training in pain management, and 64% reported receiving training in delivery of bad news. 54% report being involved in five or more end-of-life discussions in the last year with trainees reporting fewer end-of-life discussions than non-trainees; 67% of trainees reported zero to four discussions while 23% of non-trainees reported over twenty discussions (P = .009).
Conclusions
Despite many participants training in intensive care settings, providers lack the training to carry out major discussions regarding life-limiting illness, goals of care, and end-of-life independently.
Background
As palliative medicine concepts emerge as essential surgical education, there has been a resulting spike in surgical palliative research. As early as 1997, the American College of Surgeons (ACS) acknowledged the importance of palliative medicine as part of surgical care; the Robert Wood Johnson Foundation and the ACS collaborated and formed a workgroup that significantly advanced surgical providers’ knowledge and awareness of palliative medicine concepts.1,2 Journal of the American College of Surgeons published a 3-year series of surgeon-written articles about the interplay between palliative medicine and surgical care. The ACS has continued to encourage surgical residents’ involvement and knowledge of palliative medicine; in 2009, they published a guide entitled Surgical Palliative Care: A Resident’s Manual, and in 2019, the Accreditation Council for Graduate Medical Education (ACGME) included palliative skills as essential aspect of surgical education.1-3
The emergence of palliative medicine as an essential part of all surgical care is in stark contrast to historic surgical dogma that viewed mortality and comfort-focused care as a failure of the providers’ endurance, knowledge base, or technical skill. Therefore, many providers avoided consultation to a palliative medicine service until the latest stages of end-of-life care; indeed, surgeons are statistically less likely to engage palliative medicine and hospice consultants for critically ill patients. 4
Surgical residency is an opportune time for intervention and increased training in this critical nuance of surgical care. Surgical residents, despite high levels of engagement with critically ill patients, report a lack of confidence or knowledge in palliative care skills, including the delivery of bad news, management of advancing life-limiting conditions, and end-of-life care.5,6 Recent attempts to identify and improve palliative care skills in surgical residents have not been fruitful; Bradley et al (2010) showed no improvement in residents’ knowledge or skills after an institutionally developed palliative medicine curriculum. Most recent investigations into palliative medicine in surgical training have focused on surgical residents alone; there are few evaluations of current providers’ knowledge of the skills they aim to impart to their trainees. As the evidence for surgical palliative care grows increasingly obvious, the identification of deficits in surgical providers’ knowledge of palliative care is necessary to direct further training and development efforts.
Methods
A ten-question Google Forms survey was emailed to all residents, nurse practitioners and physician assistants, and attending physicians in the general surgery and surgical subspecialty departments within the Einstein Healthcare Network, a tertiary urban teaching health care system. This survey was deemed mandatory by faculty, and therefore a 100% survey completion rate was obtained for a total of fifty-six participants. Participant factors such as training level, prior postgraduate training or experience, and subspecialty were collected. Subspecialties included breast, colorectal, vascular, transplant, and plastic surgery providers across 3 medical campuses. Additional questions assessed baseline understanding of and training in palliative medicine as well as performance of essential primary palliative care during the prior month, including hosting discussions regarding end-of-life care and expectations.
Respondents were divided into 2 groups based on current training level—non-trainees (attending surgeons, nurse practitioners [NPs], and physician assistants [PAs]) and trainees (postgraduate year [PGY] 1-5 surgical residents). These 2 groups were compared using chi-squared testing. Non-trainees were further separated into PA/NPs and attending surgeons. In a sub-group analysis for trainees only, 3 groups were created based on training level and according to ACGME: PGY-1 (interns), PGY 2-3 (junior residents), and PGY 4-5 (senior residents). This sub-group analysis was compared using chi-squared testing. The level of alpha for significance was set at .05.
Results
Thirty non-trainees and 26 trainees completed the survey. Approximately 50% of respondents practice general surgery, while the remaining 50% was divided among surgical subspecialties (see Figure 1). More non-trainees than trainees reported at least 2 months of ICU-level training (90% vs 65%, P = .025). The sub-group analysis of non-trainees revealed no differences in responses between PA/NPs and attending surgeons, with the exception of reported training in intensive care settings (P = .018). Surgical specialties of respondents.
45% of respondents reported no training in palliative care skills. Less than half of participants reported training in conversations regarding discontinuation of life-prolonging measures, while 55% reported receiving training in pain management, and 64% reported receiving training in delivery of bad news (see Figure 2). Trainees trended toward more training in pain management (P = .052, trainees 69% vs non-trainees 43%); however there were no significant differences between the 2 groups in regard to reported palliative care training. Rates of training subtypes for all participants.
71% of participants reported zero to four consults to palliative medicine per month, with no significant difference between the 2 groups. When asked about the impact of COVID-19 on the rate of consults to palliative care, 50% of trainees reported an increase in interactions with palliative medicine and 67% of non-trainees reported no change (P = .056). 54% of participants reported being involved in five or more end-of-life discussions in the last year, with trainees reporting fewer end-of-life discussions than non-trainees; 67% of trainees reported zero to four discussions while 23% of non-trainees reported over twenty discussions (P = .009). As trainees progressed through residency, they reported more involvement in discussions regarding end-of-life, with a significant difference between PGY-1 and more senior residents (P = .024; see Figure 3). Additionally, as expected, trauma and critical care-trained specialists reported more training in palliative medicine skills than other queried specialties (see Figure 4) (refer to Table 1 for a comprehensive analysis of all variables of interest). Rates of training subtypes by year of surgical training. Rates of training subtypes by specialty. Survey Responses for Trainees vs Non-Trainees.
