Pilot study of a condensed communication skills workshop for gynecologic oncology fellows.

In gynecologic oncology (GO) fellowship, devoting sufficient time to learning communication skills can be challenging due to required time and logistics. A two day workshop was previously piloted at a single institution with GOs and found to be beneficial. We sought to implement that curriculum in a condensed form. We conducted two four-hour sessions with 4 GO fellows at a single institution over 4 months. Sessions consisted of a didactic in communication skills led by faculty with VitalTalk™ training, followed by application with a simulated patient. Cases were developed and previously used in a two-day workshop at another institution. Fellows were surveyed prior to both sessions and after the second session. Perceived confidence was assessed on a Likert scale (1 to 5). An improvement was defined by an increase of ≥1 in Likert score. All fellows reported that the educational quality of the sessions was "excellent," that the time in between sessions was "just right," allowing them to apply skills learned in the first session prior to the second. After both sessions, at least three of the four fellows reported an improvement in confidence in nearly 50% (10/21) of the communication topics assessed. GO fellows perceived improvements in communication skills with condensed half-day training seminars.

Introduction

Communications skills for gynecologic oncologists (GO) are crucial given that providers perform surgery, provide longitudinal cancer care, and counsel patients at the end of life. A recent survey of GO fellowship program directors found that PD prioritized communication topics as the most important palliative care skills for fellows to learn during fellowship, and >60% of programs reported explicit teaching on specific communication skills (Lefkowits et al., 2014). In a separate survey of current and recently graduated GO fellows, the majority noted never having received feedback on discussing goals of care (Eskander et al., 2014).

Numerous means of teaching communication skills have been studied. VitalTalk™ is an evidence-based strategy to teach communications skills to clinicians that has been used successfully in oncology and critical care (Arnold et al., 2015; Back et al., 2007). Recently, Lefkowits et al. demonstrated that 20 GO providers found a workshop in VitalTalk-based communication skills training to be of high quality and to deliver practice-changing education (Lefkowits et al., 2019). In GO fellowship however, devoting sufficient time to learn communication skills can be challenging due to the appropriately required time and logistics. Our objective was to implement and evaluate the effectiveness of a previously piloted and newly condensed communication workshop in a cohort of GO fellows.

Methods

Institutional Review Board approval was obtained for this study. We conducted two four-hour sessions with 4 GO fellows at a single institution over 4 months. There was approximately 10 weeks in between the two workshops; this was done intentionally to allow the fellows the time to practice the skills learned in the first session. The GO fellowship at this program does not include a dedicated rotation in palliative care. The workshops were condensed from a consecutive two-day workshop at Magee Women's Hospital developed by (Lefkowits et al., 2019) which was modeled on the National Cancer Institute VitalTalk program (Available from URL: www.vitaltalk.org [accessed May 9, 2019, 2019]). Sessions consisted of a didactic in communications skills led by faculty with VitalTalk training, including a focus on strategies in delivering serious news and responding to emotions with empathy, as well as eliciting values and addressing goals of care. The VitalTalk trainer is not a gynecologic oncologist, and is an appointed faculty at our institution. This was followed by application with simulated patients; during these small group sessions, simulations included deliberate skills practice with close supervision and immediate facilitator feedback. A GO faculty member was present for the didactic session, but was not present for the patient simulations.

In an effort to condense the sessions to allow for completion in four hours, the group had two cases with simulated patients, instead of three cases as used by (Lefkowits et al., 2019). In addition, we did not include cases from the fellows' own practice.

Fellows were surveyed prior to both sessions, and after the second session. Perceived confidence was assessed on a Likert scale (1 to 5). An improvement was defined by an increase of ≥1 in Likert score.

Results

Of the four fellows who participated in these workshops, two were on clinical rotations, and two were participating in research. Two of the four fellows reported never having had explicit training on responding to emotions or delivering serious news; three fellows had never had training on eliciting patient values. All fellows agreed that the interval of time between the two workshops was “just right,” and that the interval of time between the two workshops allowed for application of the skills learned in the first seminar. All four of the fellows strongly agreed on the value of the sessions; the statements surveyed are listed in Table 1.

Table 1

Fellows' impression of the workshops – 4/4 “strongly agreed” with the following.

The skills I gained during the workshop were a valuable trade off to the activities I would have done otherwise.

Practicing these skills using simulated patients will make me feel more comfortable in patient encounters.

Delivering serious news requires a discrete set of skills like other medical procedures.

