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GI fellows require more guidance on personalizing liver disease consults

In an objective structured clinical examination, researchers found that gastroenterology fellows could successfully summarize clinical findings and discuss treatment plans with standardized patients, but were challenged by time to decide the appropriate amount of information to convey in one setting.

“Ensuring patient satisfaction is key in successful management of care. Best practice entails balancing patients views of physician-patient communication and ensuring the adoption of a patient-centered communication approach,” Naomi Chaudhary, MD, from the New York University School of Medicine, and colleagues wrote. “Our results suggest that the fellows were not well positioned to present data in a patient-specific manner and that they might not meet their professionalism milestone requirements. ... Fellows need to be taught how to better read a patient’s biases and emotional reactions.”

Twelve second-year gastroenterology fellows participated. The objective structured clinical examination consisted of four case scenarios with standardized, trained patients with instructions and a 5-item checklist to rate the fellows’ performance.

According to the researchers, the challenge for the fellows was to “communicate effectively with the [standardized patients] and to acknowledge that each patient had an emotionally charged issue to overcome” while the observers simultaneously assessed the fellows’ clinical knowledge in a simulated office setting.

Shared decision-making case

The fellows encountered a case of a young nursing student who was recently diagnosed with acute hepatitis C after a needle stick injury to assess their ability to discuss the risks for transmission, possibility of spontaneous clearing of the virus, treatment options and to share therapeutic decision-making with the patient.

All 12 fellows successfully summarized findings and 85.71% explained the various treatment options. None, however, objectively explained deferral treatment. In evaluating themselves, 55.6% of the fellows felt they could have performed better in this case.

Breaking bad news case

In a “bad news” scenario, the fellows were to counsel a 54-year old man recently diagnosed with cirrhosis secondary to chronic alcohol use and discuss the risk for complications.

Most fellows (76.92%) received high ratings for professionalism and providing clear information as well as emotional support. However, the standardized patient did not feel a sufficient amount of information was provided, particularly treatment and follow-up plans, nor was the patient satisfied with the amount of shared decision-making.

“A new or terminal diagnosis is often met with intense emotions, which abruptly obliterate the conversation,” the researchers wrote. “Understanding the patient’s reactions as well as responding to and focusing on the emotional needs provide the foundation for compassionate as well as effective communication. Maximizing these skills would help ensure better outcomes.”

Health literacy case

The researchers assessed the fellows’ ability to identify the health literacy of a Chinese patient with chronic hepatitis B and educate the patient about the disease in a culturally sensitive manner. The researchers defined below-basic health literacy as the ability to perform simple literacy activities such as reading short instructions.

Only 42.86% recognized and properly evaluated the patient’s poor reading skills in a compassionate and clinically sensitive manner. However, the fellows performed well with patient education, counseling and treatment plan development.

“Many times, patients who are labeled noncompliant may in fact not understand the information that is given to them,” the researchers wrote.

End-of-life case

Regarding a patient with end-stage liver disease who was not a transplant candidate, the fellows were to educate the patient on the importance of advanced directives such as do-not-resuscitate orders and other end-of-life considerations such as hospice care.

All fellows were rated as having effectively summarized findings and treatment plans and 85.71% discussed the details of advanced directives and hospice care.

While 67% of the fellows felt they had performed well in the end-of-life case, only 22% to 33% felt they performed well overall.

“The fellows identified time as a challenge. It is likely that they would have been able to better communicate treatment options if given more time. Perhaps agenda setting would be useful in these complicated discussions,” the researchers wrote. “In real life, many of these encounters are at the beginning of a long-term therapeutic relationship so the need to convey every detail in the first visit is quite unnecessary. However, some fellows perceive these exercises as a test and want to be as thorough as possible, which is likely undesirable in a real-life encounter. It made us wonder how best to instruct fellows on how to strike the right balance in delivering patient information corresponding to the interpersonal communication skills (communication) milestone.” – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures.