Curriculum Innovations: Implementing a Neuropalliative Care Curriculum for Neurology Residents

Objectives

We developed and piloted a longitudinal multimodal curriculum in neuropalliative care (MCNC) at UW using evidence-based educational materials including VitalTalk. The goal of this curriculum was to provide residents with the communication skills they need to meet the needs of persons affected by serious neurologic disease. In this study, we disseminate the details of this curriculum and evaluate its feasibility and learning outcomes so that other educators may adopt similar training programs.

In collaboration with VitalTalk and UW faculty, we identified palliative care skills that any practitioner of neurology should master and established the following educational objectives:

1. To coach residents in developing actionable skills and tools for family meetings, including sharing serious news and discussing goals of care.

2. To teach residents how to recognize and respond to patient and family emotions.

3. To establish a common language for communicating with patients, families, and clinicians around palliative care needs.

4. To improve residents' confidence and comfort in providing neuropalliative care.

Methods and Curriculum Description

Curriculum Structure

The backbone of the curriculum comprised annual summer workshops and observed patient encounters. For PGY3 and PGY4 residents, who attend didactics together, we implemented an alternating curriculum such that 1 of 2 summer workshops was offered each year. At the beginning of their PGY3, residents were assigned a track based on which summer workshop was being offered that year. Figure depicts the general curriculum design.

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Figure Longitudinal Workshop Schedule for Neuropalliative Care Curriculum With Alternating Schedule for PGY3–4 Residents

ICU = intensive care unit; PGY = postgraduation year.

Additional foundational neuropalliative care education provided included the following:

1. At least 1 annual foundational neuropalliative didactic on amyotrophic lateral sclerosis, neuro-oncology, the neuro-intensive care unit (ICU), and general neuropalliative care.

2. One additional didactic each for multiple sclerosis and neurodegenerative diseases is planned.

3. Each of the 2-hour summer workshops was followed by 1-hour midyear refreshers, which served as opportunities to check in with learners on how they were applying their neuropalliative care skills.

4. As the curriculum evolved, we observed how emotionally taxing providing neuropalliative care can be for residents. Residents were encouraged to explore the challenging conversations and feelings that arise when caring for sick or dying patients at monthly palliative care discussion groups (called “death rounds”).^11,12 We also set up quarterly peer support check-ins for residents in this curriculum.

Results and Assessment Data

Discussion and Lessons Learned

This longitudinal MCNC meets the ACGME milestone requiring neurology residents to acquire proficiency in palliative care and develop skills in patient-centered and family-centered communication.⁶ Using evidence-based teaching methods and content, its experiential MCNC design is supported by research in both medical education and adult learning, which suggests that the most successful curricula allow people to be active agents in their own learning.^7,10,17 Our program incorporates recommended teaching methodologies including SP encounters, direct observation and coaching, acronyms, and pocket cards accessible through VitalTalk.^7,17

The theoretical background for our curriculum's teaching methods and structure is informed by transformative learning. We found that there were several components to optimally apply this theory to neuropalliative education: (1) experiential learning such as SP encounters and observed patient encounters provided learners the opportunity to critically examine how they discuss serious news and synthesize new perspectives in communication; (2) toolsets and learning modules from VitalTalk and the feedback from peers and mentors guided residents toward taking on intended communication skills from these patient encounters; and (3) we supported learners while we took them out of their comfort zone because challenging residents in these ways can be detrimental to learning without an environment of safety and respect.¹⁸ For this reason, key parts of the curriculum included training faculty and residents on providing constructive feedback and support groups where residents could process these intense experiences. We are encouraged in our application of transformative learning theory by learner feedback. One resident experienced a substantial shift in the perspective of end-of-life conversations and wrote an unsolicited email about their “first time” being involved in a “good death” experience.

We evaluated curricular outcomes by assessing changes in residents' learning (level 2 on the Kirkpatrick model training evaluation system).¹⁵ Data collected from preworkshop and postworkshop questionnaires suggest that the program increased residents' confidence in practicing certain neuropalliative skills. It is possible that skills in which residents reported unchanged or diminished confidence may reflect the Dunning-Kruger effect,¹⁹ whereby individuals become more aware of their knowledge deficiencies as they gain expertise.

Our training program demonstrates other outcomes related to educational interventions such as feasibility and adoption. Feasibility, an implementation outcome which measures the extent to which an innovation can be made,²⁰ is demonstrated by our successful recruitment and retention of learners and implementation of the curriculum over the past 4 years. We encouraged workshop attendance by incorporating the program into protected learning time, minimized resources required by using an alternating curriculum, and promoted faculty investment by disseminating background on the purpose of our curriculum. Although ensuring that residents practice their communication skills in real clinical settings was challenging at first, we resolved this by tracking observed patient encounters with a faculty feedback form and making this a requirement for graduation. Finally, successful adoption of the program, defined as learners' intention to use this practice,²⁰ is supported by residents' feedback on how helpful the training had been in their clinical encounters.

This study has several limitations. Although feasibility is demonstrated by the successful implementation of our curriculum, analysis of its efficacy is limited by the small sample size. Some factors potentially contributing to the sample size include our relatively small residency class, difficulty attaining 100% attendance because of the high clinical demands on residents and competing work hours, and data limited to the most recent workshops. In addition, the number of resident responses was different for our presurveys and postsurveys, limiting the accuracy of comparison between the 2 groups. We could not match individual residents between the samples because they were anonymous. Our questionnaires assess changes in learners' attitudes toward neuropalliative care but do not measure higher Kirkpatrick levels such as changes in clinical behavior or patient outcomes.¹⁵ This workshop was developed and conducted at a single institution and, therefore, may not be automatically generalizable to other institutions. For example, some medical centers may not have neurologists trained in palliative care, but one potential solution would be to partner with outside facilitators, now that virtual learning has become more universal. We believe that most neurology residencies can adapt this format to suit their individual needs and resources.

This experience has several implications for education in neuropalliative care. We effectively adapted VitalTalk to teach neuropalliative communication skills and believe this can be feasibly performed at other institutions. Most VitalTalk training programs for physicians comprised a single or limited number of sessions, but we believe that the 3-year longitudinal nature of our curriculum promotes long-term changes in behavior through deliberate practice and reinforcement over time.^21,22 We, therefore, encourage other institutions to consider adopting longitudinal neuropalliative curricula. Based on this experience and learner feedback, we believe that experiential learning, which pushes learners out of their comfort zone in a supportive environment, puts them in the best position to change their practice and recommend educators to consider transformative learning as a theoretical foundation for their curricula.

Future directions for our program may include improving our sample size by expanding the training program to include our neurology fellows and faculty and a multicenter study including neurology programs outside UW. We are also continuously improving our SP scenarios, including incorporation of diverse patient backgrounds, common socioeconomic barriers, and current challenges such as the recent COVID-19 pandemic. Finally, we collaborated with multiple faculty members in the development of this curriculum and believe that its content can be further improved by involving even more stakeholders in its design, including patients and families, neurology subspecialists, residents, and interprofessional team members.

In conclusion, we present a longitudinal MCNC, which provides simulated content, validated teaching resources, and recommended pathways to deliver that content. We hope our description of this curriculum can help other residency programs apply similar interventions.