Delivering serious news is an essential procedure that all fellows should learn.

The delivering serious news curriculum taught me new skills I plan to use in future encounters.

Observing other fellows during the simulation improved my communication skills.

Peer feedback during the simulation improved my communication skills.

Simulated practice facilitating delivering serious news prepared me better than clinical experience alone.

Simulated practice facilitating delivering serious news should be a required component of fellowship.

All fellows reported that the educational quality of the sessions was “excellent” and that such training should be repeated. All fellows reported that the time in between the sessions was “just right,” and that i allowed them to apply skills learned in the first session prior to the second session. After both sessions, all fellows noted an improvement in confidence in at least one of the communication topics assessed. At least three of the four fellows reported an improvement in confidence in nearly 50% (10/21) of the communication topics assessed (Table 2).

Table 2

Areas in which 75% of GO fellows reported an improvement in confidence.

Area	Number of fellows reporting an improvement in confidence (≥1 increase) in Likert score of perceived confidence (n = 4)
	Research fellows (n = 2)	Clinical fellows (n = 2)
Name the key steps of delivering serious news	2	2
Bring up advanced care planning	1	2
Elicit a patient's goals of care from a patient or family member	2	1
Lead a family conference	1	2
Manage conflict that arises during a family meeting	2	1
Describe comfort-focused care	1	2
Respond to patients or family members who have not accepted the seriousness of the patient's illness	2	1
Discuss religious or spiritual issues with a patient or family member	2	1
Counsel a patient or family member about what to expect in the dying process	2	1
Teach and mentor learners about how to facilitate delivering serious news	2	1

Following the sessions, two fellows (50%) reported a lower confidence score in the area of “using self-care techniques to prevent burnout and compassion fatigue;” both respondents had reduction in confidence by one level. The confidence of the other two fellows in this area did not change following the sessions. Both of the fellows who reported this were on clinical rotations; the fellows on research did not have a change in their self-reported level of confidence in this area. There were no other areas in which more than one fellow reported a reduction in confidence.

Discussion

We found that our condensed communication skills workshop, designed specifically for the specialty of GO, was found to be acceptable and valuable to a cohort of GO fellows. All of the fellows noted improved confidence in at least one communication skill. In addition, the fellows all strongly agreed on the importance of training in communication skills. This is consistent with prior studies of communication skills training (Lefkowits et al., 2019; Back et al., 2003).

We found that in the areas in which three out of the four fellows reported an improvement in confidence, this was often due to improvement reported by both fellows on research rotations, and one of the fellows on clinical rotations. Given that the fellows seldom have opportunity to practice such communication skills in hospital or clinic during their research years, it may be that this intervention was more significant for these two individuals who did not have as much GO clinical exposure in which to frame the training.

An incidental finding of the surveys pertained to 50% of the fellows noting a lower confidence score in “using self-care techniques to prevent burnout and compassion fatigue” following the two sessions. This may be due simply to self-report response bias, and it was the only area in which more than one fellow reported decreased confidence. Although the topics of burnout and compassion fatigue were not explicitly addressed during the communication training, the need for awareness of one's own emotions were highlighted. This may have led fellows to reflect on the demands of their specialty and occupation, leading to increased anxiety and/or compassion fatigue (Hlubocky et al., 2016). Although this is a subtle finding of a small study, it may be that education on resilience (Back et al., 2016) would be an appropriate adjunct to communication skills training.

The strengths of this pilot study include its use of a national recognized curriculum in communication skills that has been applied successfully in GO (Lefkowits et al., 2019). The limitations of the study include the application at a single institution. In addition, 50% of the fellows were on research rotations, during which they have significantly fewer clinical experiences; this may have led to an under- or overestimation of the impact of their experience. Although the surveys were anonymous, the small number of participants may have limited the perception of anonymity. The inclusion of a GO faculty member in a portion of the session may have led to survey response bias.

An additional limitation was the use of self-assessment as the primary outcome. We did not objectively measure the workshops' impact on the fellows' skills, as has been done in similar communication skills training (Back et al., 2007). However, in an assessment of GO fellows learning skills pertaining to breaking bad news, self-reported scores were found to accurately predict objective assessment of skill (O'Meara et al., 2014).

Although this educational program did not require significant resources, its implementation does entail participation of faculty with communication skills training, and the compensation and preparation of simulated patients. Our condensed curriculum adds feasibility to the potential for regionally or nationally centralized workshops on communication skills training for GO fellows.