Educational Intervention to Improve Code Status Discussion Proficiency Among Obstetrics and Gynecology Residents

Abstract

Background:

Obstetrics and gynecology (OB/GYN) residents receive little formal training in conducting code status discussions (CSDs).

Objective:

We piloted an educational intervention to improve resident confidence and competence at conducting CSDs.

Design:

The OB/GYN residents at a single institution participated in a 3-part educational program. First, participants reviewed a journal article and completed an online module. Second, they received a didactic lecture followed by a resident-to-resident mock CSD. Finally, participants had a videotaped CSD with a standardized patient (SP). Pre- and postintervention surveys and performance evaluations were analyzed. A subgroup analysis was performed on those with completed data sets.

Results:

Participants included 24 residents in postgraduate years (PGY) 1 to 4: 85% were female with a mean age of 29 years; 83% completed the entrance survey; 63% completed the SP CSD; and 42% completed of all parts of the intervention. Residents initially felt most prepared to discuss treatment options (3.3/5 on a Likert scale) and less prepared to discuss hospice, end-of-life care, and code status (2.2/5, 2.2/5, and 2.3/5, respectively). Performance during the resident-to-resident CSD was variable with scores (% of skills achieved) ranging from 27% to 93% (mean 64%). Performance at the SP encounter was similar with scores ranging from 40% to 73% (mean 56%). After intervention, residents felt more prepared for CSDs (3.7/5) and end-of-life care (3.9/5). The subgroup analysis failed to show a significant change in skill performance from the first to the second CSD.

Conclusion:

Participants found the components of this intervention helpful and reported improved confidence at conducting CSDs.

Keywords

obstetrics and gynecology resident code status discussion intervention education evaluation

Introduction

Eliciting a patient’s code status is an aspect of primary palliative care that requires education and practice. House staff routinely documenting code status in the medical record, however, often report inadequate skills and lack of training.¹ Techniques and best practices of code status discussions (CSDs) include providing details about the likelihood of success, providing recommendations, and allowing the patient to lead the discussion.^2,3 Some experts suggest there are times when resuscitation should be discouraged or not offered.⁴ Documentation of code status on hospital admission is a standard in many hospitals, although not often achieved.

Physicians generally perform poorly when evaluated for proficiency at conducting a CSD. The SUPPORT trial showed that 46% of do not resuscitate orders in an inpatient unit were written within 2 days of death.⁵ While this trial is dated, more recent studies continue to highlight the challenges of effective end-of-life communication. Audiotaped CSDs led by internal medicine residents revealed that during a CSD, only 55% of residents mentioned chest compressions, only 13% of residents mentioned likelihood of surviving CPR, and residents usually did the majority of the talking.⁶ Attempts at improving CSD efficacy and frequency among both resident and attending physicians have been generally unsuccessful.^5,7,8 Various resident educational interventions have been studied for their effectiveness and feasibility. Interventions have included a combination of self-directed reading, faculty-led lectures, resident-to-resident role play, and interviews with a standardized patient (SP).^9

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Obstetrics and gynecology (OB/GYN) providers elicit code status for terminally ill patients with gynecologic malignancies as well as more rarely for critically ill obstetric patients with severe complications of pregnancy. While a gynecologic oncologist elicits code status more commonly, a generalist OB/GYN should still be able to competently confirm code status as cases of obstetric critical care involving an often otherwise healthy new mother are intensely challenging. We piloted an intensive educational intervention to teach CSD skills among OB/GYN residents by combining aspects of different published interventions and incorporating them into a clinically busy OB/GYN residency program. Our aim was to evaluate the feasibility, effectiveness, and satisfaction of this intensive educational intervention.

Materials and Methods

Study Design

This was a prospective, observational study to assess the feasibility, effectiveness, and satisfaction of an educational intervention aimed at increasing confidence and competence of OB/GYN residents at conducting a CSD. The intervention consisted of a journal article review and online module on CSD technique, an intensive workshop with palliative care didactics, a simulated resident-to-resident CSD, and a videotaped CSD with a SP. Entry and exit surveys were administered. The Columbia University Irving Medical Center (CUMC) Institutional Review Board approved the study protocol.

