Department of Surgery, University of Wisconsin. Madison, Wisconsin.
Department of Medicine. University of California San Francisco. San Francisco, California.
J Surg Educ. 2019 Jan-Feb;76(1):165-173. doi: 10.1016/j.jsurg.2018.05.015. Epub 2018 Jul 4.
Surgeons often conduct difficult conversations with patients near the end of life, yet surgical education provides little formalized communication training. We developed a communication tool, Best Case/Worst Case, and trained surgeons using a one-on-one resource intensive format that was effective but difficult to scale for widespread dissemination. We aimed to generate an implementation package to teach surgeons using fewer resources without sacrificing fidelity.
DESIGN, SETTING, AND PARTICIPANTS: We used the Replicating Effectiveness Programs framework to guide our implementation strategy and tested our intervention with 39 surgical residents at 4 institutions from September 2016 to June 2017. The implementation package consisted of: (1) instructional video, (2) checklist to assess competence, (3) learner manual, and (4) instructor manual. We focused on 3 implementation outcomes: feasibility, fidelity, and acceptability to participants.
Attendance rates ranged from 16% to 75%. Site leaders had little difficulty identifying suitable instructors; however, resident recruitment proved challenging. Sixty-nine percent of residents completed the post-training assessment and the mean score was 12.8 (range 8-15) using the 15-point checklist. Across sites, 69% strongly agreed that Best Case/Worst Case is better than how they usually approach high-stakes conversations and 100% felt prepared to use the tool after training. Instructors reported that the training provided residents with the necessary skills to perform the fundamental elements of Best Case/Worst Case.
Using implementation science we demonstrated that a resource intensive communication training intervention can be successfully modified for group-learning and wide-scale dissemination. However, we identified barriers to implementation, including challenges with feasibility and programmatic buy-in that inform not only resident education but also communication skills training more broadly.
外科医生在患者生命末期经常进行困难的对话，但外科教育几乎没有提供正式的沟通培训。我们开发了一种沟通工具，名为“最佳情况/最差情况”，并使用一对一的资源密集型格式对外科医生进行培训，这种格式虽然有效，但难以广泛传播。我们的目标是生成一个实施包，以便在不牺牲保真度的情况下，用更少的资源来教授外科医生。
设计、设置和参与者：我们使用复制有效性计划框架来指导我们的实施策略，并在 2016 年 9 月至 2017 年 6 月期间，在 4 个机构的 39 名外科住院医师中测试了我们的干预措施。实施包包括：（1）教学视频，（2）评估能力的检查表，（3）学习者手册，和（4）教师手册。我们专注于 3 个实施结果：可行性、保真度和参与者的可接受性。
出席率从 16%到 75%不等。现场负责人几乎没有发现合适的教师；然而，住院医师的招募被证明是具有挑战性的。69%的住院医师完成了培训后的评估，使用 15 分制检查表的平均得分为 12.8（8-15 分）。在所有站点中，69%的人强烈认为“最佳情况/最差情况”比他们通常处理高风险对话的方法更好，100%的人在培训后感到准备好使用该工具。教师报告说，培训为住院医师提供了执行“最佳情况/最差情况”基本要素所需的技能。
我们使用实施科学证明，资源密集型沟通培训干预措施可以成功地修改为小组学习和广泛传播。然而，我们发现了实施的障碍，包括可行性和计划内支持方面的挑战，这些不仅对住院医师教育，而且对更广泛的沟通技能培训都有影响。