Discussion
This study presents a complete picture of the baseline knowledge, skills, and training in palliative care concepts in an entire surgical department at an urban teaching health care network. Less than half of surgical providers at our tertiary health care network reported training in palliative care skills, and trainees were significantly less likely to hold goals of care discussions with patients and family members. With a great number of trainees engaging in training in ICU-level care, the low rate of training in palliative care skills presents a significant deficit in training and knowledge that must be rectified. In addition to being a core skill as identified by the ACGME, 3 the ability to hold conversations about prognosis, guide intensive shared decision-making and end-of-life discussions, and manage acute and chronic pain in serious illness is critical to developing a complete and humanistic surgeon.1,2,5,7,8 Surgeons routinely conduct discussions about risks and benefits in the setting of obtaining informed consent; however, palliative medicine should be incorporated throughout the patient’s disease course. While palliative specialists are frequently available for consultation in critical conditions, it is unrealistic and burdensome to expect that all prognostic or palliative discussions be held by palliative specialists. Instead, surgeons and palliative specialists can work together to deliver patient-centered, goal-directed care. In addition to allowing patients to make well-informed, thoughtful decisions about their medical care, there is evidence that ongoing involvement with palliative medicine, in addition to active treatment, can increase survival in certain diseases. 9
Recent studies into surgical palliative care have identified 3 key areas that require further study: measuring outcomes that matter to patients; communication and decision-making; and delivery of palliative care to surgical patients. 10 We believe that assessing the current status of both residents and faculty regarding existing knowledge and skills is essential to developing a road map to accomplishing these three priorities. Suwanabol et al (2018) found that major barriers to surgeon engagement with palliative care in an oncologic setting included lack of prior knowledge and training, communication challenges, prognostication difficulties, and patient and family expectations. 11 Ongoing training and education are necessary to improve both baseline knowledge and professional engagement with palliative care concepts. In our investigation, 50% of non-trainees have received no training in palliative care concepts, a shocking percentage as these individuals are responsible for training the new generation of surgeons. Non-trainees are also most likely to perform primary palliative care; without formal training, it is difficult to quantify the quality of these interactions and if best practices are being followed. It is encouraging that a higher percentage of learners endorse training in palliative care skills; this implies that palliative medicine has been incorporated into the curriculum over time. However, as 37% of trainees endorsed no training in palliative care skills, we must acknowledge that there is still significant work to be done. Bonnano et al (2019) conducted a survey to investigate surgical resident and faculty perception of palliative care skills and knowledge; their findings correlated well with our own findings, with about half of surgical residents reporting the ability to lead goals of care conversations, administer comfort care, and deliver bad news. 12 At our institution, we found that, despite most trainees reporting training in palliative care concepts, they are significantly less likely to engage in goals of care conversations or those regarding end-of-life or prognosis than non-trainees. Despite perhaps having more formal communication training, residents do not ultimately dictate decisions in patient care and especially not when it pertains to end-of-life care. Although trainees may have a more robust skillset and be more comfortable with the idea of having these conversations, they are not seen as being the appropriate parties to do so given the hierarchy in medicine and responsibility of care that lands on the attending surgeon. In addition, trainees reported a lower rate of consults to palliative medicine during the COVID-19 pandemic, illustrating a lack of awareness of the necessity of ongoing discussions about quality of life after critical illness. This presents a major deficit in the development of a skill that is crucial to the evolving surgeon and illustrates the importance of intentional involvement of learners in all aspects of surgical care. Bonnano et al (2019) found that surgical residents desired formal education in palliative care skills, and Raoof et al (2016) introduced a novel half-day palliative care skills training workshop into their surgical curriculum with improvement in knowledge, attitudes, and perceived skills of general surgery residents.12,13
Sub-Group Analysis Based on Resident Year.
With the support of the ACGME and the ACS, palliative care has taken its place as an essential skill in an early surgeon’s training. Next steps should include the expansion of this survey to other surgical residencies to continue to formulate an understanding of current knowledge. This project also did not include evaluation of surgeons’ attitudes regarding the role of palliative medicine in restorative and rehabilitative care, focusing on a more traditional understanding of the field. Additionally, further efforts must be made to intentionally include palliative medicine lectures, workshops, and practical application of skills during surgical residency. Non-trainees would also benefit from training in these skills, so that current learners may continue to benefit from formally trained faculty. Our findings provide crucial information about the baseline knowledge and skills in a small surgical department and should be utilized to develop further palliative medicine training for aspiring surgeons.
Conclusion
Despite many participants training in intensive care settings, providers lack the training to carry out major discussions regarding life-limiting illness, goals of care, and end-of-life independently, including conversations regarding discontinuation of life-prolonging treatments, pain management, and delivery of bad news. Trainees in a surgical residency program practice these skills much less frequently, crucially missing a chance to hone essential skills prior to practicing independently. The surgeons’ role as a healer aligns well with palliative medicine’s ability to potentially prolong life with better quality, though we suspect this is not well understood by surgeons. Future studies are needed to explore the surgeon’s understanding of the role of palliative subspecialists beyond end-of-life and alongside treatments intended to be restorative and rehabilitative. More formal and practical training in palliative care skills is needed to appropriately train aspiring and currently practicing surgeons to practice patient-centered, humanistic medical care.
Footnotes
Author Notes
The data presented in this article have been previously presented at the following conferences:
Philadelphia Academy of Surgery Trainee Research Competition, February 2021
Albert Einstein Medical Center Philadelphia Resident Research Competition, May 2021
Owen H Wangensteen Scientific Forum at American College of Surgeons Clinical Congress, October 2021
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.