Setting

The CUMC OB/GYN residency program is housed at the New York Presbyterian Hospital–Columbia Irving Campus and has 24 residents. Protected didactic time occurs in Thursdays from 9:30 am to 11 am. At the time of this study, there was no established curriculum to teach CSD skills to residents due to limited available didactic time and difficulty in prioritizing of topics outside of general obstetrics and gynecology and its subspecialties.

Participants

All OB/GYN residents at CUMC were approached via e-mail in June 2015 to voluntarily participate. Informed consent was obtained after an information session was held. An entrance survey was administered via SurveyMonkey Inc. to gather demographic data, assess previous education regarding CSDs, and evaluate resident’s confidence at performing CSDs using a Likert scale. This survey was adapted from a similar intervention among internal medicine residents with permission from the author.⁹ Each participant was given a de-identified study ID: their birthday combined with the first 3 letters of their mother’s maiden name. One study investigator (B.M.) had access to the study IDs.

Intervention

The first component of the intervention included an at home journal article review and 1-hour interactive online module that addressed CSD communication techniques and barriers to effective communication.^3,13 Second, participants attended a 90-minute workshop during protected didactic time, which consisted of a lecture by palliative care faculty followed by resident-to-resident role play of a simulated CSD. Two workshops were held to capture residents who were on vacation, night float rotation, or were unable to attend due to clinical duties. Participants were not allowed to repeat the didactic session. Residents simulated a case of a woman presenting to the emergency department with stage IV ovarian cancer with pulmonary metastases and shortness of breath. Palliative care faculty evaluated resident performance using a Learner Evaluation Tool adapted from the Medical College of Wisconsin, Inc Palliative Care Programs (Copyright 2003). This tool rated learners’ performance during the resident-to-resident mock CSD by assigning checks for completed aspects of a CSD.

The third part of the intervention consisted of a videotaped 20-minute CSD with an SP, a paid actor who facilitates simulation of a clinical encounter. The same palliative care faculty member evaluated resident performance during the SP encounter with the same Learner Evaluation Tool used for the resident-to-resident mock CSD. Resident performance was kept confidential. Standardized patient sessions were held monthly from August 2015 to December 2015 to accommodate participation of all available participants. Participation concluded with an exit survey detailing which parts of the intervention were most useful and perceived proficiency at leading a CSD using a Likert scale, also adapted with permission by Szmulkeiwicz et al.

Analysis

Descriptive statistics were utilized to characterize the survey question response frequencies. A subgroup analysis including those who completed all 3 components of the study was performed to compare performance at the resident-to-resident mock CSD and the SP CSD. Paired t tests were used to compare average scores from the first evaluation (conducted after the resident-to-resident mock CSD) to the second evaluation (conducted after the SP CSD). A 2-sample test of proportions was used to compare individual skill performance on key skills that were determined a priori. All analyses were performed in SAS version 9.3 (SAS Institute Inc., Cary, North Carolina).

Results

Participation and Baseline Characteristics

All 24 OB/GYN residents participated in a simulated CSD as a part of this study. Ten residents completed all 3 components of the intervention (Figure 1). Of the 20 participants who completed the intake survey, 85% were female, and the median age was 29 years and included residents from postgraduate years (PGY) 1 to 4 (Table 1). Half (50%) of the participants reported having had between 1 and 3 hours of prior end-of-life (EOL) care education; however, 15% reported no prior EOL care education. Only 30% of participants completed a prior palliative care or hospice rotation. The majority of participants (67%) had some contact with palliative care providers during residency training. Notable differences between those with completed data sets to the entire group included a higher representation of PGY 1 (50% compared to 30% in the larger sample) and a higher proportion of participants who had a prior palliative care or hospice rotation (60% compared to 30% in the larger sample). Experience during residency in conducting CSDs varied as expected with the representation of PGY 1 to 4 residents (Figure 2).

Table 1.

Participant Characteristics.

