(1075) Expecting More: Bringing Mastery Learning to Late Goals-of-Care Discussions in the ICU

Tuesday, January 23, 2024

8:45 AM – 9:45 AM MT

Location: Connections Central - RST 09

First Author(s)

Noah Einstein, MD, (he/him/his)

McGaw Medical Center of Northwestern University
Chicago, Illinois

Co-Author(s)

JV

Julia Vermylen, MD

Physician
Northwestern University, United States
GW

Gordon Wood, MD

Physician
Northwestern University, United States
JW

James Walter, MD

Physician
Northwestern University, United States
EC

Elaine Cohen, MD

Physician
Northwestern University, United States
MS

Melanie Smith, MD

Physician
Northwestern University, United States

Introduction: Communication impacts patient outcomes, particularly in the intensive care unit (ICU), where effective goals of care conversations have been associated with improved outcomes. These conversations, commonly referred to as late goals of care (LGOC) discussions, are considered high stakes interventions, often occur near the end of life and precede withdrawal of life sustaining measures. There is no standard educational approach that ensures competency in the important skills required to lead LGOC conversations. Simulation-Based Mastery Learning (SBML) is a method of competency-based medical education that has been used in procedural and communication skills training. The aim of this study is to develop a LGOC SBML curriculum for critical care medicine (CCM) fellows and set a defensible minimum passing standard (MPS) ensuring rigorous and uniform skill acquisition.

Methods: Using the REMAP framework as the model for LGOC conversations, we created an assessment tool (AT) with checklist and scaled items. The AT was iteratively updated using a modified delphi process with a 12-member panel with expertise in medical education, critical care, palliative care, communication, and ethics. A pilot group of fellows participated in a pretest LGOC discussion with a simulated patient and received feedback with the AT. After a one-day workshop involving deliberate practice in small group sessions using VitalTalk methodology, fellows completed a posttest encounter. A separate expert panel set the MPS using the Mastery Angoff method.

Results: The developed AT included 18 checklist items and 6 scaled items with an inter-rater reliability avg kappa=0.90 and global rating scale items avg intraclass coefficient of 0.88. In the pilot, 10 CCM fellows improved from a median score of 52% (IQR 44%, 72%) on pretest to 96% (IQR 82%, 97%) on posttest (p < 0.005).The expert group panel set the MPS at 88% with an improvement in passing rate from 10% to 70% (p=0.02).

Conclusions: To our knowledge, this is the first study to develop an AT and a competency-based curriculum for LGOC discussions, demonstrating feasibility and marked skill improvement. This curriculum leads to uniformly high skill levels in LGOC discussions and has the potential to improve ICU outcomes.