Characteristic	Response From Total Cohort (%), N = 20^a	Response From Subset With Completed Data Sets (%), N = 10^b
Sex
Male	3 (15%)	2 (10%)
Female	17 (85%)	8 (80%)
Age
Median	29	28
Average	28	28.6
PGY
1	6 (30%)	5 (50%)
2	5 (25%)	2 (20%)
3	4 (20%)	3 (30%)
4	5 (25%)	0 (0%)
Intended specialty
MFM	6 (30%)	4 (40%)
REI	4 (20%)	0 (0%)
Oncology	4 (20%)	3 (30%)
Family planning	1 (5%)	0 (0%)
Academic generalist	1 (5%)	1 (1%)
Undecided	4 (20%)	2 (20%)
Prior EOL education (lectures, seminars)
0 hours	3 (15%)	0 (0%)
1–3 hours	10 (50%)	4 (40%)
4–10 hours	4 (20%)	4 (40%)
10–40 hours	2 (10%)	1 (10%)
>40 hours	1 (5%)	1 (10%)
Prior palliative care or hospice rotation
Yes	6 (30%)	6 (60%)
No	14 (70%)	4 (40%)
Contact with palliative care providers during residency
Yes	12 (67%)	6 (60%)
No	6 (33%)	4 (40%)
Have you ever experienced the death of a parent, sibling, or child? (N = 18)
Yes	0 (0%)	0 (0%)
No	18 (100%)	10 (100%)
Have you ever personally faced a lift-threatening illness? (N = 18)
Yes	0 (0%)	0 (0%)
No	18 (100%)	10 (100%)

Abbreviations: EOL, end of life; MFM, maternal–feta medicine; PGY, postgraduate year; REI, reproductive endocrinology and infertility.

^aTwenty of the 24 total participants who completed the intake survey.

^bTen of the 24 total participants who completed all parts of the intervention.

Participants agreed that clarifying a patient’s wishes at the EOL is important (94% agree). Most (78%) participants disagreed that it is solely the responsibility of the attending physician to address code status and similarly disagreed (94%) that is the patient’s responsibility to bring up the topic. Despite the perceived importance of clarifying code status at the EOL, few residents reported direct training to perform such skills; 75% or more of residents responded “no” to the question of receiving direct training or feedback regarding telling a patient about a diagnosis, discussion of code status, discussion of prognosis, discussion of hospice, or discussion about the type of care patients would like to receive at the EOL. More participants reported direct teaching regarding discussing treatment options (50% received instruction, 37% received feedback).

Participants’ perceived confidence at performing parts of EOL care at the beginning of the study and after all parts is displayed in Table 2. Before intervention, participants felt least confident about discussing code status (2.3/5), discussing the type of EOL care a patient desires in the context of their values and treatment goals (2.2/5) and talking to patients about hospice (2.2/5). Improvements in reported confidence were seen postintervention across all areas of EOL care. The skills participants felt most confident about postintervention included talking about code status (3.7/5) and discussing EOL care in the context of a patient’s values and treatment goals (3.9/5). Reported confidence pre- and postintervention were highest and showed an increase for interviewing skills such as responding to patient emotions, establishing baseline patient knowledge and summarizing the conversation (Table 2). Pre- and postintervention reported confidence in teaching skills associated with EOL care was less than reported confidence at performing those skills.

Table 2.

Reported Resident Confidence About End-of-Life Discussion Skills Pre- and Postintervention.

	Average Response (Likert Scale 1 to 5^a)
	Pre- intervention	Postintervention	Difference in Score
Overall, how well prepared do you feel to perform the following tasks?
Tell patients about a new, life-threatening diagnosis	2.50	3.50	1.00
Talk to patients about their treatment options	3.30	3.50	1.20
Talk to patients about their prognosis	2.60	3.20	0.60
Talk to patient about their code status	2.30	3.70	1.40
Talk to patients about the type of care they would like to receive at the end of life based on their values and goals	2.20	3.90	1.70
Talk to patients about hospice	2.15	^b	N/A
Overall, how well prepared do you feel to teach others how to perform the following tasks?
Tell patients about a new, life-threatening diagnosis	2.22	3.12	0.90
Talk to patients about their treatment options	2.44	3.18	0.74
Talk to patients about their prognosis	2.06	2.82	0.76
Talk to patient about their code status	2.22	3.29	1.07
Talk to patients about the type of care they would like to receive at the end of life based on their values and goals	2.17	3.41	1.24
Talk to patients about hospice	1.94	^b	N/A
When discussing end-of-life care with patients, how well prepared do you feel to perform the following?
Establish what the patient understands about his or her illness	3.26	4.05	0.79
Clarify how much the patient wants to know and how he or she wants to make decisions	2.84	3.89	1.05
Inquire about the patient’s values, goals, hopes, and fears	3.00	4.17	1.17
Respond to the patient’s emotions	3.68	4.28	0.60
Summarize the conversation and establish a shared plan	3.28	3.94	0.66
Support hope while disclosing information about a poor prognosis	2.89	3.78	0.89

^a1 = not well at all, 3 = somewhat well, 5 = very well.

^bQuestion not asked on postintervention survey.

Simulated CSD Performance

Performance evaluations completed by palliative care faculty were scored based on completion (credit given) or noncompletion of each skill on the grading rubric to generate a percentage of completed skills. Mean scores for the first and second evaluations were 64% (score range 27% to 93%) and 56% (score range 40% to 73%), respectively. Individual skills that participants most commonly performed on the initial resident-to-resident simulated CSD were an introduction (100%), assuming a comfortable interpersonal distance (89%) and making appropriate eye contact (94%). However, participants scored lower during the SP CSD on the previously stated 3 skills they previously scored well on at the resident-to-resident CSD (60%, 53%, and 60%, respectively). Skills that few residents performed during the resident-to-resident CSD included suggesting a follow-up plan (28%), discussing CPR within the context of disease and prognosis (39%), making a recommendation regarding whether to receive CPR (22%), and summarizing the conversation (6%). Similar trends were seen for suggesting a follow-up plan (0%), making a recommendation regarding whether to receive CPR (0%), and summarizing the conversation (0%) at the SP CSD. The only skill that showed an increase in performance between the resident-to-resident CSD and the SP CSD was discussing CPR within the context of disease and prognosis (39% to 53%).

A subgroup analysis using only those participants who had completed all parts of the intervention was performed (N = 10). There was no difference in overall scores before and after the intervention (average score for resident-to-resident CSD 62% vs average score for SP CSD 52%, P = .222; Table 3). Core skills that were addressed during the intervention were chosen for analysis a priori with a 2-sample test of proportions: asking the patient to articulate personal goals near the EOL, discussing CPR within the context of the disease and prognosis, and making a recommendation regarding whether to receive CPR. More participants asked the simulated patient to articulate their personal goals during the resident-to-resident CSD than at the SP CSD (80% vs 30%, P = .025). More participants discussed CPR within the context of the disease and prognosis during the SP CSD than at the resident-to-resident CSD (90% vs 30%, P = .006). Few to no participants made a clear recommendation regarding CPR (resident-to-resident CSD 10%, SP CSD 0%, P = .300).

Table 3.

Comparison of CSD Skill Performance at Initial Workshop Compared to Final Standardized Patient Encounter.

	Resident-to- Resident CSD (%)	Standardized Patient Evaluation (%)	P value, N = 10^a
Total score (average percentage of total skills completed)	62	52	0.222^b
Mean individual skill score (percentage of participants who completed individual skill)
Doctor asked patient to articulate personal goals	80	30	0.025^c
Doctor discussed the use of CPR within the context of the disease and prognosis	30	90	0.006^c
Doctor made a clear recommendation regarding CPR/no-CPR	10	0	0.300^c

Abbreviations: CSD, code status discussion; CPR, cardiopulmonary resuscitation.

^aData calculated using 10 participants who completed all parts of the intervention.

^bPaired t test.

^cTwo-sample test of proportions.

Intervention Feedback

Satisfaction with the intervention was high, with 72% of participants reporting that the intervention changed the way they communicate with patients about EOL issues. Almost all (94%) participants felt that all OB/GYN residents should participate in this or a similar intervention. As shown in Table 4, participants almost unanimously agreed that all parts of the intervention were “helpful” (workshop preparation 92.3% agreed, resident-to-resident CSD and workshop 100% agreed, SP CSD 94.4% agreed). Participants most commonly agreed (84.6%) that the resident-to-resident CSD and workshop changed the way they communicate with patients (preintervention preparation 69.2% agreed, post-SP CSD 77.8% agreed). Self-reported confidence for performing CSDs was higher after all parts of the intervention. In all, 100% of participants reported the workshop preparation improved their confidence at conducting a CSD, 92.3% reported higher confidence after the resident-to-resident CSD, and 88.9% after the SP CSD.

Table 4.

Resident Satisfaction With Components of Intervention.

	Disagree (1 to 2) (%)	Neutral (3) (%)	Agree (4 to 5) (%)
Pre-workshop preparation (article and online module)^a
I found this helpful	0	7.7	92.3
This changed the way I communicate with patients	0	30.7	69.2
I feel more confident to conduct an EOL discussion after this part of the intervention	0	0	100
Palliative care workshop and resident to resident CSD discussion^b
I found this helpful	0	0	100
This changed the way I communicate with patients	0	15.4	84.6
I feel more confident to conduct an EOL discussion after this part of the intervention	0	7.7	92.3
Standardized patient simulated CSD
I found this helpful	0	5.6	94.4
This changed the way I communicate with patients	5.6	16.7	77.8
I feel more confident to conduct an EOL discussion after this part of the intervention	5.6	5.6	88.9

Abbreviations: CSD, code status discussion; EOL, end of life.

^aFive participants reported not completing the online module.

^bFive participants who filled out the exit survey did not complete the palliative care workshop.

Discussion

The Accreditation Council for Graduate Medical Education (ACGME) graduation requirements for OB/GYN residents include a proficiency with “interpersonal and communication skills that result in the effective exchange of information and collaboration with patients.”¹⁴ We successfully piloted an intervention in line with this milestone that was well received and perceived as beneficial to patient care, evidenced by the overwhelming sentiment that this intervention should we widely applied to OB/GYN programs. Our combination of self-delivered didactics combined with in-house experiential learning is an example of the “flipped classroom” model that is successfully being employed in medical education.^15,16

In our extensive literature review, we identified only one published intervention to teach EOL discussions in a surgical program. PGY 1 and PGY 3 residents in general and orthopedic surgery programs completed an online course (10 online modules) to teach EOL discussions and medical error disclosure.¹⁷ Online course usage was “moderate to low,” and pre- and postintervention observed clinical encounters failed to show significant differences (whole group analysis) in scores between the control and intervention groups. As a response to low usage of self-directed material such as readings and online modules as seen in this study, we prioritized incorporation of a substantial in-person component to our intervention. Their higher completion rate of 77% compared to our 42% completion of both CSDs is likely due to the fact that both observed clinical encounters were previously established program requirements independent of the study.

Self-reported confidence in CSD skills improved at the postintervention survey compared to the preintervention survey. Participants at baseline felt most confident with the set of skills that are also useful outside the context of a CSD (discussion of treatment options, establishing patient illness understanding, responding to a patient’s emotions). Participants reported the least confidence both pre- and postintervention with teaching CSD skills with only modest improvements. This likely reflects that effective teaching requires advanced practice unlikely to have been achieved over the course of a single intervention. The skills that showed the most improvement were the ones most directly targeted by the intervention: confidence in addressing code status (score difference 1.4) and discussing care in the context of values and goals (score difference 1.7). While improvements in self-reported confidence are reflective of an impactful intervention, they might not correlate with skill acquisition and proficiency.

Our subgroup analysis for those with complete data sets compared performance between the 2 simulated CSDs. A proposed explanation for the decrease in performance from the resident-to-resident CSD to the SP CSD stems from a reviewer’s observation that 1 SP’s dramatic performance made it difficult for the CSD to proceed effectively. Additionally, the SP discussion occurred 1 to 5 months after the intervention, possibly resulting in poor skill retention. Another possible explanation is that the nature of the intervention itself, limited in scope and lacking ongoing feedback, practice, and mentorship, precluded meaningful objective impact on participant performance.

Performance in specific skills ranged over the course of the intervention. There was a statistically significant increase in the percentage of people who “discussed the use of CPR within the context of the disease and prognosis” from 30% to 90% (P = .006). This was the skill that was most directly taught in all parts of the intervention. The statistically significant decrease in the percentage of people who “asked the patient to articulate personal goals” (80-30%, P = .025) could reflect this skill as a more specific task that was performed more frequently after it was recently taught. The low completion of “making a clear recommendation regarding CPR” likely reflects that this is a more advanced skill that requires additional practice. Ultimately, it is difficult to draw direct conclusions from this subgroup analysis, as the cohort of 10 participants is small.

This study has inherent limitations in its design and implementation within a clinically busy OB/GYN residency program. The only feasible way to incorporate a videotaped SP encounter into this intervention was to conduct the sessions outside of the limited protected didactic time. Our solution of monthly sessions to capture residents as they passed through their oncology rotation caused a delay in the time between the initial parts of the intervention and the final SP session of 1 to 5 months. Other researchers have used “booster sessions”¹⁸ to review material before a postintervention evaluation; however, this was not feasible for this intervention.

Our study sample of 24 residents (10 with complete data sets) provides limited statistical power for analysis. Despite our efforts at increasing participation, only 75% of participants completed the portion of the intervention scheduled during protected academic time. Lower participation was seen for the SP encounter outside of protected academic time. The subset of participants who completed all parts of the intervention limits the ability to generalize results to the entire study population. The overrepresentation of PGY 1 residents could influence results because more advanced residents are likely to have more experience and a greater comfort level with CSDs over time. The overrepresentation of participants who had a previous hospice or palliative care rotation could also impact results as prior training could influence participant confidence and performance. The overrepresentation of PGY 1 residents is due to the support of a physician assistant on the oncology service who facilitated PGY 1 participation, while the overrepresentation of those with previous palliative care experience is likely a random finding as participation was mostly influenced by resident scheduling and availability.

The nonrandomized nature of the intervention limits the ability to draw conclusions that the intervention per se improved confidence or scores. Experience during the time period between the resident-to-resident CSD and the SP CSD could also contribute to increased confidence. Additionally, the impact of this and similar interventions on actual patient care has also not yet been proven. In a study by Curtis et al, internal medicine residents and nurse practitioners underwent a simulation-based communication skills intervention.¹⁹ They failed to show improvements in patient-reported quality of communication and quality of EOL care despite demonstrating skill acquisition. Until the optimal methods of teaching EOL and CSD communication skills are proven, educational institutions will rely on some combination of didactics and simulation.

Strengths of our study include our ability to incorporate a multifaceted and comprehensive intervention into a busy OB/GYN residency program, which was viewed positively by the residents. Residents almost unanimously rated all parts of the intervention as helpful and believed the intervention should be widely applied to OB/GYN residents. Didactics and evaluations were conducted by impartial palliative care faculty who had little to no prior interaction with the residents they were teaching and evaluating. The SP evaluation allowed participants to be challenged with an actor who closely resembled a patient. We believe that our intervention can be adapted to fit with the schedule of other OB/GYN programs with departmental support.

OB/GYN residency programs have limited time for didactic instruction often at the expense of topics such as CSD skills. Despite this, all OB/GYN residents should achieve proficiency at counseling patients regarding resuscitation preferences. Our intervention was challenging to coordinate as expected; however, it led to improved self-reported confidence in CSDs, improvement in a key CSD skill, and was well received. Integrating these important topics into OB/GYN residency programs will be an ongoing challenge. Further study is warranted to determine the extent and delivery of education on CSD skills that will maximize skill retention.

Footnotes

Authors’ Note

Original work was previously presented in poster format at New York Presbyterian Oncology Quality Improvement Symposium (June 2016) and New York Obstetrical Society Meeting (April 2016).

Declaration of Conflicting Interests

The authors declared no potential conflict of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Wright is a recipient of a grant National Cancer Institute (NCI; R01CA16912) from the National Cancer Institute. Dr. Tergas is a recipient of an NCI Diversity Supplement (CA197730